The differential diagnosis of abdominal pain during pregnancy encompasses both gynecologic and non-gynecologic etiologies [9]. Gynecologic etiology includes spontaneous abortion, threatened preterm delivery, ovarian torsion, inflammatory pelvic disease, whereas non-gynecologic etiology includes appendicitis, cystitis, urinary tract stones. The large size of the myoma and the distance between the placenta and the myoma are associated to adverse obstetric outcomes [10]. However, our case shows that also small myomas located far from the placenta can worsen and may require surgical management. Surgical management is deemed necessary if pain persists for more than 72 hours due to possible necrosis and peritoneal inflammation [11]. Ultrasound is the diagnostic method of first line, but magnetic resonance might be necessary if ultrasound images are unclear. In our case, both the two ovaries were not visualized by ultrasound, thus we performed magnetic resonance, which clearly showed the torsion of a small peduncolated myoma. Since conservative management failed, the woman underwent surgery because the untreated torsion of myoma leads to necrosis, infarction, and peritonitis, resulting to significant maternal morbidity [4].

A very recent systematic review shows that only 70 cases are described in literature, of which in 60 cases laparotomy was chosen, while only 10 were subjected to laparoscopy [5]. The size of myomas ranges from 4 to 40 cm and the gestational age at which the myomectomy is performed, ranges from 8 to 26 weeks. The vast majority of women delivered at term by cesarean section and only 3 pregnancies ended with spontaneous abortion. With regard to the surgical procedure, the choice between laparotomy and laparoscopy is still debated [5]. Given the current lack of evidence-based guidelines concerning the route of myomectomy during pregnancy, we preferred the laparotomic approach. In our case, laparotomic myomectomy was safely performed, but was probably associated to fetal malpresentation.

Long bones fractures are unpredictable complications of the birth-related injury and can still happen by cesarean section during breech extraction [12]. Although there is paucity of data because of its rarity, humerus fracture is generally associated with vaginal breech delivery and emergency cesarean section. To our knowledge, this is the second case of humerus fracture after elective cesarean section. In the previous case [12], cesarean section was performed for transverse lie and the operating obstetrician reported difficult extraction of the baby, inverted T extension was needed and disengagement of the right hand by traction was performed. Similarly, in our case, fetal extraction was difficult, but no energetic traction was applied on the upper limbs. We hypothesized that spontaneous dislodgment of the fetal arm, which occurred twice, might have led to humerus injury. Obstetric risk factors that may predispose to long-bones fractures are prematurity, instrumental delivery, macrosomia, malpresentation, abnormal lie, and multiple pregnancy [7]. In our case, the transverse lie might have led to arm dislodgment and consequently humerus fracture occurred.

Clinical findings of humerus fracture should be promptly differentiated from brachial plexus injury, since postnatal remodeling is very rapid, effective and rarely fails to heal when humerus fracture is detected early [12].  In our case, although brachial plexus injury was suspected during the initial examination, the correct diagnosis was promptly obtained by radiography. Pediatricians should be aware that in the setting of complicated deliveries, both vaginally and abdominally, complete examination of the newborn should include careful investigation of the limbs, even if excessive traction and rotation are not applied to the forarm.

In conclusion, our case report shows that antepartum laparotomic myomectomy is a safe procedure when uterine myoma is subserosal. However, the surgical procedure might lead to fetal malpresentation. During elective cesarean section spontaneous fetal movements can lead to humerus fracture. Because fetal movements are unpredictable, we believe that we could have not neither prevented nor avoided birth injury. Parents should be counseled that cesarean section has been reported to reduce the incidence of birth injury, although long bones fractures are rare but still known complications during planned cesarean section. However, appropriate investigation and management prevent future deformities and disabilities.

Authors’ contribution:

• C. Rossi: project development, manuscript writing;
• Anfossi and G. Dicuonzo: collected data about the pregnancy, commented on the previous versione of the manuscript;
• Martino and G. Lovascio: collected data about the antepartum myomectomy, commented on the previous versione of the manuscript.

All the Authors read and approved the final version, and gave final consensus on the publication.
The patient gave written informed consent to the potential publication.

Statement and declaration: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. The Authors have no conflict of interest to declare.