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Myomectomy of a massive uterine myoma during cesarean section under regional anesthesia
Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 196e197
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Research Letter
Myomectomy of a massive uterine myoma during cesarean section under regional anesthesia Yueh-Ping Huang a, Ming-Che Hsu b, Chien-Nan Lee c, Shou-Zen Fan b, Li-Kuei Chen b, * a
Department of Anesthesiology, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, Taipei, Taiwan c Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, Taipei, Taiwan b
a r t i c l e i n f o Article history: Accepted 11 July 2012
This study reports the case of a successful myomectomy of a huge fibromyoma (30 cm 25 cm 25 cm) in a 37-week pregnant woman undergoing cesarean section (CS) delivery under combined spinal epidural anesthesia. The advantages of performing CS under combined spinal epidural anesthesia include gradual titration of the anesthetic and adjustment of the levels as required during surgery. This case is unique in that there are no previous reports of the resection of an unusually located (adhered to the right side of the diaphragm) fibromyoma of this size during a CS delivery. The patient involved in this study was a healthy 28-year-old nulliparous woman with an anterior wall subserosal uterine myoma, measuring about 10 cm in diameter, which was accidentally discovered during a routine health checkup 2 years previously. An abdominal sonogram taken at the 34th gestational week showed a massive fibromyoma (30 cm 25 cm 25 cm), and another smaller tumor at the uterine fundus. Placenta previa totalis was also noted. Consequently, a CS was scheduled at the 37th gestational week. After adequate hydration, spinal anesthesia was induced and achieved a T4-level sensory blockade. A 16G epidural catheter was inserted to sustain postoperative analgesia and to achieve intraoperative anesthesia. A 2912 g male baby was delivered through vertex extraction. The delivery was uneventful; therefore, the obstetricians evaluated the feasibility of removing the myoma. Although the myomas appeared to be huge, they were wellencapsulated and subserous. Therefore, the obstetrician decided
* Corresponding author. Department of Anesthesiology, National Taiwan University Hospital, Number 7 Chung-Shan South Road, Taipei, Taiwan. E-mail address: [email protected] (L.-K. Chen).
to proceed with the myomectomy procedure. The larger tumor was so big that it adhered to the right side of the diaphragm during the pregnancy. The patient complained of nausea on manipulation of the tumor during surgical resection, so sedation was induced with intravenous propofol infusion. The initial heart rate was around 90 beats/min, but went up to 140 beats/min during the myomectomy. The patient's blood pressure was around 90/60 mmHg. Four units of packed red blood cells were transfused to replace the ongoing blood loss. Blood pressure gradually returned to around 110/ 60 mmHg. Finally, the two uterine myomas, measuring 5290 g and 576 g, were removed (Fig. 1). The total operation time was 4 hours and 10 minutes with a blood loss amounting to 1000 mL. The patient recovered well after the CS, without any adverse effects. Myomectomy during CS remains a controversial topic. However, a recent study showed that there were no differences in the mean hemoglobin change, the incidence of postoperative fever, and the length of hospital stay between patients with fibromyomas who underwent a myomectomy during a CS delivery and those without fibromyomas that underwent CS deliveries [1]. Intraoperative hemorrhage can be decreased by oxytocin infusion or by ligating the uterine artery with a tourniquet [2,3]. Moreover, the uterus in the postpartum phase is physiologically better adapted to control hemorrhage because myometrial contractions help constrict the blood vessels. Kaymak et al [4] reported the findings of a study where 40 out of 120 women with myomas underwent myomectomy during CS. The incidence of hemorrhage was found to be 12.5% in the myomectomy group even though 60% of the patients in this group had larger myomas and more than 30% of the removed fibroids were intramural as compared with the nonmyomectomy group (6 cm in diameter). Umezurike and Feyi-Waboso [5] reported a case of myomectomy at the 20th week gestational stage with the tumor weighing 7.7 kg. In order to resect the tumor, laparotomy was performed under general anesthesia with endotracheal intubation. The current literature reports an increase in the rate of myomectomies being performed during CS deliveries. This study was a unique case wherein a fibromyoma had adhered to the right side of the diaphragm, which is unusual. Moreover, the enormous size of the fibromyoma made it the first reported tumor of its kind to be resected during CS.
http://dx.doi.org/10.1016/j.tjog.2012.07.043 1028-4559/Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
Y.-P. Huang et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 196e197
197
References [1] Li H, Du J, Jin L, Shi Z, Liu MY. Myomectomy during cesarean section. Acta Obstet Gynecol Scand 2009;88:183e6. [2] Kwawukume EY. Caesarean myomectomy. Afr J Reprod Health 2002;6:38e43. [3] Sapmaz E, Celik H, Altungul A. Bilateral ascending uterine artery ligation vs. tourniquet use for hemostasis in cesarean myomectomy. A comparison. J Reprod Med 2003;48:950e4. [4] Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L. Myomectomy during cesarean section. Int J Gynaecol Obstet 2005;89:90e3. [5] Umezurike C, Feyi-Waboso P. Successful myomectomy during pregnancy: A case report. Reprod Health 2005;6:38e43.
Fig. 1. Resected uterine myomas, weighing 5290 g and 576 g.
Conflicts of interest The authors have no conflicts of interest relevant to this article.
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Research Letter
Myomectomy of a massive uterine myoma during cesarean section under regional anesthesia Yueh-Ping Huang a, Ming-Che Hsu b, Chien-Nan Lee c, Shou-Zen Fan b, Li-Kuei Chen b, * a
Department of Anesthesiology, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, Taipei, Taiwan c Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, Taipei, Taiwan b
a r t i c l e i n f o Article history: Accepted 11 July 2012
This study reports the case of a successful myomectomy of a huge fibromyoma (30 cm 25 cm 25 cm) in a 37-week pregnant woman undergoing cesarean section (CS) delivery under combined spinal epidural anesthesia. The advantages of performing CS under combined spinal epidural anesthesia include gradual titration of the anesthetic and adjustment of the levels as required during surgery. This case is unique in that there are no previous reports of the resection of an unusually located (adhered to the right side of the diaphragm) fibromyoma of this size during a CS delivery. The patient involved in this study was a healthy 28-year-old nulliparous woman with an anterior wall subserosal uterine myoma, measuring about 10 cm in diameter, which was accidentally discovered during a routine health checkup 2 years previously. An abdominal sonogram taken at the 34th gestational week showed a massive fibromyoma (30 cm 25 cm 25 cm), and another smaller tumor at the uterine fundus. Placenta previa totalis was also noted. Consequently, a CS was scheduled at the 37th gestational week. After adequate hydration, spinal anesthesia was induced and achieved a T4-level sensory blockade. A 16G epidural catheter was inserted to sustain postoperative analgesia and to achieve intraoperative anesthesia. A 2912 g male baby was delivered through vertex extraction. The delivery was uneventful; therefore, the obstetricians evaluated the feasibility of removing the myoma. Although the myomas appeared to be huge, they were wellencapsulated and subserous. Therefore, the obstetrician decided
* Corresponding author. Department of Anesthesiology, National Taiwan University Hospital, Number 7 Chung-Shan South Road, Taipei, Taiwan. E-mail address: [email protected] (L.-K. Chen).
to proceed with the myomectomy procedure. The larger tumor was so big that it adhered to the right side of the diaphragm during the pregnancy. The patient complained of nausea on manipulation of the tumor during surgical resection, so sedation was induced with intravenous propofol infusion. The initial heart rate was around 90 beats/min, but went up to 140 beats/min during the myomectomy. The patient's blood pressure was around 90/60 mmHg. Four units of packed red blood cells were transfused to replace the ongoing blood loss. Blood pressure gradually returned to around 110/ 60 mmHg. Finally, the two uterine myomas, measuring 5290 g and 576 g, were removed (Fig. 1). The total operation time was 4 hours and 10 minutes with a blood loss amounting to 1000 mL. The patient recovered well after the CS, without any adverse effects. Myomectomy during CS remains a controversial topic. However, a recent study showed that there were no differences in the mean hemoglobin change, the incidence of postoperative fever, and the length of hospital stay between patients with fibromyomas who underwent a myomectomy during a CS delivery and those without fibromyomas that underwent CS deliveries [1]. Intraoperative hemorrhage can be decreased by oxytocin infusion or by ligating the uterine artery with a tourniquet [2,3]. Moreover, the uterus in the postpartum phase is physiologically better adapted to control hemorrhage because myometrial contractions help constrict the blood vessels. Kaymak et al [4] reported the findings of a study where 40 out of 120 women with myomas underwent myomectomy during CS. The incidence of hemorrhage was found to be 12.5% in the myomectomy group even though 60% of the patients in this group had larger myomas and more than 30% of the removed fibroids were intramural as compared with the nonmyomectomy group (6 cm in diameter). Umezurike and Feyi-Waboso [5] reported a case of myomectomy at the 20th week gestational stage with the tumor weighing 7.7 kg. In order to resect the tumor, laparotomy was performed under general anesthesia with endotracheal intubation. The current literature reports an increase in the rate of myomectomies being performed during CS deliveries. This study was a unique case wherein a fibromyoma had adhered to the right side of the diaphragm, which is unusual. Moreover, the enormous size of the fibromyoma made it the first reported tumor of its kind to be resected during CS.
http://dx.doi.org/10.1016/j.tjog.2012.07.043 1028-4559/Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
Y.-P. Huang et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 196e197
197
References [1] Li H, Du J, Jin L, Shi Z, Liu MY. Myomectomy during cesarean section. Acta Obstet Gynecol Scand 2009;88:183e6. [2] Kwawukume EY. Caesarean myomectomy. Afr J Reprod Health 2002;6:38e43. [3] Sapmaz E, Celik H, Altungul A. Bilateral ascending uterine artery ligation vs. tourniquet use for hemostasis in cesarean myomectomy. A comparison. J Reprod Med 2003;48:950e4. [4] Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L. Myomectomy during cesarean section. Int J Gynaecol Obstet 2005;89:90e3. [5] Umezurike C, Feyi-Waboso P. Successful myomectomy during pregnancy: A case report. Reprod Health 2005;6:38e43.
Fig. 1. Resected uterine myomas, weighing 5290 g and 576 g.
Conflicts of interest The authors have no conflicts of interest relevant to this article.