Study finds myomectomy at cesarean section can be performed safely

An Egyptian retrospective cohort study of myomectomy during cesarean section (CS) in the Journal of Gynecology Obstetrics and Human Reproduction concluded that the procedure can be performed safely, without an increase in peripartum maternal morbidity.

Although myomectomy may prolong the operative time and the postoperative hospital stay, there are numerous potential benefits including avoiding a follow-up operation to remove uterine fibroids.

The study was conducted at Mansoura University Hospital in Egypt between January 2015 and December 2019 and included pregnant women diagnosed with uterine fibroids during the index pregnancy as documented antenatally and at surgery.¹

Women who underwent myomectomy during CS (intervention group; n = 91) were compared with women for whom myomectomy was not performed during CS (control group; n = 87).

In the intervention group, 72.5 % of women had one myoma and 27.5% had two myomas, compared to 70.1% of women in the control group with one myoma and 29.9% with two.

The two most frequent types of myoma for each group were interstitial and subserous: 38.5% and 39.6% prevalence in the intervention group and 37.9% and 46.0% in the control group, respectively.

The site of the myoma was the anterior uterine wall in 50.5% of cases in the intervention group and 55.2% in the control group, followed by the posterior uterine wall in 20.9% and 20.7% of cases, respectively.

The average size of the myoma was 7.54 cm in the intervention group and 7.90 cm in the control group.

There were no significant differences in the amount of blood transfusions or postoperative hemoglobin levels between the two groups.

The authors used procedures to minimize blood loss, including prophylactic rectal insertion of misoprostol, oxytocin infusion, and bilateral uterine artery ligation.

However, the mean operative time was significantly higher in the myomectomy group than in the control group: 80.22 minutes vs. 56.67 minutes (P < 0.001).

The mean length of postoperative hospital stay was 2 days in both groups, although the range was 1 to 4 days in the intervention group vs. 1 to 2 days in the control group (P < 0.001).

Removal of myoma during CS requires more time for adequate hemostasis, especially if more than one myoma is involved, according to the authors. The authors also previously inserted an intraperitoneal drain in all patients who underwent cesarean myomectomy for early identification of intraperitoneal hemorrhage and prevention of intraperitoneal collection of blood, thus patients needed a longer postoperative hospital stay for removal of the drain before discharge.

Despite employing perioperative aggressive procedures to try to minimize the risk of hemorrhage related to myomectomy, three complementary ligatures and two hysterectomies were required in the intervention group.

Furthermore, three patients had bilateral ligation of the anterior division of IIA to control bleeding, which was not adequately controlled by uterine artery ligation and oxytocin infusion, resulting in controlled bleeding in two of the patients, but failure in the other patient who underwent hysterectomy.

Cesarean hysterectomy was performed in only two patients, due to occurrence of intractable hemorrhage related to myomectomy. One cesarean hysterectomy was scheduled after failure of IIA ligation to control bleeding, while the other hysterectomy was undertaken without trial of IIA ligation.

However, no patient needed relaparotomy after cesarean myomectomy.

“The strength of our study lies in having a control group and including patients with more than one myoma with relatively larger sizes and different sites,” wrote the authors, whereas the retrospective nature of the study is a limitation.

The authors noted that a well-designed, multicenter, randomized controlled trial is necessary to make definitive conclusions about myomectomy at the time of CS.

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Reference

1. El-Refaie W, Hassan M, Abdelhafez MS. Myomectomy during cesarean section: a retrospective cohort study. J Gynecol Obstet Hum Reprod. Published online August 26, 2020. DOI:10.1016/j.jogoh.2020.101900