The Trend in Cesarean Myomectomies and The Risk of Obstetrical Complications in Korea

Background To evaluate the pregnancy outcomes and the risk of adverse obstetrical outcomes from cesarean myomectomy (CM) compared to cesarean section (CS)-only and to investigate the trend of surgeons in choosing CM. Methods A retrospective cohort study was done of all patients who underwent CS that was complicated with leiomyoma at two university hospitals from January 2010 to May 2020. All patients were categorized into the CM group or the CS-only group. We analyzed the demographic factors, obstetric factors, surgical outcomes, and possible risk factors for adverse outcomes between the two groups. Results A total of 438 women in the CS-only group and 341 women in the CM group were included. Women who underwent CS-only had significantly more history of a previous myomectomy and multiple leiomyomas compared to women who underwent CM. The gestational days at delivery and the pregnancy complications were significantly higher in the CS group. The mean size of the leiomyomas was larger in the CM group than in the CS only group (5.8 ± 3.2 cm vs 5.2 ± 3.1 cm, P = 0.005). Operation time and history of previous CS and preterm labor were higher in the CM group. It seems that preterm labor and abnormal presentation were relatively higher in the CM group than in the CS group due to the presence of leiomyoma. There were no significant differences in the pre and postoperative hemoglobin levels. The size of the leiomyoma (odds ratio [OR] = 1.162; 95% confidence interval [CI]: 1.07 – 1.25; P < 0.001) and operation time > 60 minutes (OR = 2.461; 95% CI: 1.45 – 4.15) were significant independent predictors of adverse outcomes after CM. Conclusions Cesarean myomectomy is a reliable and safe approach to prevent the need for another operation for remnant leiomyoma. In this study, surgeons seemed to perform CM when uterine leiomyomas were large, the subserosal type, or few in number. Standardized treatment guidelines for myomectomy during cesarean section in pregnant women with uterine fibroids should be established.

The dilemma of cesarean myomectomy: Is it safe or not?

To evaluate the safety and effectiveness of myomectomy during cesarean section. The data of fifty-four pregnant who underwent cesarean myomectomy and twenty-six pregnant with uterine leiomyoma who had cesarean section without myomectomy between the years of 2017 and 2020 in our tertiary clinic were examined retrospectively. There was no significant difference in terms of maternal age, weeks of gestation, gravida, parity, use of additional uterotonics, type of leiomyoma, size of leiomyoma, cesarean indications, blood transfusion requirement, postoperative fever, preoperative hemoglobin (g/dl), change in hemoglobin (g/dl), preoperative hematocrit (%), change in hematocrit (%), length of hospital stay between the two groups (p˃0.05). While no significant difference was observed according to the location of the leiomyomas between the anterior, fundal and posterior location between the two groups, cervical leiomyomas were significantly higher in the CS group (p˂0.05). This study shows that cesarean myomectomy is a safe procedure in selected cases. It also offers the advantage of avoiding a second operation in patients.

A case series of caesarean myomectomy

Uterine fibroids are benign, monoclonal tumors of smooth muscle cells of the myometrium. Most fibroids do not increase in size during pregnancy and are not always removed when encountered during cesarean section. Objective was to see the outcome of patients undergoing cesarean myomectomy. The study design was observational study. All patients undergoing cesarean section with uterine fibroid of size more than 5 cm. In carefully selected patients and with use of intraoperative vasopressin, myomectomy may be safely accomplished at the time of caesarean section by experienced surgeons. cesarean myomectomy is safe and successful if patient selection is done carefully and does not add to any additional post-operative morbidity.

Cesaraean myomectomy: A lesson learnt

Cesarean myomectomy (CM) has been a controversial surgical procedure. It is fraught with increased blood loss and its associated postoperative morbidities of anemia, blood transfusion and sepsis or even an unintended obstetric hysterectomy. This case reports a life-threatening hemorrhagic shock in a patient for whom 2 large myomas were extracted during cesarean section. Safety of CM depends on proper case selection with small sized, subserous, pedunculated fibroids and the speed and skill of surgeon.

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.

Cesarean myomectomy: a case report and review of the literature

Background Routine myomectomy at the time of cesarean section has been condemned in the past due to fear of uncontrolled hemorrhage and peripartum hysterectomy. It is still a topic of debate worldwide. However, in recent years, many case studies of cesarean myomectomy have been published validating its safety without any significant complications. Case presentation We describe the case of a 27-year-old gravida 2 para 1 live birth 1 North Indian woman with one previous lower segment caesarean section (LSCS) at 35 weeks with labor pains and scar tenderness. Her recent ultrasound (USG) report suggested a single live intrauterine pregnancy with an intramural fibroid of 8.6 × 6.5 cm located in the left anterolateral wall of the lower uterine segment. The patient was taken up for emergency cesarean section along with successful removal of the myoma, which was bulging into the incision line, causing difficulty in closure of the uterine wound. Prophylactically, oxytocin infusion, bilateral ligation of uterine arteries, and injection vasopressin (diluted) was administered to decrease the blood loss. The patient was discharged after 7 days without any complications. Conclusions Routine myomectomy at the time of cesarean section is not a standard procedure and is not accepted worldwide. However, it may be considered a safe option in carefully selected cases in the hands of an experienced obstetrician with appropriate hemostatic technique. Large multicenter randomized controlled trials should be conducted to evaluate the best practice guidelines for cesarean myomectomy.

Caesarean Myomectomy among Patients Undergoing Lower Segment Caesarean Section in a Tertiary Care Center

Pregnancy with uterine myoma increases the risk of abortion, fetal malpresentation, placenta previa, postpartum hemorrhage, hysterectomy and risk to neonate and mother. Caesarian myomectomy is a safe and cost-effective procedure especially when performed by an experienced surgeon only in selected cases. Here, we present our experiences of cesarean myomectomy on ten patients presenting to our center in a period of one year. The most common indications were breech presentation and previous cesarean section. The most common site was anterior, except one which was posterior and the common type is intramural. Despite prophylactic measures, two cases had a postpartum hemorrhage of 2000ml and 700ml, respectively and one even received a blood transfusion. No cases of hysterectomy, neonatal morbidity and mortality were noted in these cases. In our experience, cesarean myomectomy in uterine fibroids has been a safe procedure with limited intraoperative and postoperative complications.