Int J Gynecol Obsret, 1992, 38: 125-129
125
International Federation of Gynecology and Obstetrics
Letters to the Editor Elective cesarean hysterectomy for uterine fibroids To the Editor
January 27th, 1992
Cesarean hysterectomy has not been universally accepted as a popular procedure in obstetrics, mainly because of its association with high morbidity, as most of these cases were done under life-threatening emergency circumstances [ 11. Nevertheless, in countries where there is a high incidence of uterine fibroids, it is possible that women can benefit from this two-in-one procedure. We selected patients who had an obstetric indication for cesarean section, suffered from symptomatic uterine fibroids, and had no desire for future pregnancies. The eight patients who were identified had a mean age of 37.9 years (range 31-45 years). There was zero mortality and negligible morbidity. The mean operating time was 88 min and there was a mean blood loss of 863 ml. Five patients received blood transfusions (Table 1) and the anemia of one patient who refused blood transfusion and whose post-
operative hemoglobin fell to 6.1 g/d1 was eventually corrected with oral hematinics. Elective cesarean hysterectomy has been found to be an uncommon procedure, and except for a large series in the United States [2], very few have been done for uterine fibroids. Plauche et al. [2] did 4 in 93 cases and Sturdee and Rushton [3] documented 5 out of 12 in their 15-year series. Fibroids are one of the most common indications for hysterectomy among black populations, and so this option warrants consideration. The selection criteria should be stringent as surgery is longer and is associated with more bleeding than is elective cesarean section. Two units of blood must be available, as there is usually heavy but short-lived intraoperative bleeding. Asymptomatic fibroids in pregnancy should not be an indication for this procedure. For these women, delivery should be vaginal cesarean section performed only if
Table 1. Elective cesarean hysterectomy: surgical outcome. Pre-op Hb (g/d])
Duration of surgery (min)
Blood loss (ml)
Units transfused
Post-op Hb (g/d0
Hospital stay (days)
Birthweight (kg)
13.8 10.4 11.3 10.2 12.5 12.5 11.1 10.2
75 105 15 90 90 90 75 105
SO0 1000 500 700 800 1000 1200 1200
0
13.0 9.7 10.3 8.5 10.6 11.4 7.3 6.1
4 7 5 4 4 6 6 6
2.95 3.5 2.25 3.15 3.40 4.10 3.42 3.13
1 1
1 1 2 1 0
Keywords: Elective cesarean hysterectomy; Fibroids.
Inr J Gynecol Obsret 38
126
Lerters to the Editor
there is an obstetric indication, and tubal ligation should be rendered if sterilization is requested. Our average hospitalization was 5.25 days, compared with 7.1 days in a North American study [2]. In Trinidad, where bed space is limited, this is a major concern. An intangible advantage is that trainees benefit by participating in the operation under an elective setting, which may prove invaluable when they have to cope with the eventual emergency. Our analysis supports the option of an elective cesarean hysterectomy in women under the circumstances outlined above. We recommend that obstetricians consider this approach when faced with pregnant patients suffering with uterine fibroids. G.V. Nar~~yaushgh S. Ramsewak w. Kissoon
2
3
Park RC, Duffy WP: Role of caesarean hysterectomy in modern obstetric care. Clin Obstet Gynecol23: 601, 1980. Plauche WC, Gruich FG, Bourgeois MO: Hysterectomy at the time of cesarean section: analysis of 108 cases. Obstet Gynecol 58: 459, 1981. Sturdee DW, Rushton DI: Caesarean and postpartum hysterectomy 1968-1983. Br J Obstet Gynecol 93: 270, 1986.
Correspondence
to:
C.V. Narnyansingb Department of Obstetrics and Gynecology University of the West Indies Port of Spain General Hospital Trinidad, West Indies
January
rudimentary uterine horn pregnancy 27th, 1992
A case of noncommunicating rudimentary uterine horn pregnancy is presented. A 20-year-old woman, gravida 2, para 1, was admitted to the hospital in her sixteenth week of gestation because of sudden onset of abdominal pain, nausea and vomiting. She had delivered an immature stillborn infant at 26 weeks of gestation 1 year previously. On admission, there were signs of shock and peritoneal reaction. A tender, 16 weeks pregnant size uterus could be hardly palpated at pelvic examination. A single dead fetus was seen at ultrasonography. The uterine wall could not be demonstrated exactly at the right fundus and a large quantity of fluid was Keyvvordx Uterine rupture; Rudimentary uterine horn pregnancy. Int J Gynecol Obsret 38
1
University of the West Indies Port of Spain San Fernando General Hospital Trinidad
Rupture of noncommunicating To the Editor
References
observed in the abdomen. Detibrinated blood was obtained at culdocentesis. Immediate laparotomy revealed a fetus weighing 600 g with the placenta lying free among the blood and clots. A ruptured right rudimentary horn which was attached to the left hemiuteri with a thick fibrotic band was discovered. No communication between the two cavities was found. Corpus luteum was seen at the right ovary (Fig. 1). Excision of the right rudimentary horn and ipsilateral salpingectomy were carried out. Both kidneys were palpated to be normal, and later a normal intravenous pyelogram was obtained. Five units of whole blood were transfused. Her postoperative convalescence was uneventful. Rudimentary uterine horn pregnancy is rare and its incidence has been estimated between MOO 000 and l/140 000 deliveries [2,4]. Pregnancy can occur only via transperitoneal
125
International Federation of Gynecology and Obstetrics
Letters to the Editor Elective cesarean hysterectomy for uterine fibroids To the Editor
January 27th, 1992
Cesarean hysterectomy has not been universally accepted as a popular procedure in obstetrics, mainly because of its association with high morbidity, as most of these cases were done under life-threatening emergency circumstances [ 11. Nevertheless, in countries where there is a high incidence of uterine fibroids, it is possible that women can benefit from this two-in-one procedure. We selected patients who had an obstetric indication for cesarean section, suffered from symptomatic uterine fibroids, and had no desire for future pregnancies. The eight patients who were identified had a mean age of 37.9 years (range 31-45 years). There was zero mortality and negligible morbidity. The mean operating time was 88 min and there was a mean blood loss of 863 ml. Five patients received blood transfusions (Table 1) and the anemia of one patient who refused blood transfusion and whose post-
operative hemoglobin fell to 6.1 g/d1 was eventually corrected with oral hematinics. Elective cesarean hysterectomy has been found to be an uncommon procedure, and except for a large series in the United States [2], very few have been done for uterine fibroids. Plauche et al. [2] did 4 in 93 cases and Sturdee and Rushton [3] documented 5 out of 12 in their 15-year series. Fibroids are one of the most common indications for hysterectomy among black populations, and so this option warrants consideration. The selection criteria should be stringent as surgery is longer and is associated with more bleeding than is elective cesarean section. Two units of blood must be available, as there is usually heavy but short-lived intraoperative bleeding. Asymptomatic fibroids in pregnancy should not be an indication for this procedure. For these women, delivery should be vaginal cesarean section performed only if
Table 1. Elective cesarean hysterectomy: surgical outcome. Pre-op Hb (g/d])
Duration of surgery (min)
Blood loss (ml)
Units transfused
Post-op Hb (g/d0
Hospital stay (days)
Birthweight (kg)
13.8 10.4 11.3 10.2 12.5 12.5 11.1 10.2
75 105 15 90 90 90 75 105
SO0 1000 500 700 800 1000 1200 1200
0
13.0 9.7 10.3 8.5 10.6 11.4 7.3 6.1
4 7 5 4 4 6 6 6
2.95 3.5 2.25 3.15 3.40 4.10 3.42 3.13
1 1
1 1 2 1 0
Keywords: Elective cesarean hysterectomy; Fibroids.
Inr J Gynecol Obsret 38
126
Lerters to the Editor
there is an obstetric indication, and tubal ligation should be rendered if sterilization is requested. Our average hospitalization was 5.25 days, compared with 7.1 days in a North American study [2]. In Trinidad, where bed space is limited, this is a major concern. An intangible advantage is that trainees benefit by participating in the operation under an elective setting, which may prove invaluable when they have to cope with the eventual emergency. Our analysis supports the option of an elective cesarean hysterectomy in women under the circumstances outlined above. We recommend that obstetricians consider this approach when faced with pregnant patients suffering with uterine fibroids. G.V. Nar~~yaushgh S. Ramsewak w. Kissoon
2
3
Park RC, Duffy WP: Role of caesarean hysterectomy in modern obstetric care. Clin Obstet Gynecol23: 601, 1980. Plauche WC, Gruich FG, Bourgeois MO: Hysterectomy at the time of cesarean section: analysis of 108 cases. Obstet Gynecol 58: 459, 1981. Sturdee DW, Rushton DI: Caesarean and postpartum hysterectomy 1968-1983. Br J Obstet Gynecol 93: 270, 1986.
Correspondence
to:
C.V. Narnyansingb Department of Obstetrics and Gynecology University of the West Indies Port of Spain General Hospital Trinidad, West Indies
January
rudimentary uterine horn pregnancy 27th, 1992
A case of noncommunicating rudimentary uterine horn pregnancy is presented. A 20-year-old woman, gravida 2, para 1, was admitted to the hospital in her sixteenth week of gestation because of sudden onset of abdominal pain, nausea and vomiting. She had delivered an immature stillborn infant at 26 weeks of gestation 1 year previously. On admission, there were signs of shock and peritoneal reaction. A tender, 16 weeks pregnant size uterus could be hardly palpated at pelvic examination. A single dead fetus was seen at ultrasonography. The uterine wall could not be demonstrated exactly at the right fundus and a large quantity of fluid was Keyvvordx Uterine rupture; Rudimentary uterine horn pregnancy. Int J Gynecol Obsret 38
1
University of the West Indies Port of Spain San Fernando General Hospital Trinidad
Rupture of noncommunicating To the Editor
References
observed in the abdomen. Detibrinated blood was obtained at culdocentesis. Immediate laparotomy revealed a fetus weighing 600 g with the placenta lying free among the blood and clots. A ruptured right rudimentary horn which was attached to the left hemiuteri with a thick fibrotic band was discovered. No communication between the two cavities was found. Corpus luteum was seen at the right ovary (Fig. 1). Excision of the right rudimentary horn and ipsilateral salpingectomy were carried out. Both kidneys were palpated to be normal, and later a normal intravenous pyelogram was obtained. Five units of whole blood were transfused. Her postoperative convalescence was uneventful. Rudimentary uterine horn pregnancy is rare and its incidence has been estimated between MOO 000 and l/140 000 deliveries [2,4]. Pregnancy can occur only via transperitoneal
