CASE REPORT

CAESAREAN HYSTERECTOMY DUE TO

UTERINE ATONY ON PREGNANCY WITH
Zulmaeta, M.D, OBGYN(C) / Rahimi Rahim, M.D
Department
of Obstetric
and Gynecology,
Achmad RegionalHOSPITAL
Hospital
UTERINE
MYOMA
INArifin
TERTIER
1. INTRODUCTION
Uterine myomas are common in women of reproductive age. These
benign neoplasms may become symptomatic and can result in subfertility among
those trying to become pregnant. Hysterectomy is the most frequent surgical
treatment for symptomatic myomas, and myomectomy is the choice for women
desiring uterine preservation or future pregnancies.1
Myomas are often described according to their location in the uterus,
although many fibroids have more than one location designation.2

Approximately 10% to 30% of women with uterine myomas develop

complications during pregnancy.3 Early miscarriage is more common in women
with fibroids located in the uterine corpus (body) than in the lower uterine
segment and in women with intramural or submucosal fibroids.4

3. CASE DISCUSSIONS
Patient had pregnancy loss 2x at her first and third pregnancy on her
second month of pregnancy. Spontaneous miscarriage rates are greatly
increased in pregnant women with uterine myoma compared with control
subjects without uterine myoma.4 The size of the uterine myoma does not affect
the rate of miscarriage, but multiple uterine myomas may increase the
miscarriage rate compared with the presence of a single uterine myoma only. 4
The location of the myoma may also be important. Early miscarriage is more
common in women with myoma located in the uterine corpus (body) than in the
lower uterine segment and in women with intramural or submucosal uterine
myoma. The mechanism by which uterine myoma cause spontaneous abortion is
unclear. Increased uterine irritability and contractility, the compressive effect of
myoma, and compromise to the blood supply of the developing placenta and
fetus have all been implicated.6
Obstetric and neonatal outcomes in women undergoing myomectomy in
pregnancy are comparable with that in conservatively managed women,
although women who had a myomectomy during pregnancy were far more likely
to be delivered by cesarean due to concerns about uterine rupture.
Myomectomy at the time of
cesarean delivery should only be
performed if unavoidable to
facilitate safe delivery of the
fetus
or
closure
of
the
hysterotomy.
Pedunculated
subserosal fibroids can also be
safely removed at the time of
cesarean
delivery
without
increasing
the
risk
of
hemorrhage.2
Pregnant
women
with
uterine myomas are significantly
more likely to develop preterm
labor and to deliver preterm than
women without myoma. Multiple
uterine myomas and myomas
that contacting the placenta
appear to be independent risk
factors for preterm labor. In
contrast, myoma do not appear
to be a risk factor for preterm
premature
rupture
of
membranes (PPROM).
Myomas may distort the
uterine
architecture
and
interfere
with
myometrial
contractions leading to uterine
atony
and
postpartum
hemorrhage.
This
same
mechanism may also explain
REFERRENCES
women
with myomas
are at
1. Michael C. Pitter, Antonio R. Gargiulo, et al. Pregnancy outcomes followingwhy
robot-assisted
myomectomy.
Human reproduction,
2013; Vol.28: 99-108.
increased
risk Eur
ofJ Obstet
puerperal
2. Downes E, Sikirica V, Gilabert-Estelles J, et al. The burden of uterine fibroids
in five European countries.
Gynecol
Reprod Biol 2010; 152:96.
hysterectomy.
3. Hee Joong Lee, Errol R. Norwitz, et al. Contemporary Management of Fibroids in Pregnancy. Obstet Gynecol. 2010; 3(1): 20-27.
4. Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from
conception to delivery. Am J Obstet Gynecol 2008; 198:357.
5. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009;
91:1215.
6. Casini ML, Rossi F, Agostini R, Unfer V. Effects of the position of fibroids on fertility. Gynecol Endocrinol. 2006;22:106-109.
7. Surrey ES, Minjarez DA, Stevens JM, Schoolcraft WB. Effect of myomectomy on the outcome of assisted reproductive
technologies. Fertil Steril. 2005;83:1473-1479.
8. Celik C, Acar A, Ciek N, et al. Can myomectomy be performed during pregnancy? Gynecol Obstet Invest. 2002;53:79-83.

University of Indonesia - University of

Riau

2. CASE ILUSTRATION
Mrs. D, 35 y.o, came to Arifin Achmad hospital due to reguler contraction
since 12 hours B.A. Patient had hypertension in pregnancy since 1 day B.A, but
refused to get treatment from hospital. Hystory of severe preeclampsia in 4 th
pregnancy. Its 8th month of pregnancy, forgot LMP, routine antenatal every
month, 4 times US exam.
Obstetric hystory : G5 P2 A2, 2 live children
1. 2009, spontaneous abortion, curretage (-), Arifin Achmad hospital
2. 2009, baby girl, 2400 grams, Cesarean section due to PPROM + uterine
myoma, Arifin Achmad hospital
3. 2013, spontaneous abortion, curretage (-), Arifin Achmad hospital
4. 2014, baby boy, 3100 grams, Cesarean section due to uterine myoma +
Severe preeclampsia at Zainab Hospital
5. This pregnancy
Physical Exam:
Good condition, composmentis
BWBP 50 kg, RBW 63 kg, Height 152 cm, BMI 21,6
Haemodynamic state: BP 180/100 mmHg, HR 94 bpm, RR 18 bpm, Temp
36.6 0C Proteinuri +3 Severe preeclampsia.
General state: edema +/+
Obstetrical State: Fundal height 29 cm, back at the right side, head
presentation, at pelvic inlet. Contractions 3x10/40, FHR 124 bpm, EFW 2480
gram.
I: vulva/uretra within normal limit
Vt: thin portio, dilatation 6cm, amniotic membran (+), fetal head Hodge I.
Laboratory Findings: CBC 9,7/30,7/12.300/338.000 RBG 113
8/4

CT/BT :

US Exam: Singleton live head presentation, FHR (+), FM (+)

Fetal biometry: 79.3/291/285/63.5 mm. ~ 32-33 wga. EFW 2083 gram.
Placental implantation at fundal. AFI 7,2 cm.
Umbilical artery flow within normal limit(SDAU 2,94)
Hipo-hiperechoic with clear border feature at posterior uterine body,
PREGNANCY
OUTCOME
90x100x110 mm, suspect uterine myoma.
Baby girl, 2150 grams,
Height 43 cm, AS 5/8
BS~ 32-34 wga
Greenish and scanty
amniotic fluid
placental born
completely, 400 grams
umbilical cord length 48
cm.

Intramural myoma
at posterior uterine
body,
14x10x9cm

HYSTERECTOMY ILUSTRATION

HYSTERECTOMY OUTCOME
Anterior

Posterior, intramural
myoma, 14x10x9 cm

Intramural myoma, partial red

degeneration.