Case report

A 24 year old infertility treated primigravida with 34 weeks pregnancy was seen on 2nd of June 2011 with complain of leaking per vaginum for 12 hours. She had married life of eight years. She was referred from millitary hospital. On examination, there was a single fetus of 34 wks with cephalic presentation with regular fetal heart. Per speculam examination showed leaking and liquor was clear. Per vaginal examination showed cervical dialatation of 2 cm with cord below presenting part. Cord pulsations were felt. Her routine investigations showed Hb-9.6gm% ,blood Group Rh-O+ve, HBsAg-negative, VDRL- negative, urine routine & microscopic-NAD. She had undergone diagnostic laproscopy which revealed a unicornuate uterus of with a rudimentary horn on left side. Her ultrasonography had showed a fibroid measuring 5.1x3.9x5.2 cm involving body of uterus and partly cervix. Hysteroscopic myomectomy was done and fibroid was ressected. Her IIIrd trimester scan showed a uterine fibroid measuring 7.5 x 7.6 x 9.6 cm involving lower segment.

She was immediately taken up for ceserian section. One unit of cross-matched blood was arranged. On opening the abdomen, there was a large fibroid occupying whole of the lower segment and part of upper segment on the anteriorly. There was no place to go through the upper segment. So intrapartum myomectomy was decided. Inj. vasopressin 20U diluted in 20 ml normal saline was given over the fibroid to maintain hemostasis. A transverse incision was given over the myoma on the lower segment and whole of fibroid was enucleated .Removal of fibroid opened the lower segment. A loop of cord was first seen. A preterm female baby weighing 2.25 kg was extracted out with apgar score 7/10 at 1 min and 8/10 at 5 min. The uterus was unicornuate with a rudimentary horn on the left side. Bilateral ovaries were normal. Lower segment contracted slowly with 40 U syntocinon drip. Inj. methylergometrine and Inj. Prostadin was given. Hemostasis was maintained. Abdomen was closed in layers.

Average blood loss during during surgery was about 750ml. Duration of surgery was about 1 hr. 10 min. She received 1 unit of blood transfusion and antibiotic coverage. Baby was admitted in NICU for seven days. Patient was discharged on 10 th post-operative day with a Hb of 9.0 gm/dl.

About the Author

Singh Urvashi1, Panchpal Shivangi2.

1. Lecturer, department of obstetrics and gynaecology, Moti Lal Nehru Medical College, Allahabad.
2. 3rd year resident.

Discussion

Fibroids are found in 25% of reproductive age women.Acurate incidence is difficult to ascertain as majority of fibroids are asymptomatic.However,the reported prevalence in pregnancy varies from 0.09 to 3.9%.1 Fibroids,particurly submucous may cause infertility or repeated pregnancy loss.The risk of myomectomy in terms of excessive haemorrhage is significantly greater in the IIIrd trimester.In a series of 9 patients who underwent ceserian myomectomy,3 of them had profuse bleeding and required a hysterectomy.2 However,some studies have shown that there is no significant diffence in blood loss,the need for blood transfision and postoperative morbidity between women undergoing ceserian and ceserian hysterectomy.3,4 Also,unicornuate is associated with poor reproductive performance.Chances of pregnancy reaching term is 20-30% and a live birth rate is of 40% in a unicornuate uterus.5

References

1. Ouyang DW,Economy KE,Norwitz ER.Obstetric complications of fibroids.Obstet Gyecol Clin North Am 2006 Mar;33(1):153-69.
2. Exacoustos C,Rosati P.Ultrasound diagnosis of uterine myomas and complications of pregnancy.Obstet Gynecol 1993 Jul;82(1);97-101.
3. Kwawukume EY.Caeserian myomectomy .Afr J Reprod Health 2002 Dec;6(3):38-43.
4. Brown D,Fletcher HM,Myrie MO,Reid M.Ceserian myomectomy-a safe procedure.A repropecticve case controlled study.J Obstet Gynecol 1999 Mar;19(2);139-141.
5. Raga F,Bauset C,Remohi J,Bonilla-Musoles F,Simom C,Pellicer A.Reproductive impact of Mullerian anomamlies.Hum Repord 1997 Oct;12(10);2277-81