Miomectomia concomitentă operației cezariene: controverse, indicaţii şi complicaţii

Introduction

Uterine myomas are the most common pelvic tumors in women, intramural fibroids being the most commonly observed type, accounting for 33-35% of all fibroids. The incidence of uterine myomas during pregnancy ranges from 0.5% to 5% of all pregnancies and with prevalence peaks between 30 and 39 years old⁽¹⁾. Age serves as a significant risk factor for fibroid development, and with the trend of delayed childbearing, myomas are increasingly identified during pregnancy. As a result, obstetricians are encountering a growing number of pregnant patients with myomas, necessitating the management of associated complications. In pregnant women with fibroids, there is an elevated risk of complications such as spontaneous abortion, malpresentation, placenta praevia, preterm birth, caesarean delivery, and both peripartum and postpartum hemorrhage.

Myomectomy during caesarean section remains a subject of ongoing debate. Historically, it has been discouraged due to concerns about the risk of uncontrolled hemorrhage and the potential challenges in closing the fibroid cavity⁽²⁾. Most obstetricians are trained to avoid removing uterine fibroids during caesarean deliveries, except in cases where the fibroids are small and pedunculated. However, the emerging evidence suggests that, with appropriate case selection, performing myomectomy during caesarean section can be a safe procedure and may improve pregnancy outcomes in subsequent gestations compared to cases where fibroids are left untreated⁽³⁾. Most experts advise against removing large or intramural myomas during caesarean delivery. Performing myomectomy at the time of caesarean section eliminates the need for a subsequent surgical intervention, thereby reducing overall healthcare costs and preventing myoma-related complications in future pregnancies. Furthermore, performing myomectomy during caesarean section has been shown to facilitate uterine involution during the postpartum period and decrease the risk of fibroid-related complications later in life, including menorrhagia, anemia and pain. The contractile activity of the postpartum uterus contributes positively to fibroid excision by aiding in hemostasis and minimizing intraoperative bleeding⁽⁴⁾.

Myomas exceeding 5 cm in diameter have been associated with adverse obstetric outcomes such as preterm labor, premature rupture of membranes and postpartum hemorrhage. Recent findings indicate that myomectomy can be performed safely during caesarean delivery when careful consideration is given to factors such as uterine contractility, anatomical location, number and size of myomas, and the proximity of large vascular structures⁽⁵⁾.

Indications and contraindications
for myomectomy during caesarean section

The existing literature indicates that coagulopathy disorders and fibroid localization near major pelvic vessels are significant risk factors for severe perioperative and postoperative hemorrhage, often rendering cesarean myomectomy contraindicated. Conver­sely, fibroids located in the lower uterine segment that obstruct the safe delivery of the fetus or complicate uterine suturing may necessitate removal during caesarean delivery. Despite the recognition of specific scenarios where caesarean myomectomy is warranted, the standardized guidelines for this procedure are lacking, highlighting the need for further research to establish clear recommendations⁽⁶⁾.

The established indications for the removal of uterine fibroids during caesarean section include atypical intraoperative appearance of fibroids, obstruction of the lower uterine segment that hinders fetal delivery, and the presence of pedunculated or anterior fibroids. Additionally, fibroids that complicate uterine wound closure, resulting in significant blood loss, may also warrant removal during the procedure⁽⁷⁾.

Optimal hemostasis techniques
in caesarean myomectomy

When considering caesarean myomectomy, specific precautions should be taken to minimize the risk of hemorrhage and other complications. The selection of the abdominal incision should ensure adequate surgical exposure, with a classical uterine incision being necessary in cases where access to the lower uterine segment is challenging. Pharmacological measures to reduce the bleeding risk should be implemented, including the administration of intravenous tranexamic acid prior to the procedure and intravenous oxytocin at the time of fetal delivery. The use of additional uterotonics was defined as the administration of oxytocin, prostaglandins, or both, beyond the routine perioperative and postoperative administration of oxytocin, as specified by hospital protocols and international guidelines⁽⁸⁾. Oxytocin can be administered either intravenously or by local injection. Additionally, the application of a hemostatic tourniquet after delivery but before fibroid removal can further mitigate the intraoperative blood loss. It is essential for the surgical and anesthetic teams to be prepared for prolonged operative time, extended anesthesia exposure, and potential substantial blood loss. In a study involving a control group for subserosal and intramural fibroids, a dilute oxytocin solution was injected into the fibroid pseudocapsule to reduce perioperative hemorrhage. However, the results indicated no significant difference in blood loss between the groups⁽⁹⁾. Another study introduced the use of the purse-string suture (PSS) technique for caesarean myomectomy. This technique is predicated on the principle that the blood supply to uterine fibroids arises from vascular extensions within the uterine wall at the fibroid’s base. Consequently, ligating and securing sutures at the fibroid base effectively reduces its blood supply. Tightening the suture causes the fibroid to protrude progressively, thereby facilitating its excision from the uterine wall. This method nearly completely obstructs the fibroid’s blood supply. The findings suggested that the PSS technique effectively minimizes perioperative bleeding without causing substantial defects in the uterine wall⁽¹⁰⁾. Bilateral uterine artery ligation performed immediately after fetal delivery has been shown to significantly reduce intraoperative and postoperative blood loss, as well as the risk of peripartum hysterectomy. This intervention also decreases the likelihood of myoma recurrence and the necessity for future surgeries, without adversely affecting fertility⁽¹¹⁾.

Patients who undergo caesarean myomectomy require close monitoring during the postpartum period for signs of hemorrhage. Hemorrhage may present as vaginal bleeding or intraperitoneal bleeding, therefore vigilant monitoring of vital signs along with thorough vaginal and abdominal examinations are essential. To enhance the detection of intraperitoneal bleeding, the placement of a peritoneal drain may be considered, as was implemented in the management of our patients⁽¹²⁾.

A retrospective study involving a large patient cohort indicates that performing myomectomy during caesarean section increases the likelihood of transfusion requirements, without elevating the risk of hysterectomy or other life-threatening complications. Another retrospective case-control study was conducted comparing 40 women with fibroids who underwent caesarean myomectomy to a control group of 80 women with fibroids who underwent caesarean section alone. The study found no statistically significant difference in the incidence of hemorrhage between the two groups, which was reported as 12.5% and 11.3%, respectively⁽¹³⁾.

Personal insights and surgical techniques

In our practice, an essential element in the evaluation of pregnancies monitored by ultrasound during the first trimester is the mapping of fibroids using the FIGO classification. The FIGO classification is included in the Romanian Society of Obstetrics and Gynecology (SOGR) guidelines for gynecological ultrasound examination⁽¹⁴⁾. We typically employ a Pfannenstiel incision, which provides adequate access even for fibroids with challenging locations. During the decapsulation and excision of the fibroid, we secure the main pedicles of the fibroid. We utilize the figure-of-eight (FOE) suture technique for achieving hemostasis following myomectomy. This technique is straightforward, easy to perform, and effectively reduces the risk of rebleeding. The myoma bed represents a potential site for hematoma formation if not adequately closed. Closure is achieved by inserting the needle at the upper right corner of the incision or bleeding site and exiting at the lower left corner, followed by re-entry at the lower right corner and exiting at the upper left corner. The suture is then tightened, and a knot is secured. The hemostatic mechanism of this technique relies on applying pressure to facilitate the closure of blood sinuses at the bleeding site. Additionally, it shortens the duration of bed rest and alleviates patient’s discomfort. In cases where bleeding occurs at the myometrial suture site, we never use “X” sutures. Instead, hemostasis at the myometrial puncture sites is achieved through “U” sutures. We ensure that the myometrial sutures achieve maximum depth, incorporating all layers of the uterine wall. Uterine artery ligation is reserved for cases of uncontrolled bleeding, and it is not performed as a first-line intervention, given its role as a preparatory step for hysterectomy. We avoid addressing isolated, small, deeply intramyometrial fibroids classified as FIGO 3. Furthermore, in our medical practice, we do not address myomas whose excision would require opening the uterine cavity, focusing exclusively on FIGO types 5, 6 and 7 myomas. Postoperatively, we routinely place a drainage tube and administer oxytocin, prostaglandins and uterotonics for the following 12 hours. To date, our surgical cases have been free from severe bleeding complications, and the postoperative outcomes have been favorable.

Conclusions

The decision of whether to perform myomectomy during caesarean section remains a topic of ongoing debate. Many obstetricians are hesitant to undertake this procedure because of the associated risk of uncontrollable perioperative hemorrhage. These concerns are well founded, as the enhanced blood flow to the uterine arteries during pregnancy significantly elevates the risk of acute perioperative bleeding in caesarean myomectomy cases. The current guidelines support the performance of myomectomy during caesarean section, as experienced surgeons, operating under appropriate conditions, are generally able to effectively manage the potential complications.   

Corresponding author: Mădălina-Nicoleta Mitroiu E-mail: madalina@mitroiu.com

Conflict of interest: none declared.

Financial support: none declared.

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