LARGE ANTERIOR LOWER SEGMENT UTERINE FIBROIDS IN PREGNANCY--MANAGEMENT OPTIONS

Problem statement:

This is a case of a 37-year-old female who presented with intrauterine pregnancy at 37-week gestation and multiple uterine fibroids. A large, 14 cm anterior lower segment fibroid obstructing the fetal head warranted a cesarean section with a classical uterine incision. The patient was counseled regarding the possibility of hysterectomy due to risk of hemorrhage. This case is significant due to the unique challenges faced related to surgical approach, adequate preoperative planning, adaptability, dexterity, and intraoperative collaboration. This report highlights the extensive clinical decision-making process and intraoperative considerations that were necessary in managing this complex case, as well as discuss alternative management options.

Methods: This is a case report.

Results:

A classical uterine incision at the fundus was indicated preoperatively due to the location of a large intramural fibroid at the right lateral lower segment of the uterus. Intraoperatively, however, multiple uterine fibroids of various sizes were noted at different sites on the uterus including fundus. The area left of the midline in the lower uterine segment was free of fibroids, therefore, we made a lower segment vertical incision. The infant was delivered without complications. The uterine incision was closed in a 3 layers and satisfactory hemostasis secured. Quantitative blood loss (QBL) was 915 mL. Hysterectomy was not warranted and blood was not necessary.

Conclusion:

The management of a large lower segment uterine fibroid poses unique challenges that required careful team collaboration. While a classical uterine incision was initially planned, a swift decision had to be made intraoperatively to opt for a low vertical incision, which proved to be a successful alternative in the face of extensive fibroid involvement at the planned site. Alternative management options included uterine artery embolizationn(UAE) or placement of UAE catheter/balloon prior to uterine incision by interventional radiology, etc. Myomectomy during cesarean delivery is discouraged because of the risk of severe postpartum hemorrhage.

The authors have no relevant financial disclosures.

Institutional review board (IRB) approval not required because this is a case report.