Incidental myomectomy at time of vaginal delivery contributing to postpartum hemorrhage: A case report and review of the literature.

Background: Uterine leiomyoma are implicated in certain adverse pregnancy related outcomes such as postpartum hemorrhage. Large submucosal leiomyoma defined as greater than 5 cm, may have higher complication rates; however, high quality data is limited.

Case: A 44-year-old gravida 4 with history of two full-term vaginal deliveries presented at 40 and 2/7 weeks of gestation with premature rupture of membranes and delivered vaginally a viable female infant complicated by a postpartum hemorrhage due to uterine atony. During a manual uterine sweep for suspected retained products of conception, a submucosal leiomyoma was incidentally extracted. Uterine hemorrhage immediately ensued, requiring vasopressors, blood transfusion, and intensive care unit admission. Hemostasis was ultimately achieved with placement of a Bakri balloon.

Conclusion: This case reaffirms the association of large (greater than five centimeters) submucosal leiomyoma with severe postpartum hemorrhage. Caution should be taken with patients who have leiomyoma with these characteristics. The use of balloon tamponade in such situations may aid in hemostasis and avoidance of postpartum hysterectomy.