Myomectomy during Cesarean Section: A Safe Procedure?

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.

Do Large Uterine Fibroids Impact Pregnancy Outcomes?

Objectives

We sought to assess the prevalence of fibroids complicating pregnancy among Omani women who delivered and were followed-up at Sultan Qaboos University Hospital (SQUH) and correlate the presence of large fibroids (> 5 cm) with maternal and neonatal outcomes.

Methods

This retrospective cohort study was conducted at the Department of Obstetrics and Gynecology, SQUH, from 1 January 2011 to 31 December 2016. Demographic data included maternal age, gravidity, parity, body mass index (BMI), and history of preterm delivery. Ultrasonographic data included the total number of fibroids, number of fibroids > 5 cm in diameter, and location. The main outcomes measured were preterm delivery, preterm premature rupture of membranes (PPROM), malpresentation, intrauterine growth restriction (IUGR), mode of delivery, postpartum hemorrhage, retained placenta, and cesarean myomectomy. Fetal outcomes included birth weight and Apgar score. We used the chi-square test and t-test to calculate significant outcomes.

Results

The total number of deliveries over the study period was 24 800. Among these, 62 women had fibroids complicating pregnancy, giving an overall prevalence of 0.3%. Of the 62 women with documented uterine fibroids, 41 had fibroids > 5 cm in diameter and formed the study group, while the control group included 88 women with no fibroids and normal singleton pregnancies. The mean age, parity, BMI, and history of preterm delivery were comparable. The mean age of the study group was 32.6 years. There was no statistically significant difference in obstetric outcomes between the study and control group in terms of preterm labor (p =0.381), PPROM (p =0.536), malpresentation (p =0.237), IUGR (p =0.059), and retained placenta (p =0.296). Postpartum hemorrhage was significantly higher in the study group (p =0.018), the commonest cause was uterine atony (p =0.007). Women with large fibroids had a significantly increased cesarean section rate (p =0.002), the main indications were obstructed labor and failure to progress (62.5%). Five of the 44 women in the study group (12.8%) underwent cesarean myomectomy. Regarding neonatal outcomes, a statistically significant difference was noted in the Apgar scores.

Conclusions

Fibroids measuring > 5 cm in diameter are more likely to cause obstetric complications and are associated with higher cesarean rates. Pre-conception myomectomy is recommended for women with large fibroids.

Myomectomy during cesarean section: A retrospective cohort study

OBJECTIVE

To evaluate the value of myomectomy during delivery by cesarean section (CS) in pregnant women with uterine fibroids.

METHODS

Retrospective cohort study of pregnant women diagnosed to have uterine fibroids during index pregnancy. Women who underwent myomectomy during CS (study group; n = 91) were compared with women in whom myomectomy was not performed during CS (control group; n = 87).

RESULTS

No significant difference between both groups in the amount of blood transfusion and postoperative hemoglobin level. The operative time was significantly higher in the myomectomy group than in the control group (80.22 ± 13.06 vs 56.67 ± 8.85 min; P <  0.001). Also, the postoperative hospital stay period was significantly higher in the myomectomy group (P <  0.001).

CONCLUSION

Myomectomy during CS can be performed safely without increase in the peripartum maternal morbidities. It only may prolong the operative time and postoperative hospital stay period but it may have many benefits including avoiding another operation to remove fibroids.

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.

Myomectomy During Cesarean Section: Why Do We Abstain From?

Objectives

To assess the intra- and postoperative results of cesarean myomectomy.

Methods

A retrospective study was conducted to collect the results of cesarean myomectomy procedures performed in our tertiary center between June 2013 and December 2018. The subjects were 2219 pregnant women undergoing cesarean section at these units.

Results

A total of 2219 scheduled patients undergoing CS were included in the present study. Sixty-five patients have undergone intramural myomectomy during CS; 82 patients have had subserosal myomectomy during CS. No statistically significant differences were found between the three groups in changes of preoperative Hb, postoperative Hb, mean Hb and length of hospital stay. Operation times were significantly longer in both intramural and subserosal myomectomy groups (45.23 ± 8.498 vs. 39.02 ± 6.824 vs. 32.14 ± 5.423 min, p 0.01). Only in the intramural myomectomy group, two patients were subjected to blood transfusion (3%). Assessment of intramural myomectomy patients was carried out by taking 5 cm as the cutoff value. No statistical differences were found between the two groups in terms of mean Hb change, operation time, length of hospital stay. In the group with intramural myomectomy larger than 5 cm, two (15.38%) patients needed a blood transfusion.

Conclusions

Cesarean myomectomy operation performed by experienced surgeons has no adverse effects other than lengthening the duration of operation and can be safely implemented.

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.

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 at the time of cesarean delivery

INTRODUCTION

Myomectomy at the time of cesarean delivery has been traditionally discouraged. Recent literature has challenged this view. We present two cases of large subserosal fibroids that underwent removal without complication at the time of cesarean delivery.

MATERIALS AND METHODS

We present two patients that underwent myomectomy at the time of cesarean delivery. Case 1 had a 10 cm subserosal leiomyoma removed without complication at the time of a cesarean section for breech presentation. Case two had a fundal myoma removed without incident at the time of primary cesarean delivery for suspected macrosomia.

DISCUSSION

Myomectomy at the time of cesarean section has been traditionally discouraged. Recent studies have questioned this recommendation and demonstrated no significant increase in peri-operative complications when myomectomy is performed at the time cesarean section. Further, there is added benefit in that a future procedure is avoided.

CONCLUSION

Myomectomy at the time of cesarean delivery is both a safe and reasonable procedure.

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.

A Case Report on A Myomectomy which was Done During A Caesarean Section

Uterine myomas are being observed in pregnancy more frequently now than in the past, because many women are delaying child bearing till their late thirties, which is the time for the greatest risk of the myoma growth. Traditionally, obstetricians are trained to avoid myomectomies during caesarean sections as severe haemorrhages can occur, which may often necessitate hysterectomies. Pedunculated fibroids which can be easily removed are an exception. Here, we are reporting one case of a myomectomy which was done during a caesarean section.

Caesarean Myomectomy: Feasibility and safety

OBJECTIVES

Caesarean myomectomy has traditionally been discouraged due to fears of intractable haemorrhage and increased postoperative morbidity. However, a number of authors have recently shown that myomectomy during Caesarean section does not increase the risk of haemorrhage or postoperative morbidity.

METHODS

We present a series of 8 cases from Sultan Qaboos University Hospital, Oman, where myomectomy was performed during Caesarean section for large lower segment fibroids. Seven were anterior lower segment fibroids, while one was a posterior lower uterine fibroid which interfered with closure of the uterine incision. The antenatal course, perioperative management, and postoperative morbidity are discussed.

RESULTS

The average age of the women was 28.7 years and mean gestational age at delivery was 36.75 weeks. Regarding intra-operative blood loss, 1 patient lost 900 ml, 5 patients lost 1-1.5 litres, 2 lost 1.5-2 L, and 1 patient with a 10 x 12 cm fibroid lost 3.2 L. Despite the majority being large myomas (7 of the 8 patients had myomas >5 cm in size) and 50% being intramural, no hysterectomy was required. Stepwise devascularisation was necessary in one case and preoperative placement of uterine balloon catheters was necessary in another. The size of the fibroids was confirmed by histopathology. Myomectomy added 15 minutes to the operating time and 1 day to the hospital stay, but there was no significant postoperative morbidity. Neonatal outcome was good in all patients.

CONCLUSION

In selected patients, myomectomy during Caesarean section is a safe and effective procedure at tertiary centres with experienced surgeons.

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.

At times, myomectomy is mandatory to effect delivery

BACKGROUND

Excision of a leiomyoma has never been a choice during caesarean section.

METHOD

Myomectomy of a massive fibroid was necessitated prior to delivering the baby.

RESULTS

Delivery of a healthy was effected by Classical caesarean section.

CONCLUSION

Leiomyoma in pregnancy is not an unknown entity and is a cause of concern for being a source of excruciating pain, at times, during the ongoing gestation.Although performed rarely, it is sometimes necessary to remove a large myoma to effect delivery of the baby during Cesarean section as is depicted in the case being presented hereunder.