First Trimester Myomectomy in a Woman With Uterine Leiomyoma
Introduction Performing a myomectomy during pregnancy is extremely rare due to the risk of pregnancy loss, hemorrhage and hysterectomy. Favorable outcomes have been demonstrated with select second trimester gravid myomectomies. Literature documenting first trimester surgical management of myomas during pregnancy is scant. Patients with symptomatic myomas failing conservative management in the first trimester may be counseled to abort the pregnancy and then undergo myomectomy. Reports focusing on myomectomy in the first trimester are needed to permit more thorough options counseling for patients failing conservative management in the first trimester.
Case presentation A 30-year-old Caucasian primagravid (G1P0) was referred for termination of her pregnancy at 10 weeks due to a 14 cm myoma causing severe pain, constipation and urine retention. Her referring physician planned an interval myomectomy following the abortion. Instead, our patient underwent myomectomy at 11 weeks. Two leiomyomas were successfully removed; she delivered a healthy infant at term.
Conclusion Patients in the first trimester should not be counseled that termination followed by myomectomy is the best option for symptomatic myomas, failing conservative treatment. Management should be individualized after taking into account the patient's symptoms, gestational age and the location of the myomas in relation to the placenta. Any field providing women's health services will be impacted by the ability to offer more thorough options counseling for women with refractory myomas in the first trimester.
The prevalence of uterine myomas during pregnancy is estimated to be 0.3% to 2.6%, of which 10% result in pregnancy complications. Complications include pregnancy loss, pelvic pain, placental abruption, hydronephrosis, premature rupture of membranes, preterm labor, intrauterine growth restriction, fetal malpresentation and postpartum hemorrhage. The prevalence of these complications is increased if there are multiple masses, if a myoma is retroplacental and if a myoma is larger than 3.6 cm in diameter (200 cm). Conservative management is the first line of treatment during pregnancy and consists of bed rest, hydration and analgesics. If these measures fail, patients may be presented the option of induced abortion with myomectomy at a later date.
The literature consists mainly of case reports and retrospective studies; there are few prospective studies of pregnancy-preserving myomectomies. The majority of these surgeries were performed in the second trimester for intractable pelvic pain and had excellent outcomes: very few pregnancy losses and no hysterectomies have been reported. Traditional recommendations, including operating only on pedunculated myomas, only during the fourth and sixth month of pregnancy or only during the 14 to 15 week, warrant re-evaluation.
Literature focusing on outcomes of myomectomies performed during the first trimester is scant. This report of a first trimester myomectomy suggests that certain cases may also have the safety and advantages of second trimester myomectomy.
Abstract and Introduction
Abstract
Introduction Performing a myomectomy during pregnancy is extremely rare due to the risk of pregnancy loss, hemorrhage and hysterectomy. Favorable outcomes have been demonstrated with select second trimester gravid myomectomies. Literature documenting first trimester surgical management of myomas during pregnancy is scant. Patients with symptomatic myomas failing conservative management in the first trimester may be counseled to abort the pregnancy and then undergo myomectomy. Reports focusing on myomectomy in the first trimester are needed to permit more thorough options counseling for patients failing conservative management in the first trimester.
Case presentation A 30-year-old Caucasian primagravid (G1P0) was referred for termination of her pregnancy at 10 weeks due to a 14 cm myoma causing severe pain, constipation and urine retention. Her referring physician planned an interval myomectomy following the abortion. Instead, our patient underwent myomectomy at 11 weeks. Two leiomyomas were successfully removed; she delivered a healthy infant at term.
Conclusion Patients in the first trimester should not be counseled that termination followed by myomectomy is the best option for symptomatic myomas, failing conservative treatment. Management should be individualized after taking into account the patient's symptoms, gestational age and the location of the myomas in relation to the placenta. Any field providing women's health services will be impacted by the ability to offer more thorough options counseling for women with refractory myomas in the first trimester.
Introduction
The prevalence of uterine myomas during pregnancy is estimated to be 0.3% to 2.6%, of which 10% result in pregnancy complications. Complications include pregnancy loss, pelvic pain, placental abruption, hydronephrosis, premature rupture of membranes, preterm labor, intrauterine growth restriction, fetal malpresentation and postpartum hemorrhage. The prevalence of these complications is increased if there are multiple masses, if a myoma is retroplacental and if a myoma is larger than 3.6 cm in diameter (200 cm). Conservative management is the first line of treatment during pregnancy and consists of bed rest, hydration and analgesics. If these measures fail, patients may be presented the option of induced abortion with myomectomy at a later date.
The literature consists mainly of case reports and retrospective studies; there are few prospective studies of pregnancy-preserving myomectomies. The majority of these surgeries were performed in the second trimester for intractable pelvic pain and had excellent outcomes: very few pregnancy losses and no hysterectomies have been reported. Traditional recommendations, including operating only on pedunculated myomas, only during the fourth and sixth month of pregnancy or only during the 14 to 15 week, warrant re-evaluation.
Literature focusing on outcomes of myomectomies performed during the first trimester is scant. This report of a first trimester myomectomy suggests that certain cases may also have the safety and advantages of second trimester myomectomy.
SHARE
