Laparoscopic myomectomy during pregnancy resulting in septic necrosis of the myometrium

Abstract

Case reportA 35 year old primiparous woman attended the emer-gency department at 17 weeks of gestation for acute rightiliac fossa pain with guarding. Rebound pelvic examinationwas painful. The patient’s temperature was 38.6jC andlaboratory tests showed no leucoytosis. Ultrasound re-vealed a single intrauterine viable pregnancy equivalentto dates and additionally a uterine mass in the left lateralwall of the uterus, 5 cm in length. Due to a suspectedadnexal torsion, a laparoscopy was performed, whichrevealed a degenerating pedunculated uterine leiomyomawithout torsion of the pedicle. It was situated on theanterior surface of the uterus below the right uterine cornu.Because the woman was so symptomatic, myomectomywas performed by resection of the myoma using monopolarcutting diathermy via a hook electrode with a 40 W poweroutput. Despite the insertion of an endoloop constrictingthe pedicle prior to electroresection, the top of the pediclewas slightly electrocoagulated to ensure perfect hae-mostasis. The uterine cavity was not opened. The myomawas extracted via a transumbilical approach, by morcella-tion. Histological examination confirmed the diagnostic ofaseptic degeneration of uterine leiomyoma. Abdominalpain occurred six days post-operatively, with associatedileus and pus at the umbilical incision but with no fever.The umbilicus was irrigated with Betadine and penicillin Vwas started. Clinical improvement occurred and she wasdischarged from hospital. She returned two weeks laterwith an intestinal obstruction mass in the right iliac fossaand a recurrence of umbilical infection. Ultrasound exam-ination showed collection of 10 cm diameter, comparedwith the area of myomectomy extending to the neighbour-ing myometrium. Laparotomy was performed via an umbil-ical median incision and revealed an abscess on the anteriorsurface of the uterus. It was situated on the scar of thepedicle of the resected myoma. Following peritoneal lavage,a full thickness of myometrium was lost due to uterinenecrosis. An area approximately 7 2 cm of the amnioticsac was clearly visible (Fig. 1). The edges of the defectwere brought together with three slow absorption stitches.The remainder of the abdominopelvic cavity was normal.The right iliac fossa was drained using a natural rubbercorrugated drain (Peters Laboratories, France). Parenteralantibiotics were initiated with piperacilline and tazobactam,gardenerella vaginalis, peptostreptococcus and anaerobicnegative gram bacillus were obtained on bacteriology. Oralmedication (amoxicilline and clavulanic acid) was contin-ued for three weeks. Tocolysis was achieved using indo-methacin following laparatomy. The remainder of thepregnancy was normal. The woman was readmitted at ges-tation for 37 weeks to elective caesarean section. The babyweighed 3530 g with an Apgar score of 10 at 5 minutes oflife. During the caesarean section, adhesions were identifiedin the right iliac fossa and were divided. There was noobvious defect in the uterine wall. There was a placentaaccreta and removal of placenta was distinct. The area ofaccreta was adjacent to the previous myomectomy. Due toprofuse arterial bleeding from this area, the uterine pedicles,