The objective: to study the features of the restoration of reproductive function, the course of pregnancy and childbirth in women with a scar on the uterus after myomectomy using endoscopic technologies.Materials and methods. The study was conducted in three stages. At the first stage, the course of the postoperative period after myomectomy in 180 women of reproductive age was analyzed, of which 80 patients (1 group) underwent laparotomy myomectomy with suturing of the bed with two-row synthetic sutures; 50 patients (2 group) – laparoscopic myomectomy with suturing of the bed with two-row synthetic sutures and 50 women (3 group) – laparoscopic myomectomy with bipolar coagulation of the bed. In the second stage, 6 months after surgery, all patients were examined to rule out signs of inferiority of the myometrial scar and predict the possibility of natural childbirth. The diagnostic complex included ultrasound (US), hysteroscopy and hysterosalpingography. During the third stage, the course of pregnancy and the method of delivery in 115 (63,8%) women out of 180 in whom the desired pregnancy occurred in the range from 6 months to 5 years were analyzed.Results. Analysis of the postoperative period showed that the use of electrocoagulation worsens its course. So, in 12% of patients in group 3, subfebrile condition persisted for 6 days, which is 3,2 times more than in 1, and 3 times more than in 2 groups. ESR and leukocyte index were also significantly higher in 3 group. Against the background of an increase in leukocytes in patients of 3 group, unfavorable scar formation was also observed, which manifested itself in the form of a larger relative area of the vascular component. At the border of the myometrium and scar after myomectomy, leukocyte infiltrates were found in 18,2% of patients in 1 group and in 30,7% in 2 group, and after coagulation of the bed – in 100%. Therefore, it is advisable to plan natural childbirth in patients after myomectomy with suturing of the uterine wall, regardless of surgical access. However, there are some advantages of laparoscopic access with coagulation of the bed – the shortest duration of the operation and less intraoperative blood loss.After pre-pregnancy complex of diagnostic manipulations in 47 pregnant women out of 115 revealed signs of inferiority of the scar on the uterus after myomectomy, which was an indication for routine caesarean section (CS). But the frequency of detection of a defective scar was different in each group: in 1 groups and 2, the planned CS was performed for every fourth woman, in 3 group - for every second. These data indicate an adverse effect of laparoscopic coagulation of the fibroid bed on the healing of the myometrial scar. In the structure of indications for emergency CS in all comparative groups prevailed anomalies of labor, and in 3 group this fact was entirely associated with the threat of uterine rupture and scarring, while in parturients 1 and 2 groups - almost 2 times less often.In 35 patients with a scar on the uterus after myomectomy there were spontaneous preterm births by live full-term infants without asphyxia, of which 18 gave birth to group 1, 15 – 2 group, and only 2 women from 3 group gave birth per vias naturalis.Conclusions. The method of carrying out myomectomy does not affect the onset and course of pregnancy in the future, but it does matter on the ability of independent childbirth. In women who have not completed the reproductive program, it is necessary to suture the walls of the uterus during myomectomy, regardless of access. Electrocoagulation of the bed after removal of fibroids contributes to an increase in the frequency of threatening uterine rupture by 2 times. The decisive role in the management of childbirth with a myometrial scar is played not by the thickness of the lower segment, but by the presence of clinical manifestations of its failure (local soreness of the lower segment of the uterus, spotting from the genital tract, fetal hypoxia).
Uterine Rupture in the Second Trimester of Pregnancy as an Iatrogenic Complication of Laparoscopic Myomectomy
