Risk factors based on myoma characteristics for predicting postoperative complications following cesarean myomectomy

OBJECTIVES

To evaluate the influence of myoma characteristics on cesarean myomectomy and to demonstrate its additional advantages.

METHODS

Retrospective data were collected from 292 women with myomas who had undergone cesarean section at Kangnam Sacred Heart Hospital between 2007 and 2019. We performed subgroup analysis according to the type, weight, number, and size of myomas. Preoperative and postoperative hemoglobin levels, operative time, estimated blood loss, length of hospital stay, incidence of transfusion, uterine artery embolization, ligation, hysterectomy, and postoperative complications were compared among subgroups.

RESULTS

There were 119 patients who had cesarean myomectomy and 173 who had cesarean section only. An increase in postoperative hospitalization and operation time was observed in the cesarean myomectomy group compared to that in the caesarean section only group (mean difference, 0.7 days, p = 0.01, 13.5 minutes, p <0.001). Estimated blood loss, hemoglobin differences, and transfusion rates were higher in the cesarean myomectomy than in the cesarean section only group. There were no differences in postoperative complications (fever, bladder injury, and ileus) between the two groups. No hysterectomy cases were reported in the cesarean myomectomy group. In subgroup analysis, the larger and heavier the myoma, the higher the risk of bleeding that led to transfusion. Estimated blood loss, differences in hemoglobin, and transfusion rate increased depending on myoma size and weight. A significant increase in postoperative hospitalization was observed in women with larger and heavier myomas. However, there was no statistical difference among the three types of myomas.

CONCLUSION

In cesarean myomectomy, larger (≥ 10 cm), and heavier myomas (≥ 500 g), were associated with postoperative outcomes, but not the number or type of myoma. The safety of cesarean myomectomy is not inferior to that of caesarean section only, considering its positive effects such as gynecological symptom relief and avoidance of the next surgery.

The differences in characteristics of uterine leiomyomas and the diverse adverse pregnancy outcomes

Although previous studies have shown a relationship between uterine leiomyoma and pregnancy outcomes, this relationship is not yet completely understood. Many review articles have addressed this effect, but to date, none has classified this relationship according to the characteristics of the leiomyoma (i.e., type, size, number, and location). This review was conducted to evaluate and classify the relationship between leiomyoma characteristics and the effects of a leiomyoma on pregnancy and prenatal outcomes to facilitate decision-making in preconception and prenatal counselling. We examined articles published in English regarding any leiomyoma characteristics with obstetric outcomes during pregnancy using a collection of subject headings and key terms: 'leiomyomata,' 'myoma,' 'leiomyoma,' 'fibroid,' and 'pregnancy.' Many studies regarding the influence of leiomyoma characteristics on outcomes of pregnancy were identified, and the common conclusion was that the outcomes were dependent on leiomyoma characteristics. Most studies focussed on leiomyoma size, followed by type, location, and number of lesions. Different leiomyoma characteristics are related to diverse pregnancy outcomes. Therefore, it may be possible to predict the extent of the effects of these tumours on pregnancy outcomes by identifying all leiomyoma characteristics.

Cesarean myomectomy in the last ten years; A true shift from contraindication to indication: A systematic review and meta-analysis

BACKGROUND

A lot of debate is present about Cesarean myomectomy (CM) in women with uterine myoma whether to consider it a feasible and safe procedure or an absolute contraindication.

OBJECTIVE

To assess the safety and feasibility of myomectomy during cesarean section in women with uterine myoma.

SEARCH STRATEGY

Electronic search was made on MEDLINE, EMBASE, Cochrane Library, ISI web of knowledge and Scopus from January 1, 2008 to December 31, 2019 using terms "Caesarean section", "Myomectomy", "Fibroid", "Caesarean myomectomy".

SELECTION CRITERIA

All full length studies either prospective or retrospective that address caesarean myomectomy were included.

DATA COLLECTION AND ANALYSIS

The outcomes studied were haemorrhage, mean change in haemoglobin, operative time, need for blood transfusion, febrile morbidity and duration of hospital stay.

RESULTS

Total 249 studies were assessed for eligibility and 17 studies included in analysis with 6545 women. There were 4702 (71.85 %) women in caesarean myomectomy (CM) group and 1843 (28.15 %) women in cesarean section (CS) group. There was statistically significant but clinically insignificant decrease in hemoglobin [MD = 0.27, 95 %CI = 0.08-0.45, p = 0.005; very low quality], significant higher need for blood transfusion [RR = 1.45, 95 %CI = 1.05-1.99, p = 0.02; high quality] in CM group versus CS alone. The mean operative time (minutes) [MD = 14.77, 95 %CI = 6.91-22.64, p = 0.0002; moderate quality] and mean hospital stay (days) [MD = 0.36, 95 %CI = 0.19-0.53, p < 0.00001; high quality] was significantly less in CM group, though of not any clinical significance. No difference in incidence of haemorrhage [RR = 1.16, 95 %CI = 0.86-1.56, p = 0.32; moderate quality evidence] and fever [RR = 1.17, 95 %CI = 0.83-1.65), p = 0.36; moderate quality] in two groups.

CONCLUSIONS

The meta-analysis suggests CM is associated with clinical insignificant increase in operative time, blood loss and hospital stay, especially with multiple and large size myomas. CM should be preferred over CS alone especially by experienced surgeons with appropriate haemostatic techniques and tertiary care centres.

Analysis of Myomectomy during Cesarean Section: A Tertiary Center Experience

PURPOSE

This study analyzed the safety of myomectomy during the cesarean section (CS).

METHODS

Pregnant women who underwent myomectomy during CS in a tertiary center between January 2015 and November 2019 were included in the study in Group A, and pregnant women who did not have myoma and who underwent only CS were included in the study in Group B. The following information was obtained from patient files in hospital archives and was then recorded and compared: age, gravidity, parity, gestational week, characteristics of the myomas (i.e., location, size, number, and type), duration of surgery, perioperative complications, need for blood transfusion, preoperative and postoperative hemoglobin (Hb) values, duration of surgery, and hospital stay duration.

RESULTS

A total of 83 patients underwent CS plus myomectomy (Group A), and 80 patients (without myoma) underwent only CS (Group B).There were no statistically significant differences between the groups in terms of preoperative and postoperative Hb values or blood transfusion rates (p > 0.05). Hospitalization and surgery duration were significantly higher in the group that underwent CS myomectomy (p = 0.001 and p = 0.001, respectively). The mean myoma size was 8.3 ± 4.1 cm in Group A. There was a statistically significant and inverse correlation between the size of the myoma and the delivery week (p = 0.035). There was a statistically significant and positive correlation between the myoma size and hospital stay (p = 0.01).

CONCLUSION

Myomectomy during CS is safe and can be applied regardless of the location, size, type, and number of myomas. However, to make myomectomy routine during CS, multi-center studies that include more cases are needed.

Feasibility and safety of performing cesarean myomectomy: a systematic review and meta-analysis

PURPOSE

To examine the feasibility and safety of performing cesarean myomectomy on pregnant women with myomas compared to cesarean section only.

METHODS

We retrieved English articles in the PubMed, Cochrane Library, Medline and EMBASE databases from inception to April 2020. Observational studies including the comparison of patients who underwent cesarean myomectomy and cesarean section, as well as those reporting perioperative outcomes were selected. Data extraction was conducted using RevMan 5.3.

RESULTS

Twenty-three studies comprising 8,016 women were included in the meta-analysis. Of these, 3,955 underwent cesarean myomectomy, while 4,061 underwent cesarean section only. Cesarean myomectomies were associated with a greater decline in mean hemoglobin (mean difference [MD] 0.20 g/dL, 95% confidence intervals [CI] 0.06, 0.35, p = .007), greater incidence of hemorrhage (odds ratio [OR] 1.46, 95% CI 1.06, 2.01, p = .02), greater volume of blood loss (MD 45.54 ml, 95% CI 2.68, 88.41, p = .04), higher transfusion rate (OR 1.47 95%CI 1.09, 1.99, p = .01), longer operation duration (MD 10.40 min, 95% CI 8.54, 12.25, p < .001), or longer postoperative hospitalization (MD 0.18 d, 95% CI 0.12, 0.24, p < .001), compared to those who underwent cesarean section only. There was no statistical difference in postoperative fever rates (OR 1.12, 95% CI 0.77, 1.62).

CONCLUSION

Hemorrhage represents a risk factor which should not be overlooked by surgeons performing cesarean myomectomy. Intramural myomas, myomas ≥7 cm in size, and multiple myomas are associated with more intraoperative hemorrhage and prolonged operation duration. We suggest that, with appropriate hemostatic techniques and when performed by experienced surgeons, cesarean myomectomy may be safe and feasible in selected patients with myomas, regardless of size and locations, except if they are located at the cornual or close to large vessels, and in the absence of uterine atony during surgery.

Perioperative Complications of Cesarean Delivery Myomectomy: A Meta-analysis

OBJECTIVE

To assess the association of myomectomy during cesarean delivery with intraoperative and perioperative maternal morbidity.

DATA SOURCES

We searched MEDLINE (1966-2017), Scopus (2004-2017), ClinicalTrials.gov (2008-2017), EMBASE (1980-2017), and Cochrane Central Register of Controlled Trials CENTRAL (1999-2017) databases.

METHODS OF STUDY SELECTION

We selected all observational studies that reported outcomes on patients undergoing myomectomy at the time of cesarean delivery. Statistical meta-analysis was performed with RevMan 5.3.

RESULTS

Nineteen studies were included in our systematic review with a total number of 3,900 women. Among them, 2,301 women had myomectomy during cesarean delivery and 1,599 had cesarean delivery only. Women undergoing concomitant myomectomy had a mild decline in hemoglobin compared with those who had cesarean delivery only (mean difference 0.25 mg/dL, 95% CI 0.06-0.45). Myomectomy at the time of cesarean delivery is associated with longer surgical time compared with cesarean delivery alone (mean difference 13.87 minutes, 95% CI 4.78-22.95). Blood transfusion (odds ratio [OR] 1.41, 95% CI 0.96-2.07) and postoperative fever (OR 1.12, 95% CI 0.80-1.56) rates did not differ between the two groups (myomectomy compared with no myomectomy). A statistically, but not clinically, significant increase in postoperative hospitalization was evident in the myomectomy group (mean difference 0.35 days, 95% CI 0.25-0.46).

CONCLUSION

This systematic review and meta-analysis of observational studies demonstrated an association with increased operative time and hemoglobin drop in patients who underwent cesarean myomectomy compared with cesarean delivery alone. No increased rate of major hemorrhage or need for transfusion was identified. Cesarean myomectomy may be considered in cases of isolated myomas, although randomized trials are needed.

Outcome of Cesarean Myomectomy: Is it a Safe Procedure?

Objective

Myomectomy performed during cesarean section is still controversial because of the potential for associated complications, especially with large myomas. Many obstetricians avoid performing cesarean myomectomy procedures because of the risk of uncontrollable hemorrhage. However, the prevalence of pregnant women with myomas is increasing, leading to an increase in the likelihood that physicians will encounter this issue. The aim of this study was to compare outcomes and complications of patients who either had or did not have cesarean myomectomy.

Method

A total of 361 patients were evaluated in this retrospective study. Patients who had cesarean section with myomectomy and patients had cesarean section without myomectomy were compared with regard to demographics, drop in hemoglobin levels, complications, blood transfusion rates and duration of operation. These parameters were also compared when the diameter of the myoma was larger than 5 cm. Values of p < 0.01 and p < 0.05 were considered statistically significant.

Results

While maternal age and gravidity were similar in both groups (p > 0.05), the mean myoma diameter was smaller and the duration of operation was longer in the group who underwent cesarean myomectomy (p < 0.05). The reduction in hemoglobin level, rate of complications, and number of transfusions were similar in both groups (p > 0.05).

Conclusion

This study shows that myomectomy during cesarean section does not increase complications or transfusion rates and appears to be a safe procedure.

Cesarean myomectomy trends and controversies: an appraisal

OBJECTIVE

Although the first report on cesarean myomectomy (CM) was a century ago, the management of a myomectomy during a cesarean section (CS) remains controversial. The objective of this study is to provide the latest data on this topic regarding the techniques and complications of CM.

METHODS

The authors consulted the most important scientific databases investigating the indications and contraindications for CM, the operational techniques, benefits and complications.

RESULTS

CM provides the benefits of two surgeries in one laparotomy, avoiding the risks of repeated anesthesia and relaparotomy. Nevertheless, in some patients, CM may be associated with increased morbidity and, in such cases, an interval myomectomy might be a safer option. Myomas compromising fetal extraction and uterine incision and/or suturing should be preferably enucleated during CS. CM is generally considered relatively safe in cases of anterior wall myomas, subserous and pedunculated myomas, particularly if a myomectomy is feasible without additional hysterotomy. Multiple myomas, deep intramural, fundal and cornual myomas and posterior uterine wall myomas are associated with more surgical complications during CM.

CONCLUSIONS

With increasing reports in favor of CM, the risk-benefit ratio should be still evaluated with randomized controlled trials, in order to achieve more data on CM.

Myomectomy during Caesarean Birth in Fibroid-Endemic, Low-Resource Settings

If myomectomy during caesarean delivery becomes a widespread practice, it could potentially eliminate multiple surgeries for both indications. However, many surgeons have been reluctant to adopt this policy without conclusive evidence demonstrating its safety. This study reviews the publications on caesarean myomectomy especially from the African Continent with respect to duration of surgery, blood loss, length of hospital stay, and blood transfusions. Judging from the lack of large studies on caesarean myomectomy, the proportion of surgeons who attempt the procedure is largely low because of concerns about its safety. However, most of the authors suggested that the complications and morbidity following caesarean myomectomy do not significantly differ from those occurring during caesarean section alone, while fertility is apparently not compromised by this treatment. With careful patient selection, adequate experience, and efficient haemostatic measures, the procedure does not appear as hazardous as was once thought. This piece of information is relevant for counseling women who request for the simultaneous removal of previously diagnosed fibroids during caesarean section. Staff and facilities for safe management of haemorrhage are a requisite for the procedure. Large randomized trials are needed to guide decisions as to the best clinical practice regarding myomectomy during caesarean delivery.

Myomectomy during caesarean: a retrospective evaluation of 16 cases

AIM

To evaluate the results and complications of myomectomy carried out during caesarean section.

MATERIALS AND METHOD

A retrospective study of 16 patients who underwent myomectomy concurrently with caesarean section in our clinic between January 2009 and September 2012 was conducted. The pre- and postoperative haemoglobin values, number, size and total volume of excised fibroid nodules, location of fibroids, duration of operation, and duration of hospital stay of all patients were retrospectively investigated.

RESULTS

While the most common leiomyoma was transmural myoma, with ten cases encountered, the most common location was in the corpus anterior, where transmural myomas were seen in five patients. The volume of the excised leiomyomata ranged from 84 to 3.300 cm³. The average preoperative haemoglobin value of our patients was 11.4 g/dl, while the postoperative value was 10.3 g/dl. Of 16 patients included in the study, two required blood transfusions due to excessive bleeding. Uterine defects caused by the myomectomy were closed without problems in all patients, and no patient required a hysterectomy. The average time for the myomectomy and caesarean section procedure was 56.1 min. All patients were discharged without problems an average of 3.25 days after the operation.

CONCLUSION

Myomectomy carried out during caesarean section is a trusted surgical intervention regardless of the size of leiomyomata.

Cervical leiomyomas in pregnancy: report of 17 cases

AIM

To analyse the management strategies and delivery outcomes of women with cervical leiomyomas in pregnancy.

METHODS

We retrospectively analysed the pregnancy outcomes of 17 women with cervical leiomyomas. The outcome measures assessed included the volume of blood loss at delivery, need for blood transfusion, intra- and post-operative complications and length of hospital stay.

RESULTS

The mean diameter of the leiomyomas was 10.4 ± 7.2 cm, with a range of 3-30 cm. The mean blood loss was 697 ± 394 mL (range of 350-4200 mL). Six women (35.3%) required a blood transfusion. The mean duration of stay in hospital after delivery was 7.9 ± 3.9 days (range 4-20 days). There were three cases of severe haemorrhage or infection post-operation necessitating hysterectomy, and all of the leiomyomas in these cases were more than 20 cm in diameter. There was a positive correlation between the blood loss volume and the size of leiomyomas (correlation coefficient 0.638, P < 0.01).

CONCLUSIONS

The dimensions of cervical leiomyomas influences post-partum blood loss. Large cervical leiomyomas appear associated with adverse outcomes. When the leiomyomas are relatively small, an experienced practitioner could consider myomectomy during a caesarean delivery.

[Uterine necrosis after arterial embolization for postpartum hemorrhage]

Radiologic embolization of the uterine arteries is increasingly used to treat severe postpartum hemorrhage, as an alternative to surgical procedures. Guidelines have been published in order to standardize the indications as well as the technique. An important objective was to limit severe complications such as uterine necrosis. We report a case of a uterine necrosis after arterial embolization for severe postpartum hemorrhage due to uterine atony on a uterus with fibroids. This complication occurred despite the use of the recommended technique.