Myomectomy during Early Pregnancy

Abstract

Abdominal pain during early pregnancy may be caused by leiomyoma of the uterus. Inconsistency of uterine size and gestational dates in a pregnant patient with acute abdominal pain may be the first sign of leiomyoma. This 31-year-old primigravida presented with progressively worsening lower abdominal pain at 12 weeks gestational age. Ultrasonography and magnetic resonance imaging demonstrated a large fundal heterogeneous mass and an intrauterine gestation compatible with her menstrual dates. Exploratory surgery and myomectomy confirmed a large leiomyoma showing benign degenerative changes. The operative procedure was successful, and the pregnancy progressed normally. An elective cesarean section was performed at 37 weeks gestation after confirming fetal maturity by amniocentesis and serial ultrasonography. Abdominal pain in a pregnant patient with leiomyoma uteri may be attributable to degenerative changes in the myoma. Surgical intervention during pregnancy is occasionally necessary in uncommon cases of intractable pain.

Fibroids in Pregnancy???Common but Poorly Understood

“…These ultrasound features are therefore common in severe degeneration of fibroids, but it is unclear whether they antedate the onset of pain and so predict those women who would develop pain in pregnancy. Most patients respond well to oral, and in some cases parenteral, analgesics but in a few patients, the pain may be severe enough to necessitate interventions such as an epidural (17) or a even a myomectomy (18).…”

“…However, surgical management of fibroids during pregnancy or at delivery has on occasions been considered for the health and well-being of the mother or the fetus. The safety of surgical procedures for fibroids during pregnancy is the main concern, particularly intraoperative bleeding, and the risk of operating has to be balanced with that of not doing so (3,18,(38)(39)(40).…”

“…Ehigiegba and SeloOjeme reported a pregnant patient with an incarcerated pedunculated fibroid in an umbilical hernia sac, who underwent myomectomy and hernia repair at 28 weeks, and subsequently had a normal vaginal delivery at term (38). Whittich et al describe a myomectomy performed at 12 weeks gestation for intractable pain resulting from degenerative changes of a fundal fibroid in a patient whose pregnancy continued normally until delivery by elective cesarean section at term (18). A rapid growth of uterine fibroid in pregnancy may also necessitate emergency myomectomy.…”

Uterine Fibroids and Pregnancy: A Review of the Challenges

“…Non steroidal anti-inflammatory drugs (prostaglandin synthetase inhibitors) should be used with caution, especially in the third trimester because of the potential for fetal and neonatal adverse effects, including premature closure of fetal ductus arteriosus, pulmonary hypertension, necrotizing enterocolitis, intracranial hemorrhage and oligohydramnios [45]. Additional pain management, especially opioid use, and on few occasions epidural analgesia and surgical management antenatally (myomectomy), may be employed when pain is intense [46,47].…”

“…However, reports abound of successful myomectomies during cesarean section [48][49][50]. Myomectomies antenatally by laparotomic or laparoscopic approach prior to fetal viability, most especially in the second trimester of pregnancy, have been rarely carried out as a result of intractable pain from a degenerating fibroid; especially if subserosal and pedunculated, large or rapidly growing, or large fibroid (>5 cm) located in the lower uterine segment [2,47,51]. Women having myomectomy antenatally are more likely to be delivered by cesarean section due to increased risk of intrapartum uterine rupture, though some have successfully delivered vaginally [51][52][53][54].…”