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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 30  |  Issue : 5  |  Page : 620-622

Myomectomy during laparotomy for ruptured tubal pregnancy in a low-resource setting


1 Department of Obstetrics and Gynaecology, Afe Babalola University, Federal Teaching Hospital, Ido Ekiti, Nigeria
2 Department of Surgery, Afe Babalola University, Federal Teaching Hospital, Ido Ekiti, Nigeria

Date of Submission12-Feb-2021
Date of Decision12-Aug-2021
Date of Acceptance14-Aug-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Adebayo Augustine Adeniyi
Department of Obstetrics and Gynaecology, Afe Babalola University, Federal Teaching Hospital, Ido Ekiti
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_35_21

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  Abstract 


The traditional management of ruptured ectopic pregnancy has been limited to the removal of the gestational sac, securing hemostasis, and restoring hemodynamic stability with no room for the performance of other procedures such in myomectomy at the same setting. We present a case of a 37-year-old nulliparous woman who was referred for myomectomy on account of symptomatic uterine fibroids but was found to have coexisting ectopic pregnancy at presentation. She had successful total salpingectomy and myomectomy at the same laparotomy. This case demonstrated that myomectomy can be safely performed during the surgery for ruptured ectopic pregnancy in well-selected patients.

Keywords: Myomectomy, ruptured tubal pregnancy, salpingectomy


How to cite this article:
Adeniyi AA, Adeyemo OT, Ayankunle MO, Okunlola AI. Myomectomy during laparotomy for ruptured tubal pregnancy in a low-resource setting. Niger J Med 2021;30:620-2

How to cite this URL:
Adeniyi AA, Adeyemo OT, Ayankunle MO, Okunlola AI. Myomectomy during laparotomy for ruptured tubal pregnancy in a low-resource setting. Niger J Med [serial online] 2021 [cited 2021 Nov 29];30:620-2. Available from: http://www.njmonline.org/text.asp?2021/30/5/620/327960




  Introduction Top


About 12.5%–18% of uterine fibroids occur in pregnant women.[1],[2],[3] Myomectomy is often associated with significant blood loss and anemia.[2] The risk of bleeding is the main reason why myomectomy is avoided during other procedures such as cesarean delivery.[3],[4] On the other hand, the recommended treatment of ruptured tubal pregnancy has been “to open up the abdomen quickly, ligate the affected tube promptly, secure hemostasis, and close up the abdomen promptly”[5] as the poor clinical state of most patients often precludes any other procedures that may potentially benefit the patient.


  Case Report Top


A 37-year-old nulliparous woman was referred from a primary health-care center for myomectomy on account of abdominal swelling, heavy menstrual flow and ultrasound confirmed uterine fibroids. At presentation, she confirmed the history of progressive abdominal swelling of three years, heavy menstrual loss of six months and two years history of subfertility. She developed abdominal pain a few days before presentation, which was mainly located in the left iliac fossa. The menstrual cycles were regular except for the previous two cycles which were described as irregular. She was not a known hypertensive or diabetic. She gave no history of previous surgery. She was married to a 42-year-old public servant in a monogamous setting. She neither drank alcohol nor smoked cigarette. On physical examination, she was mildly pale, otherwise, the findings and the vital signs were normal. Abdominal examination revealed a 22-week pregnancy size suprapubic mass with tenderness in the left iliac region and associated guarding. The liver and the spleen were not enlarged and the kidneys were not ballotable. Pelvic examination revealed normal vulva and vagina and the cervical motion tenderness was equivocal. An initial impression of large uterine fibroids complicated by degenerative changes was made. A repeat ultrasound scan done confirmed multiple uterine fibroids with an empty uterine cavity and a left complex adnexal mass. A subsequent qualitative serum pregnancy test prompted by the history of irregular menstruation, undue abdominal tenderness and complex adnexal mass was positive. Based on the clinical and laboratory findings, a diagnosis of ectopic pregnancy was further entertained and a decision to perform exploratory laparotomy was taken, as facilities for laparoscopy were not available. The packed cell volume (PCV) was 29%. Two units of blood were crossed matched and kept for the surgery. At surgery, there was a hemoperitoneum of about 500 ml and a ruptured left ampullary ectopic pregnancy, with the gestational sac partly occluding the defect in the  Fallopian tube More Details [Figure 1]. Other findings included an enlarged uterus with two fibroid nodules (12 cm and 8 cm) at the fundus and anterior surface respectively [Figure 1] and [Figure 2]. A left total salpingectomy was performed, hemostasis was ensured and peritoneal lavage was done. After the completion of the salpingectomy, the condition of the patient was re-assessed and found to be stable. The uterine fibroids were also examined and found to be just two in number and mainly subserous and intramural in location [Figure 2] and [Figure 3]. Based on the hemodynamic stability of the patient, a decision was taken to remove the fibroids since the initial reason for referral was for myomectomy. Provision was then made for additional compatible 2 units of blood in case transfusion becomes necessary. A tourniquet (size 22 Foley's catheter) was applied around the cervico-isthmic region of the uterus. The two fibroid nodules [Figure 3] were then enucleated in turns and the cavities were closed in layers to ensure hemostasis. The vital signs parameters remained normal throughout the surgery, and she recovered promptly from anesthesia. Based on the minimal blood loss at surgery and a postoperative PCV of 28%, she was not transfused with blood. The postoperative period was uneventful and she was discharged on the fourth postoperative day in good clinical condition. At a follow-up visit a week later, the PCV was 30% and she was in a good clinical state.
Figure 1: The ectopic pregnancy and the fibroid at laparotomy (original)

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Figure 2: The fibroids before myomectomy (original)

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Figure 3: The removed fibroids and the gestational sac (original)

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  Discussion Top


The high prevalence of uterine leiomyoma, especially among the black population[3] makes it inevitable that it will sometimes coexist with other gynecological or obstetric conditions such as ectopic gestation. Most of the debates in literature have been on myomectomy during the cesarean section.[6] In the past myomectomy during cesarean section has been discouraged to prevent undue morbidity primarily resulting from hemorrhage as both procedures could be associated with significant intraoperative bleeding.[7] The few reports about myomectomy performed along with salpingectomy have been limited to un-ruptured or chronic ectopic pregnancy with small solitary pedunculated fibroids which were managed laparoscopically.[8] The present case involved the removal of fairly large fibroids. The good outcomes recorded with cesarean myomectomy[6] have probably encouraged the performance of myomectomy during other potentially risky gynecological conditions such as ectopic pregnancy as reported here. Many innovations have also been developed to reduce blood loss at myomectomy, such as the application of a tourniquet to reduce blood flow to the uterus as was done in this case. This method in its different variants such as single tourniquet,[9] triple tourniquet,[2] absorbable cervical tourniquet,[10] and use of tranexamic acid as an adjunct to the tourniquet[11] techniques have been quite effective in reducing the morbidity associated with myomectomy. The present case shows that myomectomy could be performed safely during the management of ectopic pregnancy in selected cases. The criteria for the selection of such cases should include; hemodynamically stable patients, solitary or few fibroid nodules, and preferably subserous fibroids. The performance of such opportunistic myomectomies will reduce the exposure of patients to anesthesia and repeat surgery with its attendance complications. It will also reduce the cost of surgical expenses, especially in low-resource settings where payment for healthcare is mostly out of pocket.


  Conclusion Top


The performance of myomectomy during other obstetric and gynecological procedures such as salpingectomy for a ruptured tubal pregnancy is safe in well-selected cases with the application of blood conserving techniques such as a tourniquet.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: A systematic review. BJOG 2017;124:1501-12.  Back to cited text no. 1
    
2.
Mehdizadehkashi A, Tahermanesh K, Rokhgireh S, Astaraei V, Najmi Z, Rakhshande M, et al. Uterine isthmus tourniquet during abdominal myomectomy: Support or hazard? A randomized double-blind trial. Gynecol Obstet Invest 2020;85:396-404.  Back to cited text no. 2
    
3.
Bhagavath B, Lindheim SR. Options for controlling blood loss during myomectomy. Fert Steril 2019;111:894.  Back to cited text no. 3
    
4.
Nazdar R. Success and safety of caesarean myomectomy in women with single uterine myoma. J Gynaecol Women's Health 2021;21:556054. doi: 10.19080/JGWH.2021.21.556054.  Back to cited text no. 4
    
5.
Bhagavath B. Surgical management of ectopic pregnancy. In: Goldberg J, Nezhat C, Sandlow J, editors. Reproductive Surgery: The Society of Reproductive Surgeons' Manual. Cambridge: Cambridge University Press; 2018. p. 55-62. doi: 10.1017/9781108150064.009.  Back to cited text no. 5
    
6.
Zhao R, Wang X, Zou L, Zhang W. Outcomes of myomectomy at the time of cesarean section among pregnant women with uterine fibroids: A retrospective cohort study. Biomed Res Int Vol. 2019, Article ID 7576934, 6 pages,2019. Available from: https//doi.org/10.1155/2019/7576934. [Last accessed on 2021 Sep 22].  Back to cited text no. 6
    
7.
Shah NH, Paranjpe S, Shah VN. Ectopic pregnancy with myomectomy managed laparoscopically. JPGO 2016;3:12.  Back to cited text no. 7
    
8.
Davidson JZ, Bennett TA, Jaffe IM. Laparoscopic myomectomy for haemoperitoneum from uterine leiomyoma with concomitant tubal abortion: A case report. J Reprod Med 2013;58:438-40.  Back to cited text no. 8
    
9.
Al RA, Yapca OE, Gumusburun N. A randomized trial comparing triple versus single uterine tourniquet in open myomectomy. Gynecol Obstet Invest 2017;82:547-52.  Back to cited text no. 9
    
10.
Scott P, Talor A, Yoong W, Magos A. Absorbable cervical tourniquet at open myomectomy: A pilot study. J Gynaecol Surg 2004;33-4. Available from: https//doi.org/10.1089/1042406041422253. [Last accessed on 2021 Sep 22].  Back to cited text no. 10
    
11.
Abdul IF, Amadu MB, Adesina KT, Olarinoye AO, Omokanye LO. Adjunctive use of tranexamic acid to tourniquet in reducinghaemorrhage during abdominal myomectomy – A randomized controlled trial. Eur J Obstet Gynaecol Rep Biol 2019;242:150-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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