Written informed consent was taken and the department Ethical Committee approved the case report.
A thirty year aged primigravida reported in the out-patient department of our rural based institute at 14 weeks of pregnancy for routine ante-natal check-up. Her per-abdomen findings revealed uterine size to be inconsistently increased to 22 weeks with the patient being sure of her date of last menstrual period and no history of 'quickening' as yet. Her routine investigations were normal but sonography revealed 13.4 weeks intrauterine live fetus along with a large 11.5 cm intramural leiomyoma on the anterior wall of the maternal uterus encroaching upon the cervix.
The patient was regularly followed up and twice she had had to be admitted, for a couple of days each, in the second trimester with pain abdomen and was managed conservatively. A detailed sonographic image of the fetus at 20 weeks of gestational age showed no evidence of any major structural abnormalities. During the course of pregnancy, this myoma showed progressive increase in size and the last ultrasonography at term depicted it to be 31.3 cm in its longitudinal dimension and involved not only the most of the anterior uterine portion but was also abutting on the lower uterine segment. The presenting part (cephalic) was visualized high above the internal os with this leiomyoma intervening in between. She also had pregnancy induced hypertension of and was treated with oral labetalol from 31.5 weeks onwards and the fetus showed signs of intra-uterine growth restriction.
Pelvic examination, at term gestational age, confirmed the virtual improbability of vaginal delivery. After discussion with the experienced senior sonologist, the patient and her attendants, decision for performing caesarean section was forthcoming. Also the consent for cesarean hysterectomy was sought in case of any eventuality, whatsoever.
At the time of surgery, patient's hemoglobin reading was 10.4 g/dl, nevertheless, four units of cross-matched blood were arranged.
Right sided paramedian longitudinal incision was employed which was extended supra-umbilically. The upper uterine segment was incised longitudinally followed by enucleation of a mammoth sized myoma en masse, that is, classical cesarean section with a myomectomy had to be resorted to. A live female baby weighing 2,280 g was successfully delivered with Apgar scores of 8 and 9 at 1 min and 5 min, respectively.
Incised uterine wall was sutured in three layers to obliterate any physiological dead space. Neither uterine vessels were clamped nor vasopressors were used during the intra-operative period. The myoma removed, (Figure ), was of the dimensions 33.3 × 28.8 × 15.6 cm and the intra-operative blood loss was estimated to be 1860 ml. Two units of cross-matched blood were transfused - one intra-operatively and the other one in the post-operative ward and hemoglobin reading was 9.6 g/dl on the second post-operative day.
A large leiomyoma during cesarean section.
Her post-operative recovery was uneventful and she was discharged, along with her baby, on the seventh day after surgery in a satisfactory condition.