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Myomectomy During Cesarean Section – Time To
Reconsider?
Zion Ben-Rafael, Tamar Perri, Haim Krissi, Dov
Dicker and Arie Dekel
Department of Obstetrics and Gynecology, Rabin Medical Center, Petah
Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv,
Israel
Background
Myomectomy during cesarean section is strongly discouraged in all the leading
textbooks despite the lack of any direct evidence supporting the approach.
Leiomyomata are the most common gynecologic tumors, with a reported incidence of
20-25%. Fibroids are the most common indication for hysterectomy, accounting for
over 200,000 hysterectomies per year in the United States. Fibroids affect mainly
women in their childbearing years and may be asymptomatic or cause a variety of
symptoms, including menometrorrhagia, dysmenorrhea, pelvic pain, reproductive
failure, and compression of adjacent pelvic viscera. The estimated prevalence of
fibroids in pregnancy is 1-4% (1,2).
Management depends on the goal of therapy. Hysterectomy is most often used for
definitive treatment, and myomectomy when preservation of childbearing ability is
desired. Intracavitary and submucous leiomyomata can be removed by hysteroscopic
resection, whereas intramural and subserosal fibroids are usually removed by
laparotomy. Although laparoscopic myomectomy is also technically feasible today, it
apparently has an increased risk of uterine rupture during pregnancy. Gonadotropin-
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releasing hormone-agonist induces hypogonadism and can reduce the volume of
leiomyomata, but its severe side effects and association with prompt recurrences
makes them useful only for short-term goals such as reversing anemia or shrinking an
intracavitary tumor prior to hysteroscopic resection. New approaches such as
myolysis and uterine artery embolization are currently being evaluated and may offer
more options providing their safety in women desiring fertility is established (3).
According to Te Linde (4) “ Myomectomy delivery in conjunction with cesarean
section is contraindicated. If there is a pedunculated subserous fibroid attached to the
uterus with a small pedicle, suturing and excision of the pedicle may be done easily.
However, the removal of intramural myomata from the pregnant uterus is inadvisable
due to recognized difficulty in controlling blood loss”. Bleeding may be profuse and
lead to hysterectomy. According to other textbooks, myomas resected during
pregnancy may show bizarre nuclear changes often resembling sarcoma. Furthermore,
they often undergo remarkable involution after delivery when myomectemy is much
safer (5,6). Our computer medline search yielded only one study supporting this
finding, where in large intramural leiomyomas found at cesarean section became
pedunculated postpartum, making them more amenable to myomectomy (7).
Otherwise, we were able to identify very few articles concerning myomectomy during
cesarean sections, with the majority reporting favorable results. In 1989, Burton and
colleagues (8) reported on 13 successful cesarean myomectomies with the sole
complication of intraoperative hemorrhage. They concluded that surgical management
of leiomyomata during pregnancy (and cesarean section) is safe in carefully selected
patients. Four years later, Hsieh et al (9) reviewed 47 incidental cesarean
myomectomies. The procedure added only 11 minutes to the operation time, 112 ml
to the operative blood loss and a half-day to hospitalization time. There were no
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wound infections or serious morbidity. Exacoustos et al (1) reported on nine
myomectomies performed during cesarean delivery. Of which three were complicated
by severe hemorrhage necessitating hysterectomy. They emphasized the importance
of ultrasound findings of myoma size, position, location, relationship to the placenta,
and echogenic structure in identifying women at risk of myoma-related complications.
Michalas and colleagues (10) described a patient in whom 8 fibroids obstructing the
lower part of the uterus were removed during cesarean section in the 39th week of
pregnancy. There were no maternal or fetal complications.
In 1999, Dimitrov and co-workers (11) in Bulgaria conducted a prospective study to
evaluate whether myomectomy could be performed on a routine basis during cesarean
section. In a comparison of 21 women in whom myomectomy was done during
cesarean section and 162 consecutive women after cesarean section without
myomectomy, they found that myomectomy during cesarean section increased
hemorrhage by 10%. Placental disorders (abruptio placentae and placenta previa)
were the main cause of the overall increase in blood loss. There were no postoperative
complications. The authors concluded that irrespective of the number and magnitude
of the myomas, myomectomy during cesarean section is a feasible option. The same
year, Omar and colleagues (12) described 2 large uterine myomas located in the
anterior aspect of the lower segment of the uterus complicating pregnancy at term.
Myomectomy in both instances allowed delivery of the fetus through the lower
segment, making vaginal delivery in subsequent pregnancies possible. In the most
recent study of this issue, Ehigiegba et al (13) assessed the intra- and postoperative
complications of cesarean myomectomy in 25 pregnant women. Five required blood
transfusions and none required a hysterectomy. They concluded that with adequate
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experience and the use of high dose oxytocin infusion (intra- and post-operatively),
myomectomy at cesarean section is not as hazardous as many now believe.
For the last 7 years we have been performing planned myomectomy during cesarean
section in cases in which the fibroid is known to be large enough to require surgery in
the future or is the cause of malpresentation. Meticulous attention is directed to
hemostasis, with enucleation using sharp dissection with Metzenbaum scissors and
adequate approximation of the myometrium and all dead spaces to prevent hematoma
formation. An experienced surgeon performed the first operations, but the procedure
is now more common and is performed by different surgeons including residents.
In the light of the inconclusive data in the literature, we conducted the present
retrospective analysis.
Objective
To assess the intra- and postoperative complications of cesarean myomectomy.
Methods
After completion of the CS, an interlocked suture was temporarily placed on the
uterine incision without closing it. This allowed working from within or from the
outer part of the uterus without having any significant bleeding from the incision.
Myomectomy was performed using sharp dissection. Oxytocin drip was given during
and after the enucleating the fibroid..
The files and operative records of 32 consecutive patients who underwent cesarean
myomectomy between 1997 and 2001 were reviewed for demographics, indication for
cesarean section, emergency or elective procedure, and characteristics of the fibroids.
Outcome measures were type of anesthesia, type of incision, intraoperative blood loss,
need for blood transfusion, intra- or postoperative complications, and duration of
hospital stay.
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Results
Thirty-nine myomas were removed from the 32 patients in 15 elective and 17
emergency procedures. Indications for cesarean section were obstetric (breech
presentation, more than one previous cesarean section, etc) in 26 women. Of the
reminder 3 had tumor previa, 1 degenerative myoma, and 2 previous myomectomy
with uterine cavity penetration. Ninety percent of the myomas were subserous or
intramural and 10% were submucous. Average size (largest dimension) was 6 cm
(1.5-20), with 26 myomas > 3 cm and 11 > 6 cm. Four sections (12.5%) were
classical and the reminder low segmental. Three operations were done with regional
anesthesia (9.3%) and the reminder with local anesthesia (spinal block). The
difference in hemoglobin and hematocrit levels before and 12 hours after the
operation was statistically significant compared with a group of women who
underwent cesarean section without myomectomy (p<0.05); however only 4 patients
required blood transfusion. Re-operation was done in one patient with 2 large
myomas and excessive bleeding and in another because of a hematoma below the
scar. None of the patients required hysterectomy. Six patients had postpartum fever
(18.7%). Average duration of hospitalization was 5.7 days, with 5 patients requiring
more than 6 days. There was no correlation between complications or duration of
hospital stay and patient age, gravidity, parity or indication for cesarean section.
Conclusions
Myomectomy during cesarean section is feasible. Meticulous attention to hemostasis
with enucleation using sharp dissection with Metzenbaum scissors and adequate
approximation of the myometrium and all dead spaces to prevent hematoma
formation can increase the safety of the procedure. Despite the lack of prospective
randomized studies we believe that myomectomy during cesarean section is an easy
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and safe procedure when done appropriately. The old dictum discouraging cesarean
myomectomy should be reassessed.
References
1. Exacoustos C, Rosati P, Ultrasound diagnosis of uterine myomas and
complications in pregnancy. Obstet Gynecol. 1993;82:97-101
2. Rice JP, Kay HH, Mahony BS, The clinical significance of uterine
leiomyomas in pregnancy Am J Obstet Gynecol 1989;160(5 Pt 1):1212-6
3. Haney AF, Clinical decision making regarding leiomyomata: what we need in
the next millenium. Environ Health Perspect 2000;108 Suppl 5:835-9
4. Te Linde’s Operative Gynecology; Mattingly RF: fifth edition JB Lippincott
Co, Philadelphia 1977 p219
5. Cunningham FG, Norman FG, Kenneth JL, Gilstrap LC iii, Hauth JC,
Wenstrom KD, editors, Abnormalities of the reproductive tract. In: Williams
Obstetrics, 20st edition, McGraw-Hill Medical Publishing Division, 1997, 651.
6. Cunningham FG, Norman FG, Kenneth JL, Gilstrap LC iii, Hauth JC,
Wenstrom KD, editors, Abnormalities of the reproductive tract. In: Williams
Obstetrics, 21st edition, McGraw-Hill Medical Publishing Division, 2001, 930.
7. Haskins RD Jr, Haskins CJ, Gilmore R, Borel MA, Mancuso P, Intramural
leiomyoma during pregnancy becoming pedunculated postpartally. A case
report. J Reprod Med 2001;46:253-5
8. Burton CA, Grimes DA, March CM, Surgical management of leiomyomata
during pregnancy. Obstet Gynecol 1989;74:707-9
9. Hsieh TT, Cheng BJ, Liou JD, Chiu TH, Incidental myomectomy in cesarean
section (abstart). Changgeng Yi Xue Za Zhi 1989;12:13-20
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10.
Michalas SP, Oreopoulou FV, Papageorgiou JS, Myomectomy during
pregnancy and caesarean section. Hum Reprod 1995;10:1869-70
11.
Dimitrov A, Nikolov A, Stamenov G, Myomectomy during cesarean section
(Abstract). Akush Ginekol (Sofiia) 1999;38:7-9
12.
Omar SZ, Sivanesaratnam V, Damodaran P, Large lower segment myoma-myomectomy at lower segment caesarean section--a report of two cases.
Singapore Med J 1999;40:109-10
13.
Ehigiegba AE, Ande AB, Ojobo SI. Myomectomy during cesarean section. Int
J Gynaecol Obstet. 2001;75:21-5