A 36-year-old, morbidly obese primigravida presented at our emergency room at 17 + 0 weeks of gestational age complaining of abdominal pain. At clinical examination, the uterus appeared to be of higher volume compared to the gestational age, the abdomen was painful but treatable, and the obstetrical examination was normal. The patient was then referred to US Unit of our Department for further evaluation. The sonographic assessment revealed the presence of three subserous uterine myomas located on anterior wall (maximum diameter: 13.2 cm), the right wall (maximum diameter: 12.6 cm), and the left wall (maximum diameter: 11.7 cm) of the uterus, respectively. All myomas were vacuolated inside as for suspected necrosis. The scan also showed other multiple myomas less than 3 cm in size. Vital signs were monitored (blood pressure 140/90 mmHg, maternal heart rate 124 bmp, SO2 94%, apyretic). Amniotic fluid was normal and fetal well-being was preserved. Thus, the patient was admitted to the High-Risk-Pregnancy Unit. When collecting the medical history, the first trimester ultrasound scan, performed at 11 weeks' gestation, revealed the presence of the same lesions with a size of 10.8 cm, 10.2 cm, and 6.14 cm, respectively.
Laboratory studies demonstrated rising inflammatory markers (C-reactive protein: 354 mg/L; WBC: 16.92 x 103 muL).
Due to the persistence of the symptoms, despite of two days of analgesic, antispastic, and antibiotic therapy, after multidisciplinary discussion, and a thorough counseling to inform the parents of the surgical and postoperative risks connected with uterine surgery during the gestation, the patient underwent surgery. Laparotomy approach by longitudinal skin incision, considering the volume and the position of the myomas, was performed under general anesthesia. Three huge bulky subserous pedunculated myomas were evidenced, the largest located at the uterine fundus, with a maximum diameter of 15 cm and a torsion of its pedicle (Figure 1). Furthermore, intra-abdominal adhesions were found within peritoneal cavity. Blunt dissection was undertaken to free the omentum and look for the appendix, which was normal. The three large myomas evidenced by ultrasound were removed and sent for pathologic examination. A pelvic drainage was left and removed 24 hours postoperatively. Pathology showed widespread phenomena of necrosis, especially in the myoma with torsion of its pedicle.
During the following nine days, the patient received antibiotics, low molecular heparin, and progesterone, and fetal heartbeat was checked daily. Considering the improvement in clinical condition, the patient was discharged with an indication to treatment with progesterone and low molecular heparin.
Three weeks later, at 21 weeks' gestation, the patient was admitted again due to abdominal pain. Obstetrical evaluation revealed cervical effacement and the transvaginal ultrasound scan showed a reduction of cervical length (18 mm), funneling, and sludge. An ultrasound scan was performed showing good fetal variables. Consequently, the therapy with progesterone was increased. The patient had a positive vaginal culture for Staphylococcus haemolyticus, urine culture was negative, and C-reactive protein resulted to be positive. Therefore, antibiotic therapy with macrolides was given, according to antibiogram result. A cervical cerclage was proposed to the patient, but she refused to undergo the procedure.
Hospitalization lasted for seven days; then the woman was discharged due to an improvement of her clinical condition. The patient underwent obstetric evaluation every two weeks until she presented in labor and delivered vaginally at 38 + 1 weeks' gestation a healthy female newborn of 2940 g, appropriate for gestational age according to national growth curves. Apgar score was 9/10 at 1' and 5' respectively.
To identify potentially eligible studies, we searched PubMed, Scopus, and Cochrane Library (all from inception to 16 March 2017). No language restrictions were initially applied. We used a combination of key words and text words represented by "myomectomy," "myoma," and "pregnancy."
Two reviewers (Annachiara Basso and Mariana Rita Catalano) independently screened the titles and abstracts of records retrieved through database searches. Both reviewers recommended studies for the full-text review. The screen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessed for inclusion in the systematic review. Disagreements between reviewers were resolved by consensus. For all full-text manuscripts, reference lists were analyzed in order to find additional eligible studies.