PREGNANCY COMPLICATED WITH UTERINE LEIOMYOMAS AND PLACENTA PREVIA D. MONTEIRO 1 , M. DÓRIA 1 , J. FÉLIX 1 , C. VILAS BOAS 1 , J. NEVES 1 , P. TIAGO SILVA 1 1 - DEPARTMENT OF G YNECOLOGY AND OBSTETRICS - HOSPITAL PEDRO HISPANO , ULSM, MATOSINHOS, PORTUGAL INTRODUCTION CASE REPORT C ONCLUSION THE PATIENT ACHIEVED A SUCCESSFUL PREGNANCY WITH CONSERVATIVE MEASURES. THE C-SECTION WAS SEVERELY COMPLICATED BY THE LARGE LEIOMYOMAS WHO CONTINUED TO GROW RAPIDLY DURING PREGNANCY . EVEN THOUGH HYSTERECTOMY , IF NEEDED , WAS DESIRABLY PERFORMED SOMETIME AFTER PREGNANCY , IT WAS A FORESEEABLE COMPLICATION AND WE DETERMINE THE END-RESULT SATISFYING. BIBLIOGRAPHY [1] LUMSDEN MA, HAMOODI I, GUPTA J, HICKEY M; FIBROIDS: DIAGNOSIS AND TREATMENT. BMJ. 2015 OCT 13;351:H4887 [2] DONNEZ J,DOLMANS MM; UTERINE FIBROID MANAGEMENT: FROM THE PRESENT TO THE FUTURE. HUM REPROD UPDATE. 2016 NOV;22(6):665-686 UTERINE LEIOMYOMAS ARE THE MOST COMMON BENIGN PELVIC TUMOR ON WOMEN. OFTEN ASYMPTOMATIC, 25-40% PRESENT WITH SYMPTOMS OF EXCESSIVE BLEEDING, PELVIC PAIN, MISCARRIAGE, FERTILITY PROBLEMS AND OBSTETRIC COMPLICATIONS [1]. THE LARGER AND THE MORE THEY PROTRUDE INTO THE UTERINE CAVITY , MORE LIKELY THEY ARE TO HAVE NEGATIVE EFFECTS ON CONCEPTION AND PREGNANCY[2]. METHODS AND AIM CASE REPORT OF A WOMAN SUBJECTED TO CONSERVATIVE MEDICAL AND SURGICAL TREATMENT OF SUBMUCOUS FIBROIDS IN ORDER TO PRESERVE FERTILITY . SUBSEQUENT PREGNANCY COMPLICATED BY LARGE MULTIPLE UTERINE FIBROIDS AND PLACENTA PREVIA. LITERATURE REVIEW . At 26 years old, multiple large uterine leiomyomas were diagnosed on the context of infertility investigation. Performed one cycle of ulipristal acetate followed by abdominal myomectomy of two intramural fundal and corporeal fibroids (25 and 40mm larger diameters). Four months later was re-evaluated by hysteroscopy with lysis of uterine adhesions. Suffered spontaneous early pregnancy loss 1 year later. Achieved new pregnancy at 29 years old. On the 1 st trimester evaluation, multiple large fibroids were visible, occupying the lower 2/3 of the uterus. At 29 weeks, had vaginal hemorrhage with uterine contractions. Ultrassound evaluation showed multiple fibroids (biggest with 69x41mm on the anterior isthmic portion). Moreover the PLACENTA persisted ANTERIOR PREVIA and had no signs of detachment. Was admitted for fetal lung maturation and discharged after 5 days. (A) FETAL EXTRACTION (B) VISIBLE UTERINE SUBMUCOUS FIBROIDS (C) UTERINE SUTURE BY LAYERS (D) UTERINE SUTURE BY LAYERS (A) (B) (C) (D) At 33 weeks and 3 days, had premature rupture of membranes and later started uterine contractions and vaginal hemorrhage. A c-section with median skin incision and a median fundal uterine incision was decided due to large anterior fibroids. The fetus was gently extracted by feet with difficulty due to transversal lie and non-complacent uterine wall due to the conglomerate of fibroids. Newborn with 1860g, Apgar score 9/10. The uterine contraction and suture hemostasis was successfully obtained with help of a fibrin sealant patch and a drain was left on the pelvic cavity. Six hours after surgery, the patient was hemodynamically unstable with significant blood content on the drain deposit. On exploratory laparotomy, significant hemoperitoneum was visualized with origin on the uterine suture and, after unsuccessful attempt to stop the bleeding, total hysterectomy with adnexial preservation was performed. The patient suffered disseminated intravascular coagulation and was admitted to the intensive care unit with ventilatory, circulatory and transfusional support. Both mother and child had favorable clinical evolution and the puerpera was discharged 6 days after c-section, with no later complications. (E) UTERINE MEDIAN FUNDAL SUTURE (F) FIBRIN SEALANT PATCH OVER THE UTERINE SUTURE (E) (F)

PREGNANCY COMPLICATED WITH UTERINE LEIOMYOMAS AND PLACENTA …

Download PDF Report

Upload
others
View
4
Download
0

Embed Size (px)

Citation preview

PREGNANCY COMPLICATED WITH UTERINE LEIOMYOMAS AND

PLACENTA PREVIA D. MONTEIRO1, M. DÓRIA1, J. FÉLIX1, C. VILAS BOAS1, J. NEVES1, P. TIAGO SILVA1

1 - DEPARTMENT OF GYNECOLOGY AND OBSTETRICS - HOSPITAL PEDRO HISPANO, ULSM, MATOSINHOS, PORTUGAL

INTRODUCTION

CASE REPORT

CONCLUSION THE PATIENT ACHIEVED A SUCCESSFUL PREGNANCY WITH CONSERVATIVE MEASURES. THE C-SECTION WAS SEVERELY COMPLICATED BY THE LARGE LEIOMYOMAS WHO CONTINUED TO GROW RAPIDLY DURING PREGNANCY. EVEN THOUGH HYSTERECTOMY, IF NEEDED, WAS DESIRABLY PERFORMED SOMETIME AFTER PREGNANCY, IT WAS A FORESEEABLE COMPLICATION AND WE DETERMINE THE END-RESULT SATISFYING.

BIBLIOGRAPHY [1] LUMSDEN MA, HAMOODI I, GUPTA J, HICKEY M; FIBROIDS: DIAGNOSIS AND TREATMENT. BMJ. 2015 OCT 13;351:H4887 [2] DONNEZ J,DOLMANS MM; UTERINE FIBROID MANAGEMENT: FROM THE PRESENT TO THE FUTURE. HUM REPROD UPDATE. 2016 NOV;22(6):665-686

UTERINE LEIOMYOMAS ARE THE MOST COMMON BENIGN PELVIC TUMOR ON WOMEN. OFTEN ASYMPTOMATIC, 25-40% PRESENT WITH SYMPTOMS OF EXCESSIVE BLEEDING, PELVIC PAIN, MISCARRIAGE, FERTILITY PROBLEMS AND OBSTETRIC COMPLICATIONS [1]. THE LARGER AND THE MORE THEY PROTRUDE INTO THE UTERINE CAVITY, MORE LIKELY THEY ARE TO HAVE NEGATIVE EFFECTS ON CONCEPTION AND PREGNANCY[2]. METHODS AND AIM CASE REPORT OF A WOMAN SUBJECTED TO CONSERVATIVE MEDICAL AND SURGICAL TREATMENT OF SUBMUCOUS FIBROIDS IN ORDER TO PRESERVE FERTILITY. SUBSEQUENT PREGNANCY COMPLICATED BY LARGE MULTIPLE UTERINE FIBROIDS AND PLACENTA PREVIA. LITERATURE REVIEW.

At 26 years old, multiple large uterine leiomyomas were diagnosed on the context of infertility investigation. Performed one cycle of ulipristal acetate followed by abdominal myomectomy of two intramural fundal and corporeal fibroids (25 and 40mm larger diameters). Four months later was re-evaluated by hysteroscopy with lysis of uterine adhesions. Suffered spontaneous early pregnancy loss 1 year later. Achieved new pregnancy at 29 years old. On the 1st trimester evaluation, multiple large fibroids were visible, occupying the lower 2/3 of the uterus. At 29 weeks, had vaginal hemorrhage with uterine contractions. Ultrassound evaluation showed multiple fibroids (biggest with 69x41mm on the anterior

isthmic portion). Moreover the PLACENTA persisted ANTERIOR PREVIA and had no signs of detachment. Was admitted for fetal lung maturation and discharged after 5 days.

(A) FETAL EXTRACTION (B) VISIBLE UTERINE SUBMUCOUS FIBROIDS (C) UTERINE SUTURE BY LAYERS (D) UTERINE SUTURE BY LAYERS

(A) (B) (C) (D)

At 33 weeks and 3 days, had premature rupture of membranes and later started uterine contractions and vaginal hemorrhage. A c-section with median skin incision and a median fundal uterine incision was decided due to large anterior fibroids. The fetus was gently extracted by feet with difficulty due to transversal lie and non-complacent uterine wall due to the conglomerate of fibroids. Newborn with 1860g, Apgar score 9/10. The uterine contraction and suture hemostasis was successfully obtained with help of a fibrin sealant patch and a drain was left on the pelvic cavity.

Six hours after surgery, the patient was hemodynamically unstable with significant blood content on the drain deposit. On exploratory laparotomy, significant hemoperitoneum was visualized with origin on the uterine suture and, after unsuccessful attempt to stop the bleeding, total hysterectomy with adnexial preservation was performed. The patient suffered disseminated intravascular coagulation and was admitted to the intensive care unit with ventilatory, circulatory and transfusional support. Both mother and child had favorable clinical evolution and the puerpera was discharged 6 days after c-section, with no later complications.

(E) UTERINE MEDIAN FUNDAL SUTURE (F) FIBRIN SEALANT PATCH OVER THE UTERINE SUTURE

(E) (F)