Intraoperative ultrasound assistance during myomectomy in pregnant woman.

Abstract

Intraoperative ultrasound (IUS) can provide diagnostic information to guide and assist surgeons during medical procedures. We report the case of a 37-year-old, nulliparous Caucasian woman, who was referred to our center at 8 weeks' gestation due to severe vaginal bleeding and multiple uterine myomas. Ultrasound examination showed a fundal intramural subserous myoma (157 × 90 mm) causing partial compression of the gestational sac, a left lateral intramural subserous myoma (77 × 76 mm) and a fundal subserous myoma (54 × 38 mm). Smaller myomas were also recorded. Open myomectomy was performed at 14 weeks' gestation due to acute pelvic pain which was unresponsive to medical therapy, and the persistent feeling of abdominal bulkiness. During surgery, IUS was performed to investigate the spatial relationship between the myomas and the gestational sac, the viability of the fetus and the status of the placenta. An ultrasound examiner held a finger probe (intraoperative 7-MHz convex transducer; Aplio I800, Canon Medical Systems, Zoetermeer, The Netherlands) directly onto the uterine serosa, and provided guidance to the surgeon regarding the location of the myomas, the relationship between the myomas and the endometrial cavity, and the best site for surgical incision (Figure 1). Postoperative ultrasound examination showed a regular uterine profile with only one small residual intramural myoma measuring 2 cm that did not affect the gestational sac, and normal fetal heart beat. Histological analysis confirmed the diagnosis of uterine myomas. At the time of writing, the pregnancy was progressing normally. The prevalence of uterine myomas in pregnancy ranges from 0.1% to 12.5% and differs with ethnicity (18% in African-American, 8% in Caucasian and 10% in Hispanic women)1. Most women with a uterine myoma are asymptomatic, however, 10% to 30% develop complications during gestation, at delivery or in the puerperium. Although myomectomy is a feasible procedure during pregnancy, the increased uterine blood flow and volume during pregnancy increases the risk of hemorrhage or miscarriage1. IUS with direct application of a finger probe onto the uterine surface can guide the surgeon to identify the precise location of the myomas, evaluate the relationship between the uterine cavity and the myomas, and allow early detection of perioperative complications, such as intrauterine placental hemorrhage. Previous studies have demonstrated the usefulness of IUS in identifying the location of deep myomas and the best site for uterine incision during laparoscopic myomectomy2, and in evaluating residual myomas after surgery3, 4. Other studies have shown that, during open myomectomy, IUS with direct application of the probe onto the uterine serosa is more efficient than palpation in evaluating residual myomas at the end of the surgery5. No previous publication has reported the use of IUS during myomectomy in a pregnant woman. In conclusion, we have demonstrated that IUS is a safe, easy to perform and valuable tool during myomectomy in pregnant women, as it can help the surgeon identify the location of the myoma and choose the best site for incision, and allows evaluation of the relationship between the gestational sac and the myoma and monitoring of fetal viability during surgery.