Classical cesarean section in case of lower segment fibroids a case report Abstract:This is a case reportof lower segment fibroids with live fetus in a multiparous woman managed byclassical cesarean section. This case report depicts the successful method ofmanagement of such cases if encountered especially in case where LSCS can not be done due to the fibroids present.Introduction: Leiomyoma or uterine fibroids are one of themost common benign tumours of the reproductive age group. These may remainasymptomatic and may present as an incidental finding in approximately 50% ofthe case1.
Generally the symptoms include malpresentations,dysfunctional labour, APH, PPH and also secondary infertility3. As these are estrogen dependent fibroid maygrow or undergo red degeneration during the course of pregnancy2. Thispresents as complications in a surgery. However, in this case good preoperativeworkup and mapping of the fibroid along with careful planning of the classicalcesarean section helped in the uneventful management of this patient. Case report:A 35 years old G3P2L2came to the KEM hospital with 36 weeks of pregnancy after being referred from aprivate hospital. On examination patient had normal vitals with a haemoglobinof 10.
2 mg/dl . On obstetrical examination per abdominally she was 36 weekspregnant with an oblique lie and an additional firm mass of around 20 x 19 cmspalpable below the umbilicus. Ultrasound showed a single live fetus of about 36weeks of gestation, fundal placement and 2.45 kg fetal weight with multiplefibroids :1) Large fibroid of21 x 5.
6 x 11 cms extending from the fundus right up to the cervix below.2) 2.3 x 1.4 cmsintramural fibroid on anterior wall of uterus.3) 5.6 x 3 cmsintramural fibroid on lower segement of uterus.
4) 4.7 x 3 cmsintramural fibroid on anterior wall of uterus.After the necessary preoperativeinvestigations the patient was planned for classical cesarean section (Figure1) as the Lower segment cesarean section may have led to the fibroid coming inthe line of incision and may have led to further complications in the case.Patient underwentclassical cesarean section according to the preoperative planning. A live malebaby of 3.07 kg weight was delivered out by breech presentation.
Intraoperativeobservations also included the presence of multiple fibroids (Figure 2, 3):1) 4 x 3 cms in thelower segment towards the left side2) 4 x 3 cms nearthe fundus on the anterior wall3) 15 x 10 × 10 cmsbroad ligament fibroid towards the right side extending from the intrahepaticregion to the lower segment of the uterus.The fibroids were leftalone to avoid any complications which might have occurred as pregnancy is ahypervascularised state of the uterus. The operation and the postoperativeperiod went off uneventful and the mother and the baby were both discharged onthe 7th postop day.
The uterus was 20-22 weeks in size at thedischarge time. There was no any swelling of the fibroid felt at the lowersegment as was felt previously. Discussion:Incidenceof fibroids may vary from 0.
1% to as high as 12.5%4. Generally thefibroids are unaffected with pregnancy but in some cases it may increase insize by about 10%5. Pregnancy complicated by fibroids cause theincrease in the rate of cesarean section due to malpresentation and difficult labour. About 10 – 30% of patientsdevelop complications like red degeneration, infertility and torsion6.In this case we were lucky that there were no complications seen. A classical cesarean section was planned as in this case asin the ultrasonography the fibroid was visualized from fundus to the cervix andhence, any incision taken through the lower segment entailed the risk of goingthrough the fibroid and may have led to the myomectomy.
In recent studies ithas been shown that even though there is not an increased risk in performingmyomectomy along with the cesarean10 but, in this patient there weremultiple fibroids present along with a huge fibroid extending from the fundusto the cervix and myomectomy of this fibroid may have caused an extensive blood.Therefore, the decision of not doing myomectomy with cesarean seems to bejustified. Conclusion: This case report of the patient having multiplefibroids with pregnancy was managed successfully with classical cesareansection. This is a relatively uncommon presentation as per the size and thelocation of the fibroids. The decision of not doing the myomectomy withcesarean section is also justified as the size, number of fibroids and lesschances of future complications were a deterring factor.