Myomectomy during cesarean section or non-caesarean myomectomy in reproductive surgery: this is the dilemma

Abstract

Nowadays it is quite common to encounter pregnants over 35 years with uterine fibroids (UFs), requiring cesarean section (CS). Large UFs may cause severe complications during delivery, as bleeding and hemorrhage, during vaginal or cesarean delivery. Frequently, the caesarean myomectomy (CM) is recommended, but generally obstetricians are reluctant to perform CM, since literature data do not agree on its surgical recommendation. CM is jet particularly controversial, due to increased risk of perioperative hemorrhage and cesarean hysterectomy, and UFs are often left in situ during cesarean section (CS). CM investigations are generally directed to myomectomy associated issues, whereas CS complications without CM are largely underreported. The risks of leaving UF for an interval myomectomy is underestimated and large UFs, left in uterus during CS, might cause significant early and late postoperative complications, even necessitating a relaparotomy and/or a subsequent hysterectomy. CM would be mandatory in some instances, whatever the UF diameter, to avoid further damage or complications. UFs management prior to CS should include a full counselling on pro and cons on the possible consequences of surgical decisioning. To illustrate what was discussed above, authors performed a narrative review with an expert opinion, reporting a case of a 31-year-old woman with a large UF who underwent a CS without myomectomy. Nine hours after CS, puerpera was submitted, for a massive postoperative hemorrhage and hemorrhagic shock, to an emergency relaparotomy with total hysterectomy without salpingo-oophorectomy.

Reflections on Postpartum Hysterectomy as a Possible Complication of Cesarean Myomectomy: A Long Debate

“…The authors suggested that the large-sized fibroid was the probable cause of the conservatively uncontrolled postpartum hemorrhage (PPH) and the need for a life-saving hysterectomy. They suggest that further studies on the topic will provide some additional insights regarding the risks of avoiding a CM [24].…”

Oxytocin infusion is a safe uterine bleeding controller alternative to blood transfusion in patients undergoing abdominal myomectomy

“…Unfortunately, most of these agents are expensive and show ineffective results. 12 Recently, synthetic oxytocin has emerged as a possible solution to reduce surgical bleeding during myomectomy. Oxytocin is commonly used as a uterotonic agent to control uterine bleeding during postpartum period.…”

Myomectomy during cesarian section: case report

“…4 It has been documented that a single CM is associated with a higher rate of bleeding when the leiomyoma diameter is more than 75 mm. 5 In pregnant women with coexisting fibroids, there are increased incidences of first-trimester losses, pressure symptoms, red degeneration, torsion of a pedunculated variant, malpresentation, preterm rupture of membranes and preterm labor during pregnancy, obstructed labor from a cervical or lower segment mass intrapartum and retained placenta, subinvolution of the uterus, postpartum endometritis, and postpartum hemorrhage in the immediate postpartum period. 4 Degeneration of leiomyoma occurs when there is a lack of blood supply to the fibroid and incidence increases as it grows in size.…”