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Margueritte F, Adam C, Fauconnier A, Gauthier T. Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review. Reprod Biomed Online 2021; 43:543-552. [PMID: 34353724 DOI: 10.1016/j.rbmo.2021.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- François Margueritte
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, 10 Rue du Champ Gaillard, Poissy 78300, France.
| | - Camille Adam
- Limoges University Hospital, Mother and Child Hospital, Department of Gynecology and Obstetrics and Reproductive Medicine, 8 Rue Dominique Larrey, Limoges 87000, France
| | - Arnaud Fauconnier
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, 10 Rue du Champ Gaillard, Poissy 78300, France
| | - Tristan Gauthier
- Limoges University Hospital, Mother and Child Hospital, Department of Gynecology and Obstetrics and Reproductive Medicine, 8 Rue Dominique Larrey, Limoges 87000, France
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Chao AS, Chang YL, Yang LY, Chao A, Chang WY, Su SY, Wang CJ. Laparoscopic uterine surgery as a risk factor for uterine rupture during pregnancy. PLoS One 2018; 13:e0197307. [PMID: 29787604 PMCID: PMC5963787 DOI: 10.1371/journal.pone.0197307] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 04/29/2018] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan, Taiwan
- * E-mail: (CJW); (ASC)
| | - Yao-Lung Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Lan-Yan Yang
- Clinical Trial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Angel Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Wei-Yang Chang
- Clinical Trial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sheng-Yuan Su
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Chin-Jung Wang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan, Taiwan
- * E-mail: (CJW); (ASC)
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Pop L, Suciu ID, Oprescu D, Micu R, Stoicescu S, Foroughi E, Sipos P. Patency of uterine wall in pregnancies following assisted and spontaneous conception with antecedent laparoscopic and abdominal myomectomies - a difficult case and systematic review. J Matern Fetal Neonatal Med 2018; 32:2241-2248. [PMID: 29320920 DOI: 10.1080/14767058.2018.1427060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Lucian Pop
- a Department of Obstetrics and Gynecology , Alessandrescu-Rusescu Institute of Mother and Child Care , Bucharest , Romania.,b Department of Obstetrics and Gynecology , University of Medicine and Pharmacy Carol Davila , Bucharest , Romania
| | - Ioan Dumitru Suciu
- c Department of General Surgery , Floreasca Emergency Hospital , Bucharest , Romania
| | - Daniela Oprescu
- a Department of Obstetrics and Gynecology , Alessandrescu-Rusescu Institute of Mother and Child Care , Bucharest , Romania.,b Department of Obstetrics and Gynecology , University of Medicine and Pharmacy Carol Davila , Bucharest , Romania
| | - Romeo Micu
- d Department of Mother and Child , Iuliu Hateganu University of Medicine and Pharmacy , Cluj-Napoca , Romania
| | - Silvia Stoicescu
- a Department of Obstetrics and Gynecology , Alessandrescu-Rusescu Institute of Mother and Child Care , Bucharest , Romania.,b Department of Obstetrics and Gynecology , University of Medicine and Pharmacy Carol Davila , Bucharest , Romania
| | - Ebrahim Foroughi
- e Department of Obstetrics and Gynaecology , Sheffield Teaching Hospitals , Sheffield , UK
| | - Peter Sipos
- e Department of Obstetrics and Gynaecology , Sheffield Teaching Hospitals , Sheffield , UK.,f Department of Oncology and Metabolism , University of Sheffield , Sheffield , UK
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Abbas AM, Fawzy FM, Ali MN, Ali MK. An unusual case of uterine rupture at 39 weeks of gestation after laparoscopic cornual resection: A case report. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2016. [DOI: 10.1016/j.mefs.2015.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Pregnancy Outcomes and Risk Factors for Uterine Rupture After Laparoscopic Myomectomy: A Single-Center Experience and Literature Review. J Minim Invasive Gynecol 2015; 22:1022-8. [PMID: 26012718 DOI: 10.1016/j.jmig.2015.05.016] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 05/18/2015] [Accepted: 05/18/2015] [Indexed: 12/14/2022]
Abstract
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.
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Buckley VA, Nesbitt-Hawes EM, Atkinson P, Won HR, Deans R, Burton A, Lyons SD, Abbott JA. Laparoscopic Myomectomy: Clinical Outcomes and Comparative Evidence. J Minim Invasive Gynecol 2015; 22:11-25. [DOI: 10.1016/j.jmig.2014.08.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 08/05/2014] [Accepted: 08/06/2014] [Indexed: 12/22/2022]
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Weibel HS, Jarcevic R, Gagnon R, Tulandi T. Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:128-32. [PMID: 24518911 DOI: 10.1016/s1701-2163(15)30658-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy. METHODS We conducted a survey of 49 practising obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy. RESULTS Overall, the inter-respondent agreement was fair (kappa 0.3; P < 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour. There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins. CONCLUSION Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach.
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Affiliation(s)
- Hélène S Weibel
- Department of Obstetrics and Gynecology, McGill University, Montreal QC
| | - Radomir Jarcevic
- Department of Obstetrics and Gynecology, Université de Montréal, Montreal QC
| | - Robert Gagnon
- Department of Obstetrics and Gynecology, McGill University, Montreal QC
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University, Montreal QC
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Obstetric outcomes after uterine myomectomy: Laparoscopic versus laparotomic approach. Obstet Gynecol Sci 2013; 56:375-81. [PMID: 24396816 PMCID: PMC3859018 DOI: 10.5468/ogs.2013.56.6.375] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/03/2013] [Accepted: 06/10/2013] [Indexed: 11/08/2022] Open
Abstract
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.
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Uccella S, Cromi A, Bogani G, Zaffaroni E, Ghezzi F. Spontaneous prelabor uterine rupture in a primigravida: a case report and review of the literature. Am J Obstet Gynecol 2011; 205:e6-8. [PMID: 22035954 DOI: 10.1016/j.ajog.2011.08.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 08/05/2011] [Accepted: 08/15/2011] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy.
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Hagneré P, Denoual I, Souissi A, Deswarte S. Rupture utérine spontanée après myomectomie. À propos d’un cas et revue de la littérature. ACTA ACUST UNITED AC 2011; 40:162-5. [DOI: 10.1016/j.jgyn.2010.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2010] [Revised: 08/05/2010] [Accepted: 08/17/2010] [Indexed: 11/30/2022]
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Wen KC, Sung PL, Lee WL, Li YT, Su WH, Wang PH. Myomectomy for uterine myomas through ultramini-laparotomy. J Obstet Gynaecol Res 2011; 37:383-92. [DOI: 10.1111/j.1447-0756.2010.01359.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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12
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Yazawa H, Endo S, Hayashi S, Suzuki S, Ito A, Fujimori K. Spontaneous uterine rupture in the 33rd week of IVF pregnancy after laparoscopically assisted enucleation of uterine adenomatoid tumor. J Obstet Gynaecol Res 2011; 37:452-7. [DOI: 10.1111/j.1447-0756.2010.01361.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kuroda K, Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kobayashi Y, Kobori H, Kuroda M, Itagaki K, Machida M, Takeda S. Surgery-assisted reproductive technology hybrid therapy: a reproductive procedure for an infertile woman of late reproductive age with multiple myomas. J Obstet Gynaecol Res 2009; 35:827-31. [PMID: 19751354 DOI: 10.1111/j.1447-0756.2008.00977.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Keiji Kuroda
- Department of Obstetrics and Gynaecology, Juntendo University School of Medicine, Tokyo, Japan.
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Chang WC, Chang DY, Huang SC, Shih JC, Hsu WC, Chen SY, Sheu BC. Use of three-dimensional ultrasonography in the evaluation of uterine perfusion and healing after laparoscopic myomectomy. Fertil Steril 2009; 92:1110-1115. [DOI: 10.1016/j.fertnstert.2008.07.1771] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2008] [Revised: 07/25/2008] [Accepted: 07/25/2008] [Indexed: 10/21/2022]
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Elahi SM, Odejinmi F. Overview of current surgical management of fibroids: ‘Organ-preserving modalities’. J OBSTET GYNAECOL 2009; 28:28-31. [DOI: 10.1080/01443610701814328] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kelly BA, Bright P, Mackenzie IZ. Does the surgical approach used for myomectomy influence the morbidity in subsequent pregnancy? J OBSTET GYNAECOL 2009; 28:77-81. [DOI: 10.1080/01443610701811738] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gupta S, Jose J, Manyonda I. Clinical presentation of fibroids. Best Pract Res Clin Obstet Gynaecol 2008; 22:615-26. [DOI: 10.1016/j.bpobgyn.2008.01.008] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Tzafettas J, Dovas D, Tolikas A, Fragkedakis N, Dinas K, Papathanasiou K. A Case of a Successful Pregnancy in a Woman with a Previous History of Spontaneous Uterine Rupture Following Laparoscopic Myomectomy. J Gynecol Surg 2008. [DOI: 10.1089/gyn.2007.b-02290-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John Tzafettas
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
| | - Dimitrios Dovas
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
| | - Athanasios Tolikas
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
| | - Nikolaos Fragkedakis
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
| | - Konstantinos Dinas
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
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Leidi L, Brusati M, Vespa MG. A treacherous scar. Am J Obstet Gynecol 2007; 197:553.e1-2. [PMID: 17980208 DOI: 10.1016/j.ajog.2007.08.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2007] [Revised: 06/07/2007] [Accepted: 08/21/2007] [Indexed: 11/18/2022]
Affiliation(s)
- Luciano Leidi
- Department of Obstetrics and Gynecology, Chivasso Civic Hospital, Chivasso (Turin), Italy
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Malartic C, Morel O, Akerman G, Tulpin L, Clément D, Barranger E. La myomectomie par cœlioscopie en 2007: état des lieux. ACTA ACUST UNITED AC 2007; 36:567-76. [PMID: 17597308 DOI: 10.1016/j.jgyn.2007.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 04/10/2007] [Accepted: 05/09/2007] [Indexed: 11/30/2022]
Abstract
With fifteen years of development, laparoscopy for myomectomy has proven its advantages. However, this technique remains controversial concerning its feasibility and the quality of uterine scar obtained. Laparoscopic myomectomy (LM) is usually indicated when number of myomas is less than 3 to 4 with a 8 to 9 cm maximal size. Surgical technique is standardized and intervention time becomes acceptable. Risk of conversion ranges between 1 to 3% when technique is realized by trained surgeon. Bleeding is less important compared with laparotomy and immediate postoperative complications are exceptional. Results concerning fertility are positive with more than 50% of infertile patient conceiving after surgery, this rate rising up to 61 to 76% for myomas isolated cause for infertility; these values can be compared with myomectomy realized by laparotomy. Postoperative adhesions seem to be less important after laparoscopy when compared with laparotomy but this point needs to be confirmed. Risk of uterine rupture is estimated between 0 to 1%, but this point needs for larger series evaluation and needs to be compared with pregnancies after laparotomy. Laparoscopic myomectomy is a feasible technique, safe for patients waiting for conception and has proven its interest in case of infertility.
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Affiliation(s)
- C Malartic
- Service de gynécologie-obstétrique, APHP, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
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Abstract
UNLABELLED 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.
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Affiliation(s)
- Colin A Walsh
- Department of Obstetrics and Gynecology, Sloane Hospital for Women, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York 10032, USA
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Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 2007; 87:725-36. [PMID: 17430732 DOI: 10.1016/j.fertnstert.2007.01.093] [Citation(s) in RCA: 373] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 01/11/2007] [Accepted: 01/11/2007] [Indexed: 11/18/2022]
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Abstract
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.
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Affiliation(s)
- William H Parker
- Department of Obstetrics and Gynecology, UCLA School of Medicine, Los Angeles, and Department of Obstetrics and Gynecology, Saint John's Health Center, Santa Monica, California, USA.
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Goldberg J, Pereira L. Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy. Curr Opin Obstet Gynecol 2006; 18:402-6. [PMID: 16794420 DOI: 10.1097/01.gco.0000233934.13684.cb] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Jay Goldberg
- Department of Obstetrics, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA.
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Seracchioli R, Manuzzi L, Vianello F, Gualerzi B, Savelli L, Paradisi R, Venturoli S. Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy. Fertil Steril 2006; 86:159-65. [PMID: 16764876 DOI: 10.1016/j.fertnstert.2005.11.075] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2005] [Revised: 11/23/2005] [Accepted: 11/23/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess the risks and outcome of pregnancies and deliveries after laparoscopic myomectomy (LM). DESIGN Retrospective study. SETTING Center of Reconstructive Pelvic Endosurgery, Reproductive Medicine Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. PATIENT(S) A total of 514 patients of fertile age that underwent LM at the Center were selected. INTERVENTION(S) All the surgical procedures were performed using the same technique employing a vertical uterine incision and avoiding the use of electrosurgery. MAIN OUTCOME MEASURE(S) Number and outcome of pregnancies achieved after surgery, abortion rate, preterm delivery, gestational age, malpresentation, spontaneous or cesarean delivery, and postpartum hemorrhage. We also paid particular attention to the occurrence of uterine rupture. RESULT(S) A total of 158 pregnancies were achieved. There were 43 (27.2%) spontaneous abortions, 4 (2.6%) ectopic pregnancies, and 1 (0.6%) therapeutic abortion. Only 27 patients (25.5%) had vaginal deliveries, whereas 79 (74.5%) underwent cesarean section. No instances of uterine rupture were recorded. CONCLUSION(S) Our preliminary results confirmed that LM, performed by an expert surgeon, can restore reproductive capacity, allowing patients to have a successful pregnancy.
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Affiliation(s)
- Renato Seracchioli
- Center of Reconstructive Pelvic Endosurgery, Reproductive Medicine Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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Banas T, Klimek M, Fugiel A, Skotniczny K. Spontaneous uterine rupture at 35 weeks' gestation, 3 years after laparoscopic myomectomy, without signs of fetal distress. J Obstet Gynaecol Res 2005; 31:527-30. [PMID: 16343253 DOI: 10.1111/j.1447-0756.2005.00331.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Laparoscopic myomectomy (LM) is a recently developed surgical technique, and every obstetrician should be aware of its possible complications, which can occur not only during labor but also during pregnancy. We report a case of a primigravid woman who was hospitalized at 35 weeks' gestation because of irregular abdominal pain. She conceived spontaneously 3 years after LM. After a 20-h stay on the obstetrician ward due to increased abdominal tenderness and vaginal bleeding, the patient was qualified for an emergency cesarean section without any symptoms of fetal distress in cardiotocography. During cesarean section a newborn with 9 Apgar points was delivered and a rupture of the uterine wall was seen. Dehiscence of the pregnant uterus following LM is an incidental case, and can therefore be misdiagnosed. Close attention should be paid to every pregnancy in previously operated uteri as the dehiscence of the pregnant uterus can occur without symptoms of fetal distress.
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Affiliation(s)
- Tomasz Banas
- Gynecology and Infertility Department, Jagiellonian University, Krakow, Poland.
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