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Aug 2018




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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

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Dr. Anuradha
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On Jan 2020

Important Notice

Case report
Year : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : QD04 - QD06 Full Version

Successful Removal of 147 Fibroids from the Uterus via Abdominal Myomectomy: A Case Report


Published: November 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/64584.18685
Nalini Sharma, Ritisha Basu, Subrat Panda, Wansalan Karu Shullai

1. Associate Professor, Department of Obstetrics and Gynaecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India. 2. Clinical Fellow, Department of Obstetrics and Gynaecology, Ipswich Hospital, Ipswich, United Kingdom. 3. Professor, Department of Obstetrics and Gynaecology, AIIMS, Kalyani, West Bengal, India. 4. Assistant Professor, Department of Obstetrics and Gynaecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India.

Correspondence Address :
Ritisha Basu,
IP38NW, Ipswich, United Kingdom.
E-mail: basu.ritisha312@gmail.com

Abstract

Uterine fibroids are a common gynaecological condition that can sometimes be large and multiple, significantly impacting the affected woman’s quality of life. Managing multiple fibroids in women who want to preserve their fertility can be complex, as myomectomy is more challenging compared to hysterectomy. A 30-year-old woman was admitted with complaints of heavy menstrual bleeding, severe anaemia, and an abdominal mass equivalent to a 36-week gravid uterus. Ultrasound followed by Magnetic Resonance Imaging (MRI) revealed multiple fibroids. Since she strongly desired to preserve her fertility, an abdominal myomectomy was planned. The present case highlights the removal of 147 fibroids from the patient, along with a discussion on the challenges faced during surgery and the postoperative period. The authors emphasises that such cases require a highly multidisciplinary approach and should be performed in institutions with adequate blood banks and intensive care support.

Keywords

Fertility, Haemorrhage, Hysterectomy, Intensive care

Case Report

A 30-year-old female presented at the outpatient department with heavy menstrual bleeding that had been worsening over the past six months. She also complained of extreme fatigue, weakness, palpitations, and had an abdominal mass corresponding to a 36-week gravid uterus. According to her medical history, she was diagnosed with a fibroid uterus during her first pregnancy 10 years ago, after which she underwent a laparoscopic myomectomy in 2016. She had one child who is now 10 years old, and she strongly desired to preserve her fertility. The laparoscopic myomectomy performed six years ago provided relief from her symptoms for a year, but then she started experiencing heavy menstrual bleeding again. The patient tried treatment with Gonadotropin hormone-releasing Hormone (GnRH) analogues and ulipristal acetate, but these methods failed to alleviate her symptoms or reduce the size of her fibroids.

Additionally, during the Coronavirus Disease 2019 (COVID-19) pandemic in 2020-2021, the patient was unable to follow-up on her treatment and instead relied on local herbs to manage her symptoms. The untreated heavy menstrual bleeding for two years resulted in severe anaemia. She received a blood transfusion at a local hospital and was eventually brought to the institution with a Haemoglobin (Hb) level of 2.9 gm/dL, accompanied by extreme fatigue and palpitations. On examination, the patient exhibited severe anaemia, poor nutritional status, and had an abdominopelvic mass that was mobile, firm, non tender, and had irregular contours, almost touching the xiphisternum. Ultrasound revealed multiple uterine fibroids, with the largest one measuring 10×8 cm. Distortion of the endometrial cavity was also observed. MRI of the patient revealed multiple well-defined lesions appearing iso to hypointense on long TR images, originating from the anterior and posterior wall and fundus of the uterus, located intramurally and subserosally, and causing compression of the endometrium (Table/Fig 1).

Due to the presence of multiple fibroids confirmed clinically and via imaging, the patient was advised to undergo a hysterectomy as a safer management option. However, since the patient was keen on preserving her fertility, she opted for a myomectomy after providing informed consent. The informed consent process included discussing the high possibility of requiring multiple blood transfusions, the potential need for an intraoperative hysterectomy, the risk of injury to surrounding organs such as the urinary bladder, ureter, and fallopian tube, as well as the possibility of fibroid recurrence and counselling regarding future reproductive outcomes, such as uterine rupture. Before the surgery, the patient needed a transfusion of eight units of Packed Red Blood Cells (PRBC) to increase her Haemoglobin (Hb) level to 10.5 g/dL. Additionally, 4 units of PRBC, 4 units of Fresh Frozen Plasma (FFP), and 4 units of platelets were reserved in anticipation of significant blood loss during the surgery.

The surgery was performed under general anaesthesia with a midline vertical incision, which had to be extended above the umbilicus for adequate exposure. Upon entering the abdomen, multiple fibroids were observed, distorting the shape of the uterus, with the largest measuring approximately 8×5 cm on the fundus. After assessing the feasibility of a myomectomy and inspecting and palpating the fibroids, the procedure commenced. It was decided not to administer diluted vasopressin (20 Units in 200 mL normal saline) all at once, but rather to inject it in succession around the fibroids just before enucleation. Special care was taken to avoid injury to the fallopian tube. As the enucleation of the fibroids proceeded, the endometrial cavity was opened, as several fibroids had submucosal components. The surgical challenges included complete identification of the fibroids, obliteration of the uterine dead space, achieving haemostasis, and reconstructing the uterus after the removal of 147 fibroids (Table/Fig 2). The surgery lasted for three hours, with an average blood loss of approximately 2.5 litres. During the procedure, the patient required five units of Packed Red Blood Cells (PRBC), five units of Fresh Frozen Plasma (FFP), and five units of platelets. Due to the substantial blood loss, the patient was transferred to the Intensive Care Unit (ICU) and received vasopressor support while being intubated. Extubation took place the following day, and vasopressor support was gradually discontinued 12 hours after the surgery. The patient was initiated on high-dose antibiotics (Piperacillin-tazobactam) and closely monitored for urine output. Deep Venous Thrombosis (DVT) prophylaxis was administered to the patient through anti-DVT stockings immediately after the surgery and via injection of low molecular weight heparin 24 hours later. The patient recovered well from the surgical stress and was transferred from the ICU to the ward on day 3 post-surgery. Histopathological examination revealed multiple leiomyomas. A follow-up appointment after one month demonstrated significant improvement in the patient’s symptoms and quality of life.

Discussion

Uterine fibroids, or leiomyomas, are benign smooth muscle tumours that arise from cells of the uterine myometrium. They are a common gynaecological condition, affecting up to 80% of premenopausal women (1). While many women with fibroids are asymptomatic, those with symptoms often experience heavy menstrual bleeding, abdominal pain, increased abdominal girth, urinary frequency, constipation, recurrent miscarriages, dyspareunia, and sometimes subfertility (2).

Fibroids are a significant health problem among women aged 15-54 years, accounting for 29% of gynaecologic hospitalisations (3). Additionally, fibroids account for 40%-60% of all hysterectomies and 30% of hysterectomies among young women aged 18-44 years (4). Several factors have been associated with an increased risk of developing uterine fibroids. Ethnicity appears to be a significant risk factor, with individuals of black race having a higher incidence of fibroids (1). Other risk factors, such as nulliparity, obesity, polycystic ovary syndrome, diabetes, and hypertension, also contribute to fibroid prevalence (5). Notably, multiple cutaneous and uterine leiomyomatoses have been linked to the fumarate hydratase gene, which codes for a mitochondrial enzyme. Furthermore, cytogenetic abnormalities, particularly deletions of chromosome 7, have been observed in a substantial proportion of fibroid specimens (5).

Uterine-sparing surgery is generally recommended as a treatment for multiple fibroids in women of reproductive age to preserve fertility. In those desiring fertility, myomectomy is typically recommended over Uterine Artery Embolisation (UAE). This is because UAE is associated with a higher rate of re-intervention, a higher likelihood of intrauterine adhesions, and a general lack of evidence regarding fertility and pregnancy outcomes (6),(7). UAE may also sometimes lead to inadvertent embolisation of ovarian vessels, causing a decrease in ovarian reserve and compromising reproductive function (8). However, in women of childbearing age who wish to preserve their fertility, management can be difficult in patients presenting with multiple large fibroids, particularly if a hysterectomy would be the safer and more cautious approach.

The present case report highlights the challenging case of the removal of 147 fibroids from a woman who wanted to preserve her fertility, emphasising the intraoperative and postoperative difficulties faced. Similarly, case reports in the literature discussing the removal of multiple fibroids have focused on the importance of meticulous surgical steps and the significance of decreasing blood flow to the uterus using a tourniquet and vasopressin (9),(10). Additionally, having an accurate understanding of the location of fibroids is necessary for meticulous preoperative planning. Research has shown that MRI has superior sensitivity and minimal measurement discrepancies (11).

Conclusion

The present case highlights that myomectomy in such high-risk cases can be complex and requires multidisciplinary support, including a significant need for blood products and intensive care. Such cases should only be attempted in institutions where such support is available, as timely intervention can save the patient’s life. In the postoperative period, with the background of haemorrhage, higher antibiotics should be administered to prevent sepsis, DVT prophylaxis must be ensured, and urine output should be closely monitored. It is also important to counsel the patient about the risks involved in such cases, especially when a safer alternative surgery, such as hysterectomy, is available. Additionally, one cannot ignore the effect that the COVID-19 pandemic had on this patient, as she went untreated for two years, leading to severe anaemia and the need for such a complex surgery due to the rapid growth of the fibroids.

References

1.
Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. Am J Obstet Gynaecol. 2003;188(1):100-07. Doi: 10.1067/mob.2003.99. [crossref][PubMed]
2.
Gupta S, Jose J, Manyonda I. Clinical presentation of fibroids. Best Practice & Research Clinical Obstetrics & Gynaecology. 2008;22(4):615-26. [crossref][PubMed]
3.
Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in non-gravid women of reproductive age. International Journal of Gynaecology & Obstetrics. 2011;113(1):03-13. [crossref][PubMed]
4.
Marshall LM, Spiegelman D, Barbieri RL, Goldman MB, Manson JE, Colditz GA, et al. Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstetrics & Gynaecology. 1997;90(6):967-73. [crossref][PubMed]
5.
& Okolo S. Incidence, aetiology and epidemiology of uterine fibroids. Best Practice Research Clinical Obstetrics & Gynaecology. 2008;22(4):571-88.[crossref][PubMed]
6.
Tanos V, Berry KE. Benign and malignant pathology of the uterus. Best Pract Res Clin Obstet Gynaecol. 2018;46:12-30. Doi: 10.1016/j.bpobgyn.2017.10.004. Epub 2017 Oct 16. Erratum in: Best Pract Res Clin Obstet Gynaecol. 2018 Mar 14. [crossref][PubMed]
7.
Clements W, Ang WC, Law M, Goh GS. Treatment of symptomatic fibroid disease using uterine fibroid embolisation: An Australian perspective. Aust NZJ Obstet Gynaecol. 2020;60(3):324-29. Doi: 10.1111/ajo.13120. Epub 2020 Jan 20. [crossref][PubMed]
8.
Kim HS, Tsai J, Lee JM, Vang R, Griffith JG, Wallach EE. Effects of utero-ovarian anastomoses on basal follicle-stimulating hormone level change after uterine artery embolization with tris-acryl gelatin microspheres. J Vasc Interv Radiol. 2006;17(6):965-71. Doi: 10.1097/01.RVI.0000220425.23309.15. [crossref][PubMed]
9.
Hasabe R, Tripathi NS, Bhoyar KD. Successful removal of 34 fibroids in uterus-preserving myomectomy: A case report. Int J Reprod Contracept Obstet Gynaecol. 2022;11(6):1775-78. [crossref]
10.
Bekabil TT. Successful removal of 36 fibroids from a uterus: Case report. Clin Case Rep Rev. 2015;1(2):25-26. [crossref][PubMed]
11.
Levens ED, Wesley R, Premkumar A, Blocker W, Nieman LK. Magnetic resonance imaging and transvaginal ultrasound for determining fibroid burden: Implications for research and clinical care. American Journal of Obstetrics and Gynaecology. 2009;200(5):537-e1.[crossref][PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/64584.18685

Date of Submission: Apr 08, 2023
Date of Peer Review: Jul 14, 2023
Date of Acceptance: Aug 23, 2023
Date of Publishing: Nov 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 12, 2023
• Manual Googling: Jul 29, 2023
• iThenticate Software: Aug 21, 2023 (7%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6

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