Dr. Suchitra N. Pandit | A challenging case of Primigravida with 37 weeks of Pregnancy with Multiple Fibroids
A 34 year old primigravida with huge multiple fibroids, under the care of Dr. Suchitra N. Pandit (Consultant - Obstetrics and Gynaecology, KDAH) delivered a baby on 6th December, 2012. Both mother and baby are fine now.The patient was saved from a major catastrophe arising due to severe postpartum haemorrhage leading to obstetric hysterectomy.
A very worried 34 year old primigravida with huge multiple fibroids came to Kokilaben Dhirubhai Ambani Hospital to consult Dr. Pandit for a second opinion as she had been advised termination at 20 weeks by her Gynecologist in view of severe oligohydramnios (reduced liquor) and multiple (8-9) large intramural fibroids uterus, largest measuring 10 x 8.5 x 8.5 cm with average of 5 x 5.5 x 4 cm. Her doctor had the opinion that the baby would not grow and there would be complications in view of fibroids and reduced liquor.
At Kokilaben Dhirubhai Ambani Hospital, Dr. Shefali Shah (Consultant – Radiology, KDAH) rechecked her sonography and decided to take up the challenge of continuing the pregnancy as patient was also keen for the same.The patient was under the care of Dr. Pandit since 20 weeks. Larginine (Amino acids), Sujat and high protein diet were advised to improve the liquor as well as serial growth scans and frequent follow ups were done to ensure the fetal well being. Her liquor improved fairly well. She was also kept on uterine relaxants to avoid preterm labour and steroids (2 doses) for enhancing fetal lung maturity. Baby grew well along with increasing size of multiple fibroids.
Since the main concerns were postpartum haemorrhage (due to the fibroids) and obstetric hysterectomy was a likely possibility, therefore, the Obstetric team had discussed with Dr. Vimal Someshwar (Director – Radiology, KDAH) about reducing the blood loss at delivery with the help of interventional radiology post delivery of the baby. The patient and relatives were counselled accordingly.
An elective LSCS was planned after 37 weeks of pregnancy. Dr. Someshwar did a pre-operative balloon catheterisation of the uterine arteries and later the doctors proceeded for a LSCS under GA keeping blood and ICU ready as precautionary measures. The incisions had to be modified in order to avoid cutting through the fibroids. Once baby was delivered balloon catheters were inflated to reduce the blood loss. Placenta separated easily and the uterus was sutured trying to avoid stitching through fibroids which was tricky as fibroids were occupying the lower uterus segment. Balloon catheters were removed immediately post delivery and the patient was administered additional oxytocics to ensure that uterus contracted well ; postpartum period was also uneventful.
Wound check was done on Day 4; no morbidities like fever, UTI or wound infection. Patient breast fed baby well and will be discharged soon.
Pregnancy with fibroids is a high risk case with a constant threat of preterm labour and pain, besides intrapartum chances of atonic PPH that may not be controlled with routine oxytocic and may require massive blood transfusions, selective devascularisation (uterine artery followed by internal iliac artery ligation) and finally obstetric hysterectomy if all resorts fail.
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