Reproductive Outcome Following Abdominal Myomectomy at the University of Port Harcourt Teaching Hospital: A Ten-year Review

ELI S^1,2, ABAM DS², KALIO DGB³, PEPPLE DKO³, NWOSU², GREEN K² and IKIMALO J²

Greener Journal of Medical Sciences, vol. 8, no. 3, pp. 051-056, June 2018

^1,2Mother and Baby Care Global Foundation

²Department of Obstetrics and Gynaecology University of Port Harcourt Teaching Hospital.

³Department of Obstetrics and Gynaecology Braithwaite Memorial Specialist Hospital.

INTRODUCTION

Leiomyomas or uterine fibroids, are the most common tumours in women whether Caucasian or negroid.¹ The causal relationship between uterine fibroids and infertility remains unclear.² It has a variable clinical presentation and its surgical management particularly in our environment is highly influenced by the desires of our women to preserve their uteri.

A 10-year retrospective analysis of all cases of uterine fibroids admitted into the gynaecological ward of the University of Port Harcourt Teaching Hospital was carried out. This was aimed at evaluating the clinical presentation, surgical treatment, post-operative morbidity and reproductive performance of these women.

MATERIALS AND METHODS

Between 1^st January, 2003 and 31^st December 2012, there were a total of 4287 gynaecological admissions at the University of Port Harcourt Teaching Hospital and 523 of those were for uterine fibroids. A retrospective analysis of 447 of these cases whose records were available to us was carried out. Information was obtained from the case records, gynaecological ward and theatre records of the patients. The data obtained includes age, parity, marital status, major symptoms and signs. Others include type of operation, findings at operations, post-operative morbidity and outcome of pregnancy after myomectomy in those patients with associated infertility. All the patients studied were the Negroid Race.

RESULTS

There were 4287 gynaecological admissions during the period under review out of which 523 were for uterine fibroids, thus uterine fibroids accounted for 12.2% of gynaecololical admissions.

Table 1: Ages Distribution of Patients with Uterine Fibroids

Table 1 shows the age distribution of patients with uterine fibroids requiring surgery. The age of the patients ranged from 17 to 55 years. The peak incidence (30.0%) occurred in the age group 31-35 years. Seven patient (1.6%) were aged 20 years and below while 49 patients (10.9%) were above 45 years.

Table 2: Parity Distribution

Table 2 shows parity distribution in 447 cases of uterine fibroids. Nulliparous women contributed the highest incidence of 43.4%.  12.2% 0f cases were in ground multiparous women.

Marital Status

290(65%) of the patients were married, 130(29%) were single; while 18(4%) were divorce and 9 (2%) widowed. 32% (62) of the 194 Nulliparous patients were married.

Table 3: 3A Clinical Features

Multiple percentage features         389   (87.03%)

Single percentage features              58 (12.97%)

3B UTERINE SIZE

3C      LOCATION OF FIBROID

The variable pattern of presentation of uterine fibroid is well illustrated in table 3 (A.B.C).  The main complaints were lower abdominal swelling (51.2%), menorrhagia (31.3%) and infertility (18.4%). These complaints occur singly in 12.97% of cases and in difference combinations in 87.03% cases.

Table 4: Surgery Performed

TABLE 4 is a summary of the various surgical procedures that were performed for uterine fibroids in the study population. Two hundred and seventy three patients (61%) had myomectomy, 165 (37%)  had hysterectomy while 9 patients (2%) had polypectomy. The Total Abdominal Hysterectomy (TAH)    and Bilateral salpingo- oophorectomy was done for 40 postmenopausal women who had suspicious tubes and ovaries.

Pelvic adhesions were recorded in 134 (30%) of cases. Pre and postoperative hysterosalpingo   gram were done for 82patients (18.4%) who had infertility, (and in 61 of these there was no cause identified).

Table 5: Post Myomectomy Morbidity and Mortality

Abdominal swelling, pain and discomfort were found to occur more frequently with increasing uterine size, while menorrhagia dose not bear any constant correlation with the uterine size.  The uterine size at presentation was above twelve weekscyesis in majority (83%) table 3b. Majority (230 cases or 51.45%) of the fibroids were intramural while cervical fibroids were seen in 18 (4.03%) cases table 3c.  The fibroids were multiple in 250 56.08%) of cases and single in 197 or 43.92% of cases.  79 patients (17.6%) had a hemoglobin concentration of less than10.0g/dl and were classified as having anaemia.  Dysmenorrhea was found in 3.8% of cases.

Table 5 show the postoperative morbidity and mortality associated with myomectomy. Anemia was the commonest associated morbidity found in 25% of patients after myomectomy.

The 3 mortalities from myomectomy resulted from uncorrected intra operative anemia from hemorrhage.  The mortality from hysterectomy resulted from severe genital sepsis occurring on the 21^st postoperative day. The post-operative hospital stay ranged from 7to 27 days. The average stay in hospital was 10days.

Table 6: Preganancy Out Come After Myomectomy

Table 6 shows the outcome of pregnancy following myomectomy in those women who presented with infertility without tubal disease or any other cause of infertility. 20 women achieved pregnancy within 2years of surgery. This represents 32.78% of the 61 infertile patients without any other cause of infertility But 24.4% of total (82). Spontaneous abortion occurred in 4 patients (20%), 7 (35%) achieved spontaneous vaginal delivery while 9 (45%) had caesarean delivery.

DISCUSSION

The result of this review showed that uterine fibroids accounted for 12.2% of all gynaecological admission in UPTH between 2003 and 2012. While this may be seen to be high, it is within the range of 7.8% recorded in zaria⁵ and 8.35% in ilesha⁶. The true incidence in any community is however speculative.^1,2 because majority of cases are asymptomatic and may be carried by patients throughout life unnoticed^2,6 .

Majority of the woman (50%) were in the third and fourth decades of life as similarly reported by  other workers ^5,6,7,8 . also this study supports the general observation that fibroids are common in women that are relatively infertile ⁹ and those of low parity ^10,11 as over half (58.8%) were in this  category. It may however occur in women of normal fertility and parity as found in (31.2%) of cases reviewed.

The commonest clinical presentation in this review was lower abdominal swelling. The large size of the tumor consequent upon late presentation in our environment ^3,5,6,7 probably contributes to this clinical feature. Majority (83%) presented when uterine size was above 12 weeks cyesis.

The report of menorrhagia being next to lower abdominal swelling in incidence is in agreement with similar study done in ilesa⁶, Nigeria though other workers have reported it being the commonest presentation in Nigeria women ^3,5,7. The high incidence (74.93%) of intramural and submucous fibroid, causing increasing endometrial surface and accompanying endometrial hyperplasia, however provides explanation for the incidence of menorrhagia (31.3%) observed in the study.

There is a recognized association between uterine fibroids, pelvic inflammatory disease and infertility ^{1, 7,9}  which is higher among the negroid race. Ogunniyi and fasubaa (1990) in Ilesa, Nigeria reported an association of infertility in 51% of patients with uterine fibroids in their series. In this review only 18.4% of patients presented with fertility. A high incidence of pelvic inflammatory disease said to be associated with uterine fibroids may account for the rising incidence of infertility in these patients probably due to tubal factor^10,11,12,13.

Anaemia was found in 17.6% of the patients. It is a known complication of uterine fibroids resulting from menorrhagia. In some cases polycythaemia may occur due to autonomous production of erthropoetin by the myoma cells themselves^8,10. This was not observed in this review.

Dysmenorhoea was noted in 3.8% of the patients in this review. Spasmodic dysmenorhoea is possible when a submucoustumour stimulates expulsive uterine contractions. Severe but one-sided dysmenorhoea can be caused by a single but small fibroid located at the utero tubal junction from which uterine contractions emanate ^8,13.

The reported incidence of recurrent abortions of 2.5% in this review may probably be due to implantation occurring in relation to a submucous fibroid, it has been illustrated that in 0.5% of normal pregnancies, there is coexisting uterine fibroids ^13,15.

Surgery as done in this study still remain the main stay of management of significant proportion of uterine fibroids^5,6,9,11,13. Hysterectomy with or without bilateral salpingo-oophorectomy is curative¹⁷. However unlike in the study done in ilesa, Nigeria where majority (60.1%) had hysterectomy it was only offered to 37% in this study. Myomectomy was utilized for the majority (61%) who still had reproductive and menstrual desire as advised by several workers ^{5, 7, 11, 16}.

Hormones were not employed in any of the patients because of age and size of the fibroid at presentation. These hormones only causes temporary remission, useful only for small fibroids ^17,8,19  and in woman approaching menopause ^19,20,21. In this environment cost is a discouraging factor.

The pregnancy rate following myomectomy for infertile women in this review was 32.78 %,( 24.4% of total). This is within the range of 30-40% reported by other workers. The high caesarean section rate of 45% for those who carried their pregnancy to term is not surprising because of the associated infertility and advanced maternal age ^5,7,11.

 The clinical presentation of uterine fibroids as documented in this study is similar to that of previous authors from other parts of Nigeria ^3,5,6,11,17. In our environment the surgical treatment of choice is myomectomy which carries a greater postoperative morbidity than hysterectomy¹⁷. It is possible that with availability of modern medical and surgical technique post-operative morbidity from myomectomy in our Centre would so reduce as to improve the reproductive performance of those infertility cases ^6,11,12,22 .

ACKNOWLEDGEMENT

1.   MOTHER AND BABY CARE GLOBAL FOUNDATION

2.   PRIME MEDICAL CONSULTANTS, PORT HARCOURT RIVERS STATE, NIGERIA

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