Vaginal delivery after laparotomic myomectomy during pregnancy

Introduction

The reported prevalence of uterine myomas during pregnancy is between 0.3% and 2.6%, and only 10% of these lead to pregnancy complications, such as pelvic pain, intrauterine growth restriction, placenta previa or accreta, placental abruption, dystocia and postpartum haemorrhage [1]. Surgeons are usually reluctant to perform myomectomy during pregnancy because of an increased uterine blood flow and volume can give rise to a potential risk for haemorrhagic complications, while uterine manipulation can determine adverse pregnancy outcome. However, in some rare cases surgery is compulsory: when severe abdominal pain occurs, due to degeneration or torsion and eventually necrosis of pedunculated myomas, or in the case of abdominal discomfort due to the bulky mass, which in both cases could develop an acute abdomen, potentially negatively affecting the course of pregnancy.

Laparotomic myomectomy during pregnancy has been reported as a safe approach since the end of the 19th century and nowadays the amount of evidence about laparoscopic myomectomy in pregnancy is progressively increasing, although it is only represented by case reports and series [2], [3], [4], [5], [6].

Here, we describe a case of a successful laparotomic myomectomy performed at the Obstetrics and Gynaecology department of Sant’Anna Hospital in Turin, during pregnancy at 11 weeks of gestation when an acute abdomen occurred. Surgery was followed by regular obstetrics follow-up and ended with a spontaneous vaginal delivery with no pregnancy complication.

Case presentation

A 36-year-old nulliparous woman at 11 weeks of gestations, of a spontaneous pregnancy, was referred to our hospital for acute pelvic pain. We performed an ultrasound scan, which confirmed a physiological ongoing pregnancy and revealed the presence of an angular subserous myoma of 126 × 77 mm, not previously known by the woman, arising from the uterine fundus with fluid retention in the pelvis (Figure 1 and Figure 2).

Figure 1:

Transabdominal ultrasound scan of the myoma at 11 weeks of gestation.

(A) and (B) Ultrasound scan showing the dimension of the myoma; (C) ultrasound scan showing the subserosal angular fundic myoma and colour-Doppler showing a large vascular pedicle of the myoma.

Figure 2:

Transvaginal ultrasound scan showing fluid retention in the pelvis.

Although in symptomatic myomas during pregnancy a conservative management is preferred, in our case a surgical approach was compulsory due to the onset of acute abdomen (probably due to a necrotic myoma or a subtorsion of it) being not responsive to painkillers. Considering the clinical status of our patient, a laparotomic myomectomy was performed with a uterine fundus incision and a 550 g myoma (measuring: 160 × 120 × 100 mm) was removed. We did not open the uterine cavity repairing the uterine muscle using a double layer transversal suture and introflectent interrupted stitches with Vicryl^® 1-0 thread (Ethicon, Johnson & Johnson International, Machelen, Belgium). No intraoperative blood loss or anaesthesia-related complications occurred, and the patient was discharged on the third postoperative day.

Afterwards, we scheduled clinical follow-ups every 4 weeks until delivery. Fetal biometry showed a regular fetal growth and the pregnancy progressed uneventfully until spontaneous rupture of membranes occurred at 39 weeks of gestation. Epidural anaesthesia was performed for pain relief and oxytocin iv was administered to increase contractions. An episiotomy was performed and a 2.780 kg, healthy female baby was born with an Apgar score of 9 both at the 1^st and 5^th minute. Total blood loss was 200 ml. The first active stage of labour lasted 4 h, the second stage 30 min and third stage 10 min.

At 3 months’ follow-up from delivery, mother and baby were fine and are currently healthy.

Discussion

Abdominal surgery during pregnancy can be risky for both mother and fetus, especially when the procedure involves the uterus. Surgeons usually hesitate to perform myomectomy in pregnancy because of the increased uterine blood flow and volume during gestation, which raise the risk of haemorrhagic complications and increase the likelihood of hysterectomy, while the uterine manipulation can predispose toward adverse pregnancy outcomes: miscarriage (18–35%), infection, preterm birth, uterine dehiscence [7]. These risks may be increased in the case of removal of submucous, posteriorly located, or multiple intramural myoma. However, in some cases surgery cannot be postponed. The most common indications for myomectomy during pregnancy are acute pelvic pain not responsive to medical therapy, signs of pedunculated myomas torsion and abdominal discomfort due to myoma rapid growth [8].

Traditionally, clinicians’ belief was that the primary option for first trimester symptomatic myoma, should be termination of pregnancy followed by subsequent myomectomy, however, there is evidence that myomectomy could be performed during every pregnancy trimester, depending on the setting and surgeon’s experience [1]. Evidence from prospective studies supports the feasibility and safety of myomectomy during pregnancy with uneventful subsequent course of pregnancy [8], [9], [10]. Moreover, untreated patients with uterine myomas seem to have a worse pregnancy outcome than surgically treated patients.

According the surgical technique of myomectomy, reviewing the available literature, laparoscopic myomectomy could be considered as a surgical choice during pregnancy in the case of considerably symptomatic myoma [3], [4], [5], [6]. Even if only 12 cases are described in literature, a mini-invasive approach should be encouraged in experts’ hands. However, in our patient, considering the critical severe onset of acute abdomen, a surgical approach by laparotomic myomectomy was compulsory.

Regarding mode of delivery after a myomectomy performed during pregnancy most studies describe a caesarean delivery (94% of the cases), because of an increased risk of uterine rupture (UR) [11]. UR is one of the most life-threating complications during pregnancy because it may lead to haemorrhage, shock, hysterectomy and even maternal and fetal mortality. Previous surgical interventions on the uterus are considered a risk factor for UR. This risk appears similar after both myomectomy and caesarean section (CS). The true incidence of UR after myomectomy is difficult to assess. UR is unpredictable, for this reason it is important to recognize quickly non-specific signs and symptoms, in every pregnant woman with a previous myomectomy. Most cases of UR occur in the third trimester or during labour, when intrauterine pressure is more elevated [12].

Despite this potential risk, a trial of labour should be also considered after a previous myomectomy, depending on technical conditions under which the intervention was conducted [10]. After myomectomy during pregnancy, vaginal delivery should not be considered contraindicated as diverse cases have been reported without complications in literature [4], [5], [6], both after laparotomic and laparoscopic myomectomy (13 cases and four cases, respectively, of vaginal delivery), even though they refer to only a few case reports with no clear clinical evidence on which is the best practice. For our patient, considering the data available in the literature, the spontaneous onset of labour, the desire of the woman and no other co-morbidities, we successfully decided for a trial of labour.

Counselling patients with symptomatic uterine myoma who do not respond to conservative management is challenging. Despite evidence being limited to few case series, in experts hands and in certain specific conditions, vaginal delivery after laparotomic myomectomy performed during pregnancy can be considered as an option.