A SUCCESSFUL VAGINAL MYOMECTOMY IMPROVE THE OUTCOME OF PEDUNCULATED SUBMUCOSAL FIBROID DURING CAESAREAN SECTION AT RURAL HOSPITAL: A RARE CASE REPORT

Introduction: Uterine myomas are the most common benign growths on female reproductive system, occurring in 20%-40% women with 3%-13% incidence rate in pregnancy. One type of uterine myoma is prolapsed submucosal myoma with 10% prevalence in pregnancy and only 1% of them are cervical myoma, making it a rare clinical entity.It is highly relates to infertility and encountered mostly during pre-conception period.

Case: A 27-year-old woman, G2P1 36+4 weeks of gestational age, singleton live head presentation, admitted to the emergency room Koja Hospital with water broke since one day before admission. She admitted history of chronic vaginal spotting accompanied by abdominal cramps a day before admission and came in anemic condition (haemoglobin level was 8.8 g/dl). On examination, a 5cm-diameter mass with a smooth surface, suggested pedunculated cervical fibroid was seen and a solid-supple mass in vagina with 3cm-diameter originated from posterior cervical lips (6 o’clock) was felt. On ultrasound examination, fetus was in head presentation, placenta on fundus, no retroplacental hemorrhage, estimated fetal weight was (2695) grams with oligohydroamnian (ICA 6.5). A 5cm hypoechoic mass in vagina with stalk originated from posterior cervical lips were found (feeding artery was positive); in agreement with pedunculated cervical fibroids. Patient was decided to undergo elective caesarean section and continued with vaginal myomectomy. The surgery went successfully without complications.

Discussion: Most myomectomy of pedunculated myomas during pregnancy were performed post-delivery. However, surgery during pregnancy has also been reported. Imaging such as MRI is more accurate than transvaginal ultrasound to determine the location of leiomyoma and also in planning surgery management, but it is not used in this case due to lack of facilites in the hospital. In this case, myomectomy was performed in elective caesarean section. Obara et al. stated that location of myoma and technique as significant factors for surgical treatment and postoperative care during pregnancy. In this case, the pedicle arise from posterior cervical wall, which made it an accessible section. To control bleeding, ligation and section of the 2mm vascular pedicle was considered rather than twisting. To prevent cervicitis due to external dilation of uterus, our patient received systemic antibiotics for one week.

Conclusion: Cervical leiomyomas and prolapsed submucosal leiomyomas in pregnancy are rare clinical entities. Conservative management is acceptable until the time of delivery unless complications arise. A surgical approach may be considered which is technically less challenging if the leiomyoma is pedunculated.