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Journal Pre-proof Focal Invasive Placentation Following Laparoscopic Myomectomy Rebecca Cherniak MD , Ari P. Sanders MD MSc , Ally Murji MD MPH PII: S1553-4650(20)30099-6 DOI: https://doi.org/10.1016/j.jmig.2020.02.008 Reference: JMIG 4069 To appear in: The Journal of Minimally Invasive Gynecology Received date: 31 December 2019 Revised date: 24 January 2020 Accepted date: 13 February 2020 Please cite this article as: Rebecca Cherniak MD , Ari P. Sanders MD MSc , Ally Murji MD MPH , Fo- cal Invasive Placentation Following Laparoscopic Myomectomy, The Journal of Minimally Invasive Gy- necology (2020), doi: https://doi.org/10.1016/j.jmig.2020.02.008 This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc. on behalf of AAGL. Focal Invasive Placentation Following Laparoscopic Myomectomy Rebecca Cherniak MDa, Ari P. Sanders MD MSca,b, Ally Murji MD MPHa a Department of Obstetrics & Gynecology, Mount Sinai Hospital and Women’s College Hospital, University of Toronto, Toronto, ON b Department of Obstetrics & Gynecology, Peter Lougheed Centre, University of Calgary, Calgary AB Corresponding Author: Dr. Ally Murji, MD, MPH, FRCS(C) Assistant Professor, University of Toronto Mount Sinai Hospital Address: 700 University Avenue, 3rd Floor, Toronto, Ontario, Canada, M5G 1Z5 Telephone: 1-416-586-4479 Fax: 1-416-586-4650 Email: [email protected] IRB Approval: Not required (case report). Appropriate patient consent has been obtained. Disclosures Authors RC and AM have no conflicts to disclose. Author AS reports serving as consultant with Medtronic, and consultant and speaker bureau with Hologic. Case Notes A 39-year-old nulligravid woman underwent laparoscopic myomectomy for a 6cm posterior fundal leiomyoma (FIGO Type 2-5). The uterine serosa was incised with monopolar electrosurgery and the myoma was enucleated using a laparoscopic corkscrew with blunt dissection. During this process, the endometrial cavity was entered. The endometrium was reapproximated with absorbable suture in a running fashion. The overlying myometrium was closed in three layers using barbed delayed absorbable suture in a running fashion. Surgery was otherwise uncomplicated. Sonohysterogram completed 3 months postoperatively found a normal cavity. Spontaneous conception occurred six months postoperatively. Ultrasound at 20-weeks gestation documented normal fetal anatomy and a fundal placenta. The patient presented with acute abdominal pain at 31-weeks gestation. Ultrasound revealed possible placental invasion of the posterior uterine wall (Figure 1) and MRI identified two areas of uterine dehiscence at the prior myomectomy site (Figure 2). Caesarean section was performed at 36-weeks gestation. The placenta was seen invading through a 5cm myometrial defect at the prior myomectomy site with no overlying residual myometrium (Figure 3). Following placental extraction, the defect was excised and healthy- appearing adjacent myometrium was reapproximated in three layers (Figure 4). Estimated blood loss was 1000 milliliters. Histopathology confirmed placenta accreta. Comment Laparoscopic myomectomy is often performed to preserve or enhance fertility. However, myomectomy may weaken the myometrium resulting in pregnancy complications. Our case highlights a rare complication of myomectomy: placenta accreta spectrum (PAS) disorder. PAS most commonly occurs following prior caesarean delivery (1). However, PAS has been reported following abdominal/laparoscopic (2-3) and hysteroscopic (4-5) myomectomy. PAS pathogenesis is likely of similar origin involving endometrial-myometrial interface disruption, failure of normal decidualization, and extra-villous trophoblastic infiltration (1). The incidence of placental invasion following myomectomy is reported as being rare (6). While more evidence is needed to understand pregnancy implications following myomectomy, techniques may be employed to maintain myometrial integrity following myomectomy, including multi-layer closure, barbed suture use, avoidance of endometrial cavity entry, and minimizing electrosurgery (8). Regarding pregnancy outcomes, clinicians should be vigilant of the risk of invasive placentation, especially when the placenta implants over the previous myomectomy scar. Such situations may warrant targeted imaging such as expert ultrasound and possible magnetic resonance imaging to screen for invasive placentation. If confirmed, referral should be made to multidisciplinary teams for management (7). When the area of placental invasion is focal, local excision and primary repair may be considered to preserve fertility and avoid morbidity associated with hysterectomy. References 1. Jauniaux E, Ayres-de-Campos D, Langhoff-Roos J, Fox KA, Collins S, FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO Classification for the clinical diagnosis of placenta accreta spectrum disorders: Epidemiology. Int J of Gynaecol Obstet. 2019;146(1):20-24. 2. Warshak CR, Eskander R, Hull AD, et al. Accuracy of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta. Obstet Gynecol. 2006;108(3):573- 581. 3. Al-Serehi A, Mhoyan A, Brown M et al. Placenta Accreta: An Association with Fibroids and Asherman Syndrome. Journal of Ultrasound in Medicine. 2008(11):1623-1628. 4. Tanaka M, Matsuzaki S, Matsuzaki S, Kakigano A, Kumasawa K, Ueda Y et al. Placenta accreta following hysteroscopic myomectomy. Clinical Case Reports. 2016;4(6):541-544. 5. Mathiesen E, Hohenwalter M, Basir Z, Peterson E. Placenta Increta After Hysteroscopic Myomectomy. Obstet Gynecol. 2013;122(2):478-481. 6. Gyamfi-Bannerman C, Gilbert S, Landon MB, et al. Risk of Uterine Rupture and Placenta Accreta With Prior Uterine Surgery Outside of the Lower Segment. Obstetrics & Gynecology. 2012;120(6):1332–1337. 7. Hobson SR, Kingdom JC, Murji A, et al. No. 383-Screening, Diagnosis, and Management of Placenta Accreta Spectrum Disorders. Journal of Obstetrics and Gynaecology Canada. 2019;41(7):1035-1049. 8. Flyckt R, Falcone T. Uterine Rupture After Laparoscopic Myomectomy. J Minim Invasive Gynecol. 2015;22(6):921-922). Figure 1. (file name: mruj6) Transabdominal sagittal ultrasound image of a focal posterior left outpouching defect in the posterior uterine wall at the site of previous myomectomy. Figure 2. (file name: murj4) Sagittal magnetic resonance imaging showing a fundal placenta with 3cm area of placenta invading through the posterior uterine wall with overlying myometrium measuring 1mm (arrow). Figure 3. (file name: IMG_3221) Uterine dehiscence and placental invasion of the posterolateral uterine wall identified at the time of Caesarean section. Figure 4. (file name: IMG_3285) Final uterine view following excision of area of placental invasion from the defect and repair in 3 layers. .