CESAREAN MYOMECTOMY:TO DO OR NOT TO DO?

DR SACHIN VIJAY NAIKNAWARE. GYNAEC LAPAROSCOPIC SURGEON,MUMBAI,INDIA

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Fibroids are benign tumors of uterine smooth muscles generally affecting women in childbearing age with incidence of approximately 2% in pregnant women. these fibroids may be asymptomatic but if associated with pregnancy, there is an increased incidence of 1st trimester losses,increased pain,pressure symptoms due to big fibroids,malpresentation,premature rupture rupture of membranes,and preterm labour during pregnancy.sometimes lower segment myopia or cervical fibroid may cause obstructed labour and postpartum complication,may include sub involution of uterus,postpartum haemorrhage and retained placenta.

Many a times we encounter with a fibroid during cesarian section, but due to previous belief and dictum we try not to do myomectomy during cesarian and only go ahead with cesarean. this is done because of fear of excessive bleeding after myomectomy in pregnant patient because of increased vascularity.

Due to lack of multi-center randomised trial,appropriate selection criteria,surgical techniques and national and gynaecological society guidelines, it is left to individual experiences to go ahead and do myomectomy or not.

Now-a-days uterine myxomas associated or coexistent with pregnancy are going to be observed more than before because of practice of late marriages and improved diagnostic techniques, this article is an effort to put forward a balance view considering various individual studies in which myomectomy has been done along with cesarian section.

The management of myxomas encountered at cesarean still remains a dilemma as myomectomy during cesarean has traditionally been discouraged due to risk of intractable bleeding but resent studies has described techniques to control blood loss at cesarean myomectomy including uterine artery tourniquet, bilateral uterine artery ligation and electrocautery.

Roman AS et al compared the outcomes of 111 patients who had myomectomy at cesarean with 257 patients who underwent cesarean alone. in this study no significant difference has been found in intraoperative or postoperative complications between two groups.

In a large retrospective case control study by Li Hui et al assessed the effectiveness,safety, outcome and complications of myomectomy during cesarean section in chinese women with fibroid present since antenatal period. study group comprised 1242 pregnant women with fibroids who underwent myomectomy during cesarean section was compared with 3 control groups . GROUP A comprising of 200 pregnant women without fibroid. GROUP B comprises 145 women with fibroids who underwent cesarean alone GROUP C consisting of 51 women who underwent cesarean hysterectomy. No significant differences were noted between the groups in mean haemoglobin change, the frequency of haemorrhage, postoperative fever of hospital stay.these findings support the fact that myomectomy during cesarean section is safe and effective procedure and is not associated with significant complications.

Considering the above few case studies among many it can be said that myomectomy during cesarean is safe and not always a hazardous procedure in a carefully selected patients and performed by a skilled obstetrician.as preservation of an organ without loss of its function is always a greater surgical achievement than its destruction, myomectomy is usually preferred to hysterectomy.

from the above discussion some points can be considered while reaching at decision of whether to do a cesarean myomectomy or not

1. in a carefully selected patient and resourceful setting, myo-mectomy during cesarean section is safe and effective procedure at a tertiary centres in an experienced hands.
2. myo-mectomy during cesarean is not always a hazardous procedure and can be performed safely without significant complications.
3. fibroids obstructing lower uterine segment or accessible sub-serosal or pedunculate fibroids in a symptomatic patients can be safely removed.
4. rather than doing a classical cesarean section, in case of lower segment obstructing myoma , cesarean myo-mectomy can be considered a safe and effective alternative.
5. various homeostatic measures to decrease the blood loss such as bilateral uterine artery ligation, placement of uterine artery balloon catheters,uterine tourniquets, stepwise de-vascularisation and post cesarean uterine artery embolisation would optimise the outcome and may decrease the chances of hysterectomy.
6. myo-mectomy during cesarean section done in a conventional way with making an incision on myoma and enucleation of it is done. enucleation of myopia is easier in a gravid uterus owing to greater looseness of capsule . the dead space is obliterated with 1-0 vicryl interrupted sutures.

Considering above facts it can be concluded that myomectomy during cesarean section in a carefully selected patients is safe and effective procedure.