Spontaneous uterine rupture at 35 weeks' gestation, 3 years after laparoscopic myomectomy, without signs of fetal distress

Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review

The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.

Myoma praevia and pregnancy

The association of myoma and pregnancy is becoming more frequent due to the increasing age of first pregnancy. It may affect the outcome of fertility, pregnancy, labor and peripartum course. A 37 years old patient was referred to our unit for discovering uterine leiomyoma at 37 weeks of pregnancy. Ultrasound screening showed a praevia isthmic leiomyoma measuring 16cm. A caesarean delivery was scheduled and a large interstitial isthmic uterine myoma measuring 25cm was found. Hysterectomy was corporeal. The post-operative and puerperium course was normal.

Laparoscopic uterine surgery as a risk factor for uterine rupture during pregnancy

The incidence of uterine rupture through a previous cesarean scar (CS) is declining as a result of a lower parity and fewer options for vaginal birth after cesarean. However, uterine ruptures attributable to other causes that traumatize the myometrium are on the rise. To determine whether changes in the causes of uterine rupture had occurred in recent years, we retrospective retrieved the clinical records of all singletons with uterine rupture observed in the delivery room of a Taiwanese tertiary obstetric center over a 15-year period. The overall uterine rupture rate was 3.8 per 10,000 deliveries. A total of 22 cases in 20 women (with two of them experiencing two episodes). Seven uterine ruptures occurred through a previous cesarean scar (CS ruptures, 32%), 13 through a non-cesarean scar (non-CS ruptures, 59%), whereas the remaining two (9%) were in women who did not previously undergo any surgery. All of the 13 non-CS ruptures were identified in women with a history of laparoscopic procedures to the uterus. Specifically, 10 (76%) occurred after a previous laparoscopic myomectomy, one (8%) following a hysteroscopic myomectomy, and two (16%) after a laparoscopic wedge resection of cornual ectopic pregnancy. Severe bleeding (blood loss >1500 mL) requiring transfusions was more frequent in women who experienced non-CS compared with CS ruptures (10 versus 1 case, respectively, P = 0.024). Patients with a history of endoscopic uterine surgery should be aware of uterine rupture during pregnancy.

Patency of uterine wall in pregnancies following assisted and spontaneous conception with antecedent laparoscopic and abdominal myomectomies - a difficult case and systematic review

A case of uterine rupture at 24 weeks in a pregnancy succeeding myomectomy and triple embryo transfer is described and literature is reviewed systematically to evaluate the importance of uterine rupture in pregnancies after myomectomy in general and some important sub-populations. Systematic search identified 179 papers and following a strategical selection process 45 studies were analyzed in detail, including 6 cohort and 19 observational studies, 3 case series and 17 case reports. Comparison of risk of uterine rupture after abdominal and laparoscopic myomectomy is made. In pregnancies after IVF number of embryos transferred are determined. Optimal contraceptive intervals and surgical techniques are discussed. The consequences of these observations are analyzed and conclusions are made which can assist individualizing treatment options and improve patient selection.

Two pregnancy cases of uterine scar dehiscence after laparoscopic myomectomy

Uterine scar dehiscence following laparoscopic myomectomy rarely occurs but can compromise both maternal and fetal well-being in subsequent pregnancy. We here present two cases of pregnancy complicated by preterm birth that resulted from uterine scar dehiscence following laparoscopic myomectomy. First case was a nulligravida who had scar dehiscence at 26 weeks of gestation after having a laparoscopic myomectomy 3 months prior to conception. Two weeks later, we observed her fetal leg protruding through the defect. The other case was a primigravida with a history of prior cesarean delivery, whose sonography revealed myomectomy scar dehiscence at 31 weeks of gestation. Within a few hours after observing, the patient complained of abdominal pain that was aggravating as fetal leg protruded through the defect. In both cases, babies were born by emergency cesarean section. Conservative management can be one of treatment options for myomectomy scar dehiscence in preterm pregnancy. However, clinicians should always be aware of the possibility of obstetric emergencies.

Pregnancy Outcomes and Risk Factors for Uterine Rupture After Laparoscopic Myomectomy: A Single-Center Experience and Literature Review

STUDY OBJECTIVE

To evaluate pregnancy outcomes after laparoscopic myomectomy (LSM), focusing on the risk of uterine rupture.

DESIGN

Retrospective cohort study (Canadian Task Force classification III).

SETTING

University hospital.

PATIENTS

Of 676 women who visited the obstetrics department for a pregnancy after undergoing LSM performed at the same center between 1994 and 2012, we included the 523 women who had follow-up through the end of pregnancy.

INTERVENTIONS

All patients underwent LSM, and their medical charts were retrospectively reviewed.

MEASUREMENTS AND MAIN RESULTS

Multiple myomas were removed in 35.2% of cases, intramural-type lesions occurred in 46.5% of cases, and the mean myoma diameter was 4.9 cm. Pregnancy outcomes after LSM included 400 (76.5%) full-term deliveries and 100 (19.1%) vaginal deliveries, with other adverse outcomes being no different than the general population. The mean interval between LSM and pregnancy was 14 months, and only 3 (0.6%) cases of uterine rupture occurred during pregnancy. In analysis, by reviewing the published cases of uterine rupture, we found that the mean diameter, myoma number and type, and the rate of uterine suture were similar between the ruptured cases and all of our cases of LSM.

CONCLUSION

LSM can be safely used in women of reproductive age who want to become pregnant. Uterine rupture occurs in rare cases, regardless of myoma features, but further large-scale studies are required to ascertain the detailed effects of various surgical techniques.

Obstetric outcomes after uterine myomectomy: Laparoscopic versus laparotomic approach

OBJECTIVE

To compare the pregnancy-related complications after laparoscopic and laparotomic uterine myomectomy.

METHODS

A retrospective study of 415 women who received laparoscopic (n = 340) or laparotomic (n = 75) resection of uterine leiomyomas in one center. The mean follow-up period was 26.5 months in laparoscopic group and 23.9 months in laparotomic group.

RESULTS

Fifty-four and 12 pregnancies occurred in laparoscopic and laparotomic myomectomy group, respectively. The major obstetric outcomes were similar between two groups. There was no ectopic pregnancy or preterm birth. There were two cases of obstetric complication in laparoscopic group only; one experienced neonatal death and postpartum hemorrhage due to placental abruption and the other underwent subtotal hysterectomy due to uterine dehiscence identified during Cesarean section.

CONCLUSION

Uterine rupture or dehiscence after laparoscopic myomectomy occurred in 3.7% (2/54) which lead to unfavorable outcome. Appropriate selection of patients and secure suture techniques appears to be important for laparotomic myomectomy in reproductive-aged women.

Spontaneous uterine rupture at 22 weeks' gestation in a multipara with previous hysteroscopic resection of fibroid

A 34-year-old multiparous woman presented at 22(+6) weeks' gestation with severe abdominal pain which preceded a mechanical fall down the stairs. On admission, fetal movements were felt and fetal heart rate was detected by Doppler ultrasound. Over the course of 12 h, although she maintained her vital signs, repeat laboratory and radiological investigations suggested sinister intra-abdominal pathology. Subsequently, fetal movements and heart rate ceased and the patient began to decompensate. A CT scan confirmed uterine rupture. Subsequent emergency laparotomy revealed a 2 l haemoperitoneum and lifeless fetoplacental unit in the abdominal cavity. It is postulated that this rupture occurred as a rare yet life-threatening complication of a hysteroscopic resection of fibroid that the patient underwent 1 year previously. There are no known published cases of a spontaneous uterine rupture following a hysteroscopic procedure at such an early gestation. The patient made a full physical recovery.

Spontaneous prelabor uterine rupture in a primigravida: a case report and review of the literature

A rare case of prelabor uterine rupture in a primigravida was reported. A woman with a history of uterine perforation during hysteroscopy became pregnant after donor oocyte in vitro fertilization. To provide more insight into the possible risk factors for prelabor uterine rupture in primigravidae, a literature review was performed.

Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs

OBJECTIVE

To compare clinical and effectiveness outcomes between robotic-assisted laparoscopic myomectomy (RALM) and abdominal myomectomy (AM).

STUDY DESIGN

Records were reviewed for the first 27 RALM procedures at our institution. Age, BMI, insurance status, race, uterine size, and operative indication were used to select comparable patients who had undergone AM. Clinical and efficiency outcomes were compared stratifying for uterine size, specimen weight, and matched propensity scores.

RESULTS

IV hydromorphone use was significantly lower for RALM (P < 0.01), with no significant differences in blood loss or complications. RALM patients had significantly shorter hospital stays; however, total hospital charges were higher (P < 0.0001). This likely reflects longer operating room time (P < 0.0001), which was magnified as specimen size increased (P < 0.0001).

CONCLUSION

RALM patients require less IV hydromorphone, have shorter hospital stays, and have generally equivalent clinical outcomes compared with AM patients. Additionally, as specimen size increased, the operative efficiency of RALM decreased compared with AM.

Thin anterior uterine wall with incomplete uterine rupture in a primigravida detected by palpation and ultrasound: a case report

Introduction

Uterine rupture is an obstetric complication associated with significant maternal and fetal morbidity and mortality. This disorder usually occurs with a scarred uterus, especially in a uterus with prior Cesarean section. Uterine sacculation or diverticulum may also lead to a thin uterine wall during pregnancy.

Case presentation

A 27-year-old Japanese primigravid woman was admitted to our hospital due to weak, irregular uterine contractions in her 38^th week of gestation. She had no past history of uterine surgery or known diseases. A hard mass was palpable in her abdomen. An ultrasound revealed that the anterior uterine wall was thin and bulging, with a fetal minor part beneath it which corresponded to the palpated mass. A Cesarean section was performed which revealed a thin anterior uterine wall with incomplete uterine rupture. The woman and baby were healthy.

Conclusions

Although extremely rare, an unscarred primigravid uterus can undergo incomplete rupture even without discernable risk factors or labor pains. Abdominal palpation and ultrasound may be useful in detecting this condition.

Surgery-assisted reproductive technology hybrid therapy: a reproductive procedure for an infertile woman of late reproductive age with multiple myomas

AIM

To produce a successful pregnancy in a 38-year-old infertile patient with relapsed myoma using a technique we refer to as 'surgery-assisted reproductive technology (ART) hybrid therapy' because it combines ART for cryopreservation of in vitro fertilized eggs with reproductive surgery.

METHODS

A 38-year-old nulliparous woman who had undergone abdominal myomectomy and in whom magnetic resonance imaging showed multiple myomas was treated at our University-affiliated hospital and outpatient clinic. Blastocysts were cryopreserved during the preoperative period. Laparoscopic myomectomy was performed after preoperative treatment with a GnRH agonist. Ten months after the operation, the youngest cryopreserved blastocyst was transferred into the uterus and implanted successfully.

RESULTS

Treatment resulted in successful implantation and pregnancy. In January 2008, the course of pregnancy had been uneventful and the patient gave birth to a male infant weighing 2998 grams by cesarean section at 37 weeks of gestation.

CONCLUSION

We have treated eight patients using hybrid therapy with encouraging results, and we describe these cases herein briefly.

Management of uterine fibroids in the patient pursuing assisted reproductive technologies

Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated and how should they be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate by approximately 30%. By contrast, studies have demonstrated that subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.

Preterm spontaneous uterine rupture in a non-labouring grand multipara: a case report

BACKGROUND

Uterine rupture can be a catastrophic obstetrical emergency. Many risk factors for uterine rupture have been identified, as well as a wide range of clinical presentations. In this case report, we describe the occurrence of fetal death and uterine rupture in a non-labouring, preterm patient.

CASE

A 32-year-old woman, gravida 10, para 7, who had three previous lower segment Caesarean sections, presented with minor abdominal pain and vaginal bleeding. Fetal demise was confirmed on ultrasound examination. Delivery of the fetus by lower segment Caesarean section was planned, but at laparotomy a complete uterine rupture was found, with the amniotic sac intact in the mother's abdomen.

CONCLUSION

Uterine rupture can be a fatal event for the fetus, with the mother experiencing only minor symptoms. In managing patients with risk factors for uterine rupture, clinicians must always keep the possibility of rupture in mind. Abdominal trauma and intercourse may be added risk factors for uterine rupture.

Rupture of the Primigravid Uterus: A Review of the Literature

Uterine rupture is a catastrophic obstetric complication, associated with high rates of perinatal morbidity and mortality. The most common risk factor is previous uterine surgery, and most cases of uterine rupture occur in women with a previous cesarean delivery. Traditionally, the primigravid uterus has been considered almost immune to spontaneous rupture. In fact, although spontaneous rupture of the primigravid uterus is indeed a very rare event, a number of such cases have been reported recently. Prompt recognition of uterine rupture and expeditious recourse to laparotomy are critical in influencing perinatal and maternal morbidity. Not all uterine ruptures present with the typical clinical picture of abdominal pain, hypovolemia, vaginal bleeding, and fetal compromise. Therefore, it is important to maintain a high index of suspicion for uterine rupture in women presenting with some, or all, of these features, regardless of parity. Here we provide a systematic review of cases of spontaneous uterine rupture in primigravid women reported in the literature to date. Clinical presentation, differential diagnosis, common etiological factors, complication rates, and appropriate management of this rare obstetric event are discussed.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that uterine rupture in a primigravida is a rare event, without typical signs and symptoms, and explain that the morbidity and mortality of the mother and child is directly related to a high index of suspicion and prompt treatment by the clinician.

Laparoscopic Myomectomy and Abdominal Myomectomy

Most women develop myomas during their lifetimes; however, 80% are asymptomatic. When symptoms are determined to be caused by myomas, a number of management options exist that include "watchful waiting," medical therapy, surgery, or more recently uterine artery embolization and focused ultrasound. Myomectomy, either abdominal or laparoscopic, is an approach particularly suited for those women who wish future fertility. It seems clear that, in well trained and experienced hands, well-selected patients can have myomectomy performed under laparoscopic direction. Very large myomas are not as suitable for the laparoscopic approach, but are amenable to a uterine conserving procedure via laparotomy that is facilitated by a number of preoperative and intraoperative measures aimed to minimize or replace operative blood loss. These techniques should provide selected women a uterine conserving procedure with reduced morbidity.

Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy

PURPOSE OF REVIEW

The management of uterine fibroids in patients requiring treatment who desire future fertility remains controversial. Myomectomy has been the most common operative procedure to improve pregnancy rates and outcomes. Uterine fibroid embolization is an increasingly popular, minimally invasive treatment for fibroids. This review aims to provide critical analysis of available data on pregnancy following myomectomy and uterine artery embolization.

RECENT FINDINGS

Patients with distorted uterine cavities due to submucosal fibroids of more than 2 cm have higher pregnancy rates following hysteroscopic resection. Pregnancy rates following myomectomy, both via laparoscopy and laparotomy, are in the 50-60% range, with most having good outcomes. Pregnancy rates following uterine artery embolization have not been established. Pregnancies following uterine artery embolization had higher rates of preterm delivery (odds ratio 6.2, 95% confidence interval 1.4-27.7) and malpresentation (odds ratio 4.3, 95% confidence interval 1.0-20.5) than pregnancies following laparoscopic myomectomy.

SUMMARY

Both myomectomy and uterine artery embolization are safe and effective fibroid treatments, which should be discussed with appropriate candidates. Pregnancy complications, most importantly preterm delivery, spontaneous abortion, abnormal placentation and postpartum hemorrhage, are increased following uterine artery embolization compared to myomectomy. Although most pregnancies following uterine artery embolization have good outcomes, myomectomy should be recommended as the treatment of choice over uterine artery embolization in most patients desiring future fertility.

Pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure

BACKGROUND

To evaluate pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure.

METHODS

This study conducted at a private advanced endoscopy and assisted reproductive technology centre retrospectively evaluated outcomes of 115 women who had pregnancies subsequent to laparoscopic myomectomy.

RESULTS

Of the 217 women followed up, 115 had pregnancies subsequent to a laparoscopic myomectomy. Of 141 pregnancies, there were 87 Caesarean sections, 19 vaginal deliveries, 29 abortions and 6 ectopic pregnancies. There were no incidents of uterine scar rupture in any of these pregnancies.

CONCLUSIONS

Uterine rupture during pregnancies following laparoscopic myomectomy is rare following single-layer myometrial closure.