INEVITABLE MYOMECTOMY OF EXTRUDING INTRAMURAL FIBROID DURING CAESAREAN SECTION- A CASE REPORT

Myomectomy during caesarean sections have been avoided routinely in the past in the fear of massive hemorrhagewhich may lead to obstetric hysterectomy. However in the recent times with adequate facilities and expertise, caesarean myomectomies are being performed with good outcomes. Case Presentation: A35-year-oldprimi gravida was diagnosed to have intramural fibroid - anterior 4.6*4.3cm and posterior 1.8cm*2.8cm at 8 weeks of gestation.By 13 weeks, during her NT scan there was increase in the size of anterior wall fibroid 7.0*6.6cm, the rest of NT scan and first trimester screening was normal. She developed early onset intrauterine growth restriction in her anomaly scan. She was conservatively managed as the doppler flow was normal. Her scan at 36 weeks showed estimated fetal weight at 2nd centile with normal doppler flow in breech presentation and an anterior intramural fibroid of size 9.5*8.2cm.Hence an elective caesarean section was planned at 37 weeks.Baby was delivered by breech extraction. Manual removal of placenta was done. As the uterus started contracting, the intramural fibroid started extruding, became submucosal and bulging into uterine edges. Hence planned for myomectomy. Injection vasopressin was injected into the surface of myoma,enucleation of the myoma done and myoma bed closed in 2 layers followed by the closure of uterine edges. Intra operative blood loss was around 800ml. No primary or secondary PPH noted. Patient was discharged on 5th post operative day without any complaints. Conclusions: Routine myomectomy at the time of cesarean section is not a standard procedure worldwide. However, it may be considered in carefully selected patients in centers with good facilities to tackle complications by the experienced obstetricians.