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12 Symptomatic Uterine Myoma
Fig. 12.5 Umbilical lump (arrow) from the large uterine broid at 39weeks of pregnancy. (Reproduced with per­mission from [72] under the CC Attribution License)
Intestinal obstruction from large UF presents with nausea, vomiting, the absence of stool and atus, and abdominal distension [71].
Acute urinary retention results from (1) direct compression of the urinary bladder by UF or (2) UF causing uterine retroversion with resultant acute urinary retention (see Sect. 28.1). This is found in 5% of symptomatic UF [19].
Table 12.1
eration in pregnancy
Surgical Gynecologic Acute appendicitis Hydatid mole Acute cholecystitis Adnexal torsion Acute pancreatitis Torsion of the cyst
Common differential diagnosis of red degen-
Uterine incarceration Placental abruption Ovarian tumor
Incarceration is when the uterus is xed in the hollow of the sacrum wedged between the sacral promontory and pubic rami, unable to leave the pelvis. This condition is rare and ranges from 1/3000 to 1/10,000 pregnancies [74], and unlike UF, it can lead to fetal growth restriction. The abdominal US or MRI can conrm the diagnosis (see Sect. 12.6). The most common differential diagnoses of red degeneration are in Table12.1. Differential diagnoses of intestinal obstruction are in Chap. 18 and acute urinary retention in Sect. 28.1.
12.4.2 Physical Examination
With acute UF red degeneration or UF torsion [64], an exquisitely tender abdomen with signs of localized peritoneal irritation is common. The tenderness is over the mass attached to the uterus. Fever can be present. The typical presen­tation of red degeneration is present in 50% of patients [19]. Large UF can compress the lower genital tract. In 1896, Richard Douglas wrote I
made a digital and specular examination, was unable to nd the os uteri. The right vaginal vault and iliac region were lled with a hard tumor [73].
With torsed subserosal pedunculated UF, obstetric (including non-stress test) and vaginal examinations are normal [51, 64].
12.5 Dierential Diagnosis
Differential diagnoses depend on the presenta­tion of the UF.Uterine incarceration is a differen­tial diagnosis of painful or degenerating UF [74].
12.6 Diagnosis
UF is easy to detect with diagnostic imaging. Unfortunately, 96% of bleeding UF in the general population had a preoperative diagnosis of intra­abdominal bleeding of unknown origin. The intraoperative incidental nding was a UF [30]. The preoperative diagnosis of bleeding UF in pregnancy is exceptionally rare [36, 41]. Pregnant women with UF should undergo frequent US evaluations during pregnancy to monitor fetal growth and UF size [14].
12.6.1 Laboratory Findings
Laboratory ndings depend on the cause of symptomatic UF.Leukocytosis and elevated CRP are common with UF torsion [51, 64, 75] and red degeneration. Fall in serum hemoglobin and hematocrit results from intra-abdominal or intrabroid bleeding of large UF [35]. UF torsion rarely results in bleeding and a fall in serum hemoglobin and hematocrit.
ab
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12.6.2 Abdominal Ultrasound
The abdominal US is the rst imaging modality in evaluating UF during pregnancy. It deter­mines the number, localization, vascularization, shape, and relationship between UF and the uterine cavity. The US of a degenerating UF shows a well- circumscribed uterine mass com­posed of echodense and echolucent areas (Fig.12.6). A sharp drop in residence index in Doppler means some degree of necrosis [76]. As pregnancy progresses, the UF may become
Fig. 12.6 Ultrasound of degenerating uterine broid at the uterine fundus (marked with calipers). (Reproduced with permission from [77])
inaccessible as they become soft, attened, and indistinct due to interstitial edema, often con­fused with fetal parts.
The US Doppler denes the indication for myomectomy during pregnancy [76].
12.6.3 Abdominal MRI
Magnetic resonance imaging (MRI) evaluates uterine or adnexal masses (Fig.12.7) when US is unequivocal. It was used preoperatively in 4.7% and exclusively postoperatively [24]. MRI also evaluates fetal status, the relation of the gesta­tional sac to the pedicle of the UF (Fig.12.8), and the relation of UF to other intra-abdominal struc­tures. The ndings mostly delineate compression of the colon, bladder, and proximal urethra (Fig.12.9). MRI can demonstrate a hypointense vascular pedicle representing feeding vessels that arise from the uterine arteries, coursing from the uterus into an adjacent exophytic pelvic mass— bridging vessel sign. This sign reveals the uterine origin of the pelvic mass [78]. Postoperatively, MRI evaluates the myometrial thickness at the
Fig. 12.7 T2-weighted MRI of a 12-week pregnant woman shows an 8×7×6cm cystic and solid mass with septa. (a) sagittal view; (b) coronal view. (Reproduced with permission from [79] under the CC BY 3.0)
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12 Symptomatic Uterine Myoma
Fig. 12.8 Three myomas of the anterior uterine wall. One is close to the uterine cavity and placenta implant area (*). A posterior intramural myoma (#), with hyper­intense T2 weighted signal areas, is close to the posterior wall of the gestational sac, distorting it. (Reproduced with permission from [24])
site of the dissected peduncle [35]. Intra­abdominal bleeding from bleeding UF can be detected (Fig. 12.10). Also, MRI identies the base of the cervical UF or denes the extent of concomitant endometriosis.
12.6.4 Abdominal CT
Abdominal CT is used in an emergency after an inconclusive US, especially with suspected intra­abdominal bleeding [41] or when MRI is unavail­able. CT use is common after delivery, revealing fast UF growth without free intra-abdominal bleeding [44]. UF complications are not a real emergency, and elective MRI use is common.
Fig. 12.9 Abdominal MRI without contrast shows a 10 weeks gravid uterus with pregnancy in the fundus (star), compression of the colon (empty arrow), and com­pression of the urethra (lled arrow). (Reproduced with permission from [80] under the CC BY 2.0)
Fig. 12.10 Fluid in the pouch of Douglas on abdominal MRI indicates intra-abdominal bleeding. Large subserosal myoma is above the gestational sac. (Reproduced with permission from [35] under the CC BY 2.0)
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12.7 Treatment
Operative management is contraindicated, for the
symptoms subside with rest in bed, and further
complications such as infection, are mostly
unknown.
(Wilfred Shaw)
A myoma which rests in or on an impregnated
uterus, does not of itself, demand the attention of
the surgeon. Only when the tumor produces
unpleasant symptoms is active interference
indicated.
(Theodore Landau, 1871 [81])
12.7.1 Historical Perspective
In the late nineteenth century, UF during preg­nancy was treated depending on fetal viability. For viable fetuses, Cesarean section (CS), the Porro method, was performed [82]. Jules-Émile Péan, on December 15, 1874, made the rst myomectomy [83]. John Knowsley Thornton, in 1879, performed the rst unsuccessful myomec­tomy during pregnancy in England [84]. Later, Theodore Landau and Schröder published details of successful myomectomies. John B. Murphy, in 1896, unaware of the patient’s pregnancy, made an abdominal hysterectomy for a large UF.When the uterus and UF were transected, he found a fetus of 3months gesta­tion and stated Question of pregnancy had been
thoroughly considered before operation, and thought impossible from the patient’s statements and the absence of physical signs [83]. In the
same year, Richard Douglas made an abdominal hysterectomy at term with a stillborn [73]. Florence N.Boyd, in 1904, made two abdomi­nal hysterectomies on the uterus with broids after CS with live births [85]. Victor Bonney reported the rst successful Cesarean myomec­tomy in 1913 [86]. In 1920, William Mayo reported 19 myomectomies during pregnancy [87]. More than 100 operated cases have been published [14, 33, 35, 59, 80, 87–90].
12.7.2 Conservative Treatment
Despite often dramatic presentation, the optimal treatment for a degenerating UF is a short course of analgesics, bed rest, and reassurance. The pain will often improve dramatically, and the symptoms usu­ally subside within 10days [19]. The local release of prostaglandins from a degenerating UF can stimulate uterine contractions and premature labor.
Supportive care and administration of acet­aminophen are suggested as the initial interven­tions (Grade 2C) [91]. A short course of opioids in standard doses or a 48h course of nonsteroidal anti-inammatory drugs (NSAIDs) can be given when initial measures do not control the pain. Pain may be managed with a short course of ibu­profen or indomethacin (25mg orally every 6h for 48h) [91, 92]. NSAIDs should be limited to <32weeks of gestation due to the possibility of inducing premature closure of the ductus arterio­sus, neonatal pulmonary hypertension, oligohy­dramnios, and fetal/neonatal platelet dysfunction [93]. If NSAIDs are continued for >48 h, a weekly US assessment for oligohydramnios and narrowing of the fetal ductus arteriosus should be performed [91]. If either of these ndings is noted, NSAIDs should be discontinued [91].
12.7.3 Operative Treatment
Only 2.6% of women with UF developed compli­cations that required surgical intervention [14].
12.7.3.1 Abdominal Access
Elective or emergent myomectomy is performed by laparoscopy or laparotomy, depending on the expertise, the degree of emergency and shock, and the need for simultaneous CS.Laparoscopy is mostly used for pedunculated UF [75]. Large UF, if not morcellated, are delivered through a small Pfannenstiel incision [75]. Laparotomy is still the preferred (87%), while 6.6% were oper­ated on laparoscopically [24]. For the remaining operations, there are no data. The type of abdom-
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inal incision is reported in only 6.5% [24]. For gasless laparoscopy, see Sect. 3.2.2.2.
12.7.3.2 Myomectomy
For interstitial and subserosal broids No evidence supports recommending myomectomy during pregnancy in cases of obstetric disease, bleeding, necrobiosis, or threatened preterm deliv­ery attributable to broids (Grade C).
(French Guidelines 2012 [94])
12.7.3.3 Elective Myomectomy
In the absence of data, a routine myomectomy after delivery is not indicated if a complication attributable to the broid occurred during pregnancy and the patient subsequently became asymptomatic again.
(French Guidelines 2012 [94])
It is assumed that myomectomy should be avoided when entering the uterine cavity (the risk of damage to the amniotic sac cannot be excluded) or when a safe distance between the UF and the endometrial cavity cannot be assured [14]. An accurate preoperative assessment can improve the accuracy of surgical excision and reduce the risk of intraoperative complications. Management depends upon the: (1) location of the UF, (2) size and the number of the UF, (3) relation to the pla­centa, and (4) gestational age. Available options are as follows:
• Suspicion of other acute abdominal conditions requiring exploration,
• Twisted pedunculated UF,
• Bleeding UF,
• Uncontrollable pain or ruptured red degenera­tion UF,
• Rapidly growing tumor (intrabroid bleeding or malignancy).
The most common indication of myomec-
tomy in pregnancy is intractable pain [14]. Surgical intervention must be considered if symptoms persist after 72h of therapy [92, 95].
Twisted pedunculated UF is untwisted rst
[75]. Subsequently, a linear cutting stapler is red across the stalk of the pedunculated UF at the point of torsion. Some perform appendectomy [50]. The specimens are removed using a nylon extraction bag introduced through the left lateral trocar site, and the incision is extended (if needed) to remove the bag with its contents. The procedure ends with the staple line assessment for hemosta­sis (Fig.12.11) with peritoneal irrigation.
Myomectomy for red degeneration is inevita-
ble in 2% of cases [62]. Subserosal UF myomec­tomy or simultaneous CM should be performed by intracapsular technique and pseudocapsule sparing. UF pseudocapsule contains many neuro­peptides and neurotransmitters. These substances
• Hysterectomy,
• Abortion with the removal of the tumor subsequently,
• Myomectomy with or without removing the fetus,
• The progress of pregnancy and solving emergencies if they arise.
12.7.3.4 Emergency Myomectomy
Myomectomy with the continuation of the preg­nancy is indicated for the following conditions associated with UF as follows:
• Obstetric complications/fetal compression,
Fig. 12.11 Staple line assessed for hemostasis after myomectomy at 10weeks pregnancy. (Reproduced with permission from [50])
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positively affect wound healing and improve sub­sequent sexual and reproductive functions [96]. Therefore, this technique minimizes the risk of uterine rupture during the same and further preg­nancies (see Chap. 10). The augmented vascular­ization and tissue impedance of the pregnant uterus can amplify the risk of electrosurgical damage. Therefore, monopolar and bipolar elec­trosurgery in the UF resection should be avoided [97], although most UF enucleated laparoscopi­cally were completed using bipolar diathermy [75]. Electrocautery and an argon beam coagula­tor to minimize blood loss show good results [98]. Some inject vasopressin into the capsule of UF to decrease operative blood loss [80]. After excision or extirpation, the defect should be closed with sutures and adequate hemostasis obtained. Rarely, cyst aspiration rather than myo­mectomy in a UF with cyst degeneration and pain can be performed [79].
In both forms of spontaneous bleeding, free subserosal UF bleeding into the abdominal cavity and intrabroid bleeding resulting in fast­growing, very large UF, the uterine serosa is opened to identify the capsule of the UF before dissection of the peduncle. Then, the clamps are placed on the peduncle, and the myometrium is sutured with 1–0 resorptive sutures [35]. Although not recommended, free intra- abdominal bleeding can be stopped with sutures instead of a myomectomy [37].
Acute urinary retention is due to (1) direct compression of the urinary bladder by UF or (2) UF causing uterine retroversion with resultant acute urinary retention (see Sect. 28.1).
12.7.3.5 Cesarean Myomectomy
A myomectomy during a cesarean delivery does
not seem to be associated with any more morbidity
than short-term abstention (LE3). Data on its
long-term consequences are limited. There is no
evidence to contraindicate myomectomy during a
cesarean if it is either justied or necessary (pre-
via) (grade C).
(French Guidelines 2012 [94])
Cesarean myomectomy (CM) or myomec­tomy at the time of CS has been previously debated due to the risk of perioperative compli­cations [99, 100], mainly bleeding [101]. Many advise against myomectomy at the time of CS [70], while others even advocate CM to mini­mize postoperative sepsis and postpartum hem­orrhage [98]. Canadian guidelines support both antenatal myomectomy and CM [102]. The most recent meta-analysis did not show signi­cant disadvantages compared to only CS.Compared to CS alone, an association exists between increased operative time and hemoglo­bin drop during CM.No increased rate of major bleeding or need for transfusion was identied [103]. CM (Fig.12.12) should be carried out by senior obstetricians [95]. Indications for CM
a
Fig. 12.12 Before and after Cesarean myomectomy [113]
b
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12 Symptomatic Uterine Myoma
with asymptomatic UF are [19, 95, 104] as follows:
• Single UF,
• Pedunculated UF,
• Subserosal UF,
• UF diameter≤75mm.
The optimal situation, with minimal compli­cations, is CM of UF <5cm (or volume<50cm3) through the same uterine incision performed for the CS [105]. Subserosal or intramural UF are more common than submucosal when CM is per­formed [106–110]. CM is traditionally performed as serosal intracapsular myomectomy [110], referring to the excision of UF through the uter­ine serosa. With endometrial myomectomy, the UF is enucleated from the pseudocapsule, and the endometrium is sutured after UF removal [111]. This surgical technique minimizes adhesion for­mation on uterine serosa. The main advantage of CM is that UF can be easily excised because the UF pseudocapsule in a pregnant uterus is larger than that of a non-pregnant uterus, and the myo­metrium is more elastic and less delicate during pregnancy [112].
12.8 Prognosis
12.8.1 Maternal Outcome
12.8.1.1 Maternal Mortality
The type of presentation and the type of treat­ment dictate the maternal outcome.
One of the rst (fatal) cases of twisted pedunculated UF was in 1875 [48]. Until 1890, a preantiseptic era, maternal mortality was 22% [83].
Red degeneration does not lead to maternal mortality except with complications of spontane­ous bleeding, which also does not add to mater­nal mortality.
Up to 1903, maternal mortality from bleeding UF was 75%, and no surgical treatment was attempted [33], and during the 50years (1921–
1972), it rapidly declined to 0% [33] and remained so until today [32–47].
12.8.1.2 Maternal Morbidity
Obstetric complications of UF during pregnancy are out of the scope of this book. The risk of UF-related complications during pregnancy cor­relates with the size of the UF. UF >200 cm3 show a higher rate of complications than those ≤100 cm3 [114]. The uterine wall localization (submucosal, intramural, or subserosal) may be responsible for specic adverse events. The retro­placental UF have a signicantly higher risk of complications during pregnancy than other local­izations [20, 68, 95]. The overall risk of CS from UF is more than double [115], up to 73% [19]. After myomectomy in pregnancy from any cause, CS is the mode of delivery in up to 94% [116].
The incidence of major complications with a CM is 29.5%, with intraoperative bleeding being the most frequent (27.3%) and commonly requir­ing a blood transfusion. Conversely, women with a CS alone (with a single UF) had a 15.7% rate of major complications, with intraoperative hemor­rhage occurring in 13.7% of cases [104]. Uncontrollable bleeding during CM or isolated myomectomy in pregnancy can result in a higher rate of peripartum hysterectomy [19]. African studies did not nd a difference in fetal outcomes between CM and CS with delayed myomectomy [106, 109].
The uterine rupture rate during pregnancy is increased with prepregnancy laparoscopic myo­mectomy. This can be minimized using intracap­sular myomectomy (see Sect. 12.7.3.2).
Conservatively treated red degeneration does not result in preterm labor [19].
12.8.2 Fetal Outcome
Until 1890, the abortion rate was 40% [83]. Most fetal outcomes are referred from all types of pre­sentations together. UF are associated with an elevated risk of fetal loss. The fetal loss rate is higher with multiple UF than with a single UF [117]. The pregnancy loss rate seems similar in surgically and conservatively treated patients [70,
116, 118, 119].
Fetal growth does not appear to be affected by the presence of UF [14, 120]. Rarely does large
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UF compress and distort the intrauterine cavity. This leads to fetal deformities, including dolicho­cephaly (lateral compression of the fetal skull), torticollis (abnormal twisting of the neck), pos­tural deformity, and limb reduction defects [121–124].
In the rst half of the twentieth century, fetal mortality with bleeding UF was 29% [33], with sporadic fetal deaths during the following decades [38]. During the last 50years, fetal mor­tality has been nil [33, 35–37, 41, 44–47].
Neonatal survival is excellent for elective myomectomy for painful or enlarging UF, from 92 to 97% [14]. African studies did not nd a dif­ference in fetal outcomes between patients under­going CM with those undergoing CS with delayed myomectomy [106, 109].
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