Key words
cesarean section - cesarean myomectomy - complications - myoma
Schlüsselwörter
Kaiserschnitt - Kaiserschnitt mit Myomektomie - Komplikationen - Myom
Introduction
Uterine myoma is the most common pelvic tumor in women; its prevalence increases between
the ages of 30 and 39 years [1]. Myomas reach their largest dimensions during the reproductive years and the reported
incidence of myomas in pregnancy is 0.05 – 5% [2]. Given that maternal age at pregnancy is increasing and the incidence of myoma also
increases with age, the likelihood is rising that obstetricians will encounter pregnant
patients with myomas and will need to treat the associated complications [3], [4], [5], [6], [7]. Although the rate of myomectomy procedures performed during cesarean sections is
increasing, many obstetricians are reluctant to perform this combined procedure as
they are worried about the potential morbidity and mortality rates due to uncontrollable
bleeding [1]. The majority of authors are opposed to removing large or intramural myomas during
cesarean section [6], [8]. However, a patient who undergoes myomectomy during cesarean section will not require
a second operation. This lowers the overall cost and prevents the risk of myoma-related
complications in subsequent pregnancies [9]. In addition, myomectomy during C-section accelerates puerperal involution and reduces
fibroid-related complications which can develop in later life, such as menorrhagia,
anemia and pain [10]. Myomas with diameters of more than 5 cm have been reported to be related to pre-term
labor, premature rupture of membranes and postpartum hemorrhage [10], [11]. Most studies have shown that myomectomy can be safely carried out if various factors
such as uterine contractility, anatomic localization, number and diameter of myomas,
and the presence of large vascular structures are taken into account [12], [13].
The aim of this study was to retrospectively evaluate the experience of a non-tertiary
care center of myomectomy performed during cesarean section and to investigate the
safety and feasibility of cesarean myomectomy.
Method
This retrospective study was conducted in a single center. The patient records for
the period between 2000 and 2015 were examined. The records of all cesarean sections
performed in that period were evaluated.
Investigated parameters and data collection
Patient data such as age, gravidity, week of gestation, duration of operation, duration
of hospitalization, indication for cesarean section, and the diameter and localization
of myomas were noted. Informed consent was obtained from all patients diagnosed with
uterine myoma prior to surgery. The patients served by our hospital are generally
low-income patients living in rural areas. Patients do not always seek medical help,
because they often have serious difficulties in accessing the healthcare center. Therefore,
if a myoma is diagnosed during surgery we are inclined to perform a myomectomy, as
it would otherwise require a surgical procedure at a later date. Nevertheless, we
avoid performing myomectomy if we consider it to be unnecessary or are of the opinion
that this would result in a greater risk for the patient. The assessment depends entirely
on the surgeonʼs knowledge and experience.
Prepartum to postpartum changes in hemoglobin levels and complications were recorded.
Organ damage, hemorrhage and uterine atony were considered complications. The focus
was on recorded complications (e.g., organ damage, hemorrhage and uterine atony),
postoperative drop in hemoglobin levels, and blood transfusion requirements. The women
were divided into two groups according to whether cesarean myomectomy was performed
or not. All operations were performed by surgeons who are very experienced in managing
bleeding complications. The indication for myomectomy was made by the surgeon, based
on his knowledge and experience. The two groups were compared with regard to duration
of hospitalization, transfusion rates, complications, and differences in the drop
in hemoglobin levels. Additional parameters compared in this study were age, gravidity,
week of gestation and the number and diameter of the myomas.
These parameters were also compared for cases with a myoma diameter of more than 5 cm
[14]. Myomectomy was performed using the classic techniques of blunt and sharp dissection.
After incising the tissue over the myoma to enter the fibroid pseudocapsule, blunt
and sharp dissection was carried out using scissors. Bleeding was controlled by suturing
the myoma bed with no. 1 absorbable sutures. As the study was retrospective, approval
by the Ethics Committee was not required. The study was approved by the institutional
review board.
Statistical analysis
Statistical analysis was done using the NCSS 2007 software (Number Cruncher Statistical
System; Kaysville, Utah, USA). Studentʼs t-test was used to compare differences in
age, gravidity and week of gestation between the two groups “cesarean myomectomy”
and “no myomectomy”. Mann-Whitney U-test was used to compare the duration of the operation,
length of hospital stay, numbers and diameters of myomas, and preoperative and postoperative
differences in hemoglobin levels between the two groups. Multivariate logistic regression
analysis was used to compare variables. Myoma type and the time of diagnosis were
assessed using Pearsonʼs Chi-square test, and transfusion rates were compared with
Yateʼs Continuity Correction test. Differences in hemoglobin levels in cases with
myoma diameters of 5 cm and above were evaluated by Mann-Whitney U-test, and Fisherʼs
exact test was used to compare complications and transfusion rates. Values of p < 0.01
and p < 0.05 were considered statistically significant.
Results
Demographics
There was a total of 23 150 births in the period between 2000 and 2015 at this non-tertiary
center, of which 8755 were cesarean deliveries. Myoma was diagnosed during or prior
to cesarean section in 361 cases and these cases were included in our study. The total
number of myomas, including cases with multiple myomas, was 415. The mean patient
age was 30 years, mean gravidity was 3, and mean week of gestation was 39. Diagnosis
was made during surgery in 196 (54.3%) cases and in the antenatal period in 165 (45.7%)
cases. The minimum duration of operation was 20 minutes and the maximum duration was
110 minutes. Mean length of hospital stay was 2 days, and myoma diameters ranged from
1 to 12 cm. The myoma type was intramural in 180 cases and subserosal in 181 cases
([Table 1]). All patients received 20 units of oxytocin infusion intraoperatively and 40 units
postoperatively. Prophylactic cefazolin 1 g was administered preoperatively. Indications
for cesarean section are listed in [Table 2].
Table 1 Patient characteristics, operation times, duration of hospitalization, number of
myomas.
|
|
Min – Max (median)
|
Mean ± SD
|
|
Age (years)
|
13 – 52 (30)
|
30.32 ± 5.78
|
|
Gravidity
|
1 – 10 (3)
|
3.37 ± 1.67
|
|
Parity
|
0 – 9 (2)
|
2.28 ± 1.61
|
|
Age of gestation (week)
|
32 – 42 (39)
|
38.31 ± 1.65
|
|
Duration of operation (min)
|
20 – 110 (34)
|
38.38 ± 11.22
|
|
Duration of hospitalization (days)
|
1 – 24 (2)
|
2.31 ± 1.93
|
|
Number of myomas
|
1 – 4 (1)
|
1.19 ± 0.47
|
|
Myoma diameter (in cm) (n = 434)
|
1 – 12 (3)
|
3.35 ± 2.25
|
Table 2 Indications for cesarean section.
|
|
n (%)
|
|
Foot presentation
|
2 (0.6)
|
|
Cephalopelvic disproportion
|
30 (8.3)
|
|
Placental abruption
|
5 (1.4)
|
|
Fetal distress
|
35 (9,7)
|
|
Previous cesarean section
|
243 (67.3)
|
|
Patientʼs request
|
1 (0.3)
|
|
Cord prolapse
|
1 (0.3)
|
|
Breech presentation
|
31 (8.6)
|
|
Previous myomectomy
|
1 (0.3)
|
|
Patient with diagnosed myoma
|
1 (0.3)
|
|
Oblique presentation
|
3 (0.8)
|
|
Oligohydramnios
|
2 (0.6)
|
|
Preeclampsia
|
3 (0.8)
|
|
Placenta previa
|
1 (0.3)
|
|
Transverse presentation
|
2 (0.6)
|
Comparison of patients with and without cesarean myomectomy
A total of 212 patients underwent cesarean myomectomy, and 149 patients did not have
concomitant myomectomy. The type of anesthesia used in the cesarean myomectomy group
was general anesthesia in 104 patients and spinal anesthesia in 108 patients; in the
non-myomectomy group 73 patients had general anesthesia and 76 patients received spinal
anesthesia.
In the cesarean myomectomy group, the duration of operation was longer and the mean
diameter of the myoma was smaller (p < 0.05). However, transfusion and complication
rates were similar for the two groups (p > 0.05) ([Table 3]). A statistically significant difference in preoperative and postoperative hemoglobin
levels was recorded for both groups (p < 0.05). The drop in hemoglobin levels was
similar for both groups (p > 0.05) ([Table 4]). Cases with myoma diameters of 5 cm and above were compared for the two groups.
The operation took longer in the cesarean myomectomy group (p < 0.05), but no differences
were found with regard to complication rates, transfusion requirements and drop in
hemoglobin levels (p > 0.05) ([Table 5]). All other parameters with the exception of gravidity, parity and week of gestation
had no impact on myomectomy ([Table 6]). At operation, the size of the uterine fibroid determined whether myomectomy was
performed or not. The impact of gravidity, parity, and week of gestation on myomectomy
can be explained by their effect on myoma size. We noted that as the number of previous
pregnancies, parity and week of gestation increased, the diameter of the fibroids
decreased ([Table 7]).
Table 3 Comparison of myomectomy and non-myomectomy groups.
|
|
Cesarean myomectomy (n = 212)
|
Non-myomectomy (n = 149)
|
p
|
|
a Studentʼs t-test, b Mann-Whitney U-test, c Pearsonʼs χ2 test, d Yatesʼs Continuity Correction test
* p < 0.05, ** p < 0.01
|
|
Age (years)
|
Mean ± SD (median)
|
30.26 ± 5.50 (30)
|
30.40 ± 6.17 (31)
|
a0.823
|
|
Gravidity
|
Mean ± SD (median)
|
3.41 ± 1.50 (3)
|
3.31 ± 1.89 (3)
|
b0.135
|
|
Parity
|
Mean ± SD (median)
|
2.27 ± 1.38 (2)
|
2.30 ± 1.89 (2)
|
b0.334
|
|
Age of gestation (week)
|
Mean ± SD (median)
|
38.47 ± 1.42 (39)
|
38.09 ± 1.92 (38)
|
a0.031*
|
|
Duration of operation (minutes)
|
Mean ± SD (median)
|
41.28 ± 13.41 (40)
|
36.34 ± 8.87 (34)
|
b0.002**
|
|
Length of hospital stay (days)
|
Mean ± SD (median)
|
2.42 ± 2.45 (2)
|
2.15 ± 0.70 (2)
|
b0.825
|
|
Number of myomas
|
Mean ± SD (median)
|
1.16 ± 0.38 (1)
|
1.24 ± 0.58 (1)
|
b0.301
|
|
Myoma diameter (cm) (n = 361)
|
Mean ± SD (median)
|
3.07 ± 2.21 (2)
|
3.81 ± 2.36 (3)
|
b0.001**
|
|
Type of myoma
n (%)
|
Intramural
|
116 (54.7)
|
64 (43.0)
|
|
|
Subserosal
|
96 (45.3)
|
85 (57.0)
|
c0.028*
|
|
Diagnosis obtained by
n (%)
|
Ultrasonography
|
109 (51.4)
|
56 (37.6)
|
c0.009**
|
|
Laparatomy
|
103 (48.6)
|
93 (62.4)
|
|
Transfusion required
|
No
|
199 (93.9)
|
142 (95.3)
|
d0.724
|
|
Yes
|
13 (6.1)
|
7 (4.7)
|
|
Complications
|
No
|
205 (96.7)
|
135 (90.6)
|
d0.594
|
|
Yes
|
7 (3.3)
|
14 (9.4)
|
Table 4 Drop in hemoglobin levels between groups.
|
|
Cesarean myomectomy
mean ± SD
|
Non-myomectomy
mean ± SD
|
p
|
|
a Studentʼs t-test, b Mann-Whitney U-test, c Paired samples t-test
* p < 0.05, ** p < 0.01
|
|
Hemoglobin level (g/dL)
|
Preoperative
|
11.42 ± 1.26
|
11.73 ± 1.46
|
a0.025*
|
|
Postoperative
|
10.17 ± 1.42
|
10.35 ± 1.42
|
a0.236
|
|
cp-value
|
0.001**
|
0.001**
|
|
|
|
Difference (median)
|
1.24 ± 0.75 (1.1)
|
1.38 ± 0.81 (1.2)
|
b0.111
|
Table 5 Comparison of large myomas in the myomectomy and non-myomectomy groups.
|
|
Cesarean myomectomy (n = 66)
|
Non-myomectomy (n = 31)
|
p
|
|
a Studentʼs t-test, b Mann-Whitney U-test, c Fisherʼs exact test
p < 0.01
Hgb: hemoglobin (g/dL)
|
|
Preoperative Hgb level
mean ± SD (median)
|
11.37 ± 1.25 (11.5)
|
11.54 ± 1.64 (11.6)
|
a0.563
|
|
Postoperative Hgb level
mean ± SD (median)
|
10.04 ± 1.38 (10)
|
10.12 ± 1.46 (10.2)
|
a0.790
|
|
Difference in Hgb level
mean ± SD (median)
|
1.33 ± 0.82 (1.3)
|
1.42 ± 0.85 (1.1)
|
b0.604
|
|
Duration of operation (minutes)
mean ± SD (median)
|
54.42 ± 16.05 (35)
|
37.98 ± 9.22 (35)
|
b0.001
|
|
Complications
|
No, n (%)
|
56 (84.8)
|
29 (93.5)
|
c0.327
|
|
Yes, n (%)
|
10 (15.2)
|
2 (6.5)
|
|
Transfusion
|
No, n (%)
|
58 (87.9)
|
29 (93.5)
|
c0.494
|
|
Yes, n (%)
|
8 (12.1)
|
2 (6.5)
|
Table 6 Effect of parameters on decision for myomectomy.
|
|
OR
|
95% CI
|
p
|
|
Hgb: hemoglobin
|
|
Age
|
1.009
|
0.970 – 1.050
|
0.656
|
|
Gravidity
|
0.491
|
0.255 – 0.945
|
0.033
|
|
Parity
|
2.023
|
1.040 – 3.939
|
0.038
|
|
Week of gestation
|
0.869
|
0.763 – 0.990
|
0.034
|
|
Number of myomas
|
2.149
|
1.005 – 4.593
|
0.050
|
|
Myoma diameter
|
1.000
|
0.999 – 1.000
|
0.145
|
|
Type of myoma (1)
|
0.660
|
0.427 – 1.019
|
0.061
|
|
Preoperative Hgb
|
2.518
|
0.979 – 6.482
|
0.056
|
|
Postoperative Hgb
|
0.461
|
0.180 – 1.176
|
0.105
|
|
Difference in Hgb levels
|
0.557
|
0.219 – 1.421
|
0.221
|
|
Transfusion (1)
|
2.070
|
0.141 – 30.393
|
0.596
|
|
Complications (1)
|
0.298
|
0.021 – 4.284
|
0.373
|
Table 7 Myoma diameter (centimeters) vs. week of gestation, gravidity, parity.
|
|
Myomectomy
|
|
|
No
(mean)
|
Yes
(mean)
|
|
. = No patients in this raw
|
|
Week of gestation
|
32
|
Size of myoma
|
3
|
.
|
|
33
|
Size of myoma
|
4
|
5
|
|
34
|
Size of myoma
|
4
|
4
|
|
35
|
Size of myoma
|
4
|
4
|
|
36
|
Size of myoma
|
4
|
3
|
|
37
|
Size of myoma
|
3
|
3
|
|
38
|
Size of myoma
|
4
|
3
|
|
39
|
Size of myoma
|
4
|
3
|
|
40
|
Size of myoma
|
4
|
3
|
|
41
|
Size of myoma
|
3
|
2
|
|
42
|
Size of myoma
|
.
|
2
|
|
Gravidity
|
1
|
Size of myoma
|
.
|
4
|
|
2
|
Size of myoma
|
3
|
3
|
|
3
|
Size of myoma
|
4
|
3
|
|
4
|
Size of myoma
|
4
|
2
|
|
5
|
Size of myoma
|
4
|
3
|
|
6
|
Size of myoma
|
4
|
3
|
|
7
|
Size of myoma
|
6
|
4
|
|
8
|
Size of myoma
|
4
|
3
|
|
9
|
Size of myoma
|
.
|
1
|
|
10
|
Size of myoma
|
4
|
.
|
|
Parity
|
0
|
Size of myoma
|
.
|
4
|
|
1
|
Size of myoma
|
4
|
3
|
|
2
|
Size of myoma
|
4
|
3
|
|
3
|
Size of myoma
|
4
|
2
|
|
4
|
Size of myoma
|
3
|
3
|
|
5
|
Size of myoma
|
5
|
3
|
|
6
|
Size of myoma
|
6
|
4
|
|
7
|
Size of myoma
|
.
|
3
|
|
8
|
Size of myoma
|
.
|
1
|
|
9
|
Size of myoma
|
4
|
.
|
Bleeding and uterine atony were recorded in 21 cases: 7 of these complications occurred
in the cesarean myomectomy group and 14 occurred in the non-myomectomy group. Hypogastric
artery ligation was done in 8 cases. There were no incidents of damage to surrounding
organs, no maternal deaths, and hysterectomy was not required in any case.
Discussion
This study shows that there was no difference in the rate of complications, transfusion
rates and drop in hemoglobin levels between the cesarean myomectomy group and the
non-myomectomy group, and in those with myoma diameter greater than 5 cm.
It has been repeatedly stated in the literature that routine myomectomy during cesarean
section should be avoided and should only be carried out in carefully selected patients
[15]. However, there are several advantages to carrying out myomectomy procedures during
cesarean delivery. First and foremost, it removes the need for a second operation.
Routine myomectomy during cesarean section also reduces the risk of complications
such as premature birth, dystocia or uterine atony in subsequent pregnancies and even
increases the possibility of vaginal birth in a subsequent pregnancy [16]. As regards patients who underwent myomectomy, we left the decision about the mode
of delivery in any subsequent pregnancy to the obstetrician who will treat the patient
in future. There was no follow-up of patients after the puerperal phase so we have
no data about the mode of delivery in subsequent pregnancies and whether myomectomy
was required at a later time.
The decision to perform myomectomy was based on the localization of the myoma, the
diameter of the myoma, the number and size of the vascular structures nourishing the
myoma, and the impact on uterine contractility [15]. However, when opting for myomectomy, the experience of the surgeon and the proximity
to a tertiary center must be taken into account. To ensure the safety of cesarean
myomectomies, procedures must be in place to reduce bleeding and the incision must
be carefully planned [15].
In a study by Roman et al. [17], cesarean myomectomy was carried out in 111 patients and cesarean section only was
performed in 257 patients. No difference was seen between the two groups with regard
to postoperative fever, bleeding, hemoglobin changes, and the duration of the operation
and hospitalization. However, the authors of the study stated that removal of extended
fundal and intramural myomas should be avoided during cesarean delivery [17]. Despite the small mean diameter of myomas removed in the myomectomy group, there
are reports in the literature that myomas with a size of up to 30 cm have been resected.
It has been suggested in the literature that large myomas should be removed if they
are located in the lower segment and block the birth canal or if they are symptomatic
[17]. A review of 9 studies reported that cesarean myomectomy was a safe procedure in
the hands of experienced surgeons but also emphasized that the removal of large or
intramural myomas should be avoided [18]. Another review reported that in the majority of cases, myomectomy carried out to
resect peduncular myomas and myomas with diameters of less than 6 cm was safe, but
if the myoma had a large diameter, only peduncular myomas and myomas located in the
lower segment blocking the birth canal should be resected [19]. A study of 110 cases of cesarean myomectomy compared cases with complications and
those without complications. The myoma diameter was found to be larger in the group
with complications [1]. Complications were defined as transfusion of more than 3 units of blood products,
postoperative ileus, need for re-operation, and more than 2 daysʼ hospitalization
[1]. In another study which evaluated 165 patients, myomectomy was carried out in 65
patients; operating times were longer in the myomectomy group, but there was no increase
in postoperative complications compared to the group which did not undergo myomectomy
[20]. In the same study, a comparison of the myomectomy group based on the diameter of
the myoma found no difference with regard to complications, requirement for blood
transfusion, changes in hemoglobin levels and postoperative fever [20]. The authors stated that the removal of myomas larger than 5 cm in diameter during
cesarean delivery was safe [20]. In a similar study with fewer cases, cesarean myomectomy was carried out in 76
patients and cesarean delivery without myomectomy in 60 patients; the study reported
similar rates with regard to blood transfusions, duration of hospitalization and changes
in hemoglobin levels [21]. As in our study, the duration of the operation was longer in the cesarean myomectomy
group [21]. The authors of that study reported that cesarean myomectomy was a safe alternative
[21]. There are some case reports of myomectomy being carried out to treat myomas with
extremely large diameters. Lenza et al. [22] reported the successful removal of a myoma with a diameter of 22 cm during cesarean
delivery. Similarly, a case was reported where 40 cm myoma was removed after bilateral
ligation of the uterine arteries to reduce the possibility of bleeding [23]. Huang et al. [24] reported the removal of a 5290 g myoma during a 4-hour operation with no complications
and a mean blood loss of 1000 cc.
The number of cases in our study was larger than in the above-mentioned studies. In
our study, the mean myoma diameter was 3.67 cm in the non-myomectomy group and 2.90 cm
in the myomectomy group (p = 0.001). The surgeons working in our center at the time
of the study were more inclined to remove myomas with small diameters. There are several
explanations for this. There was a tendency to remove small myomas because of the
risk of possible bleeding. The decision also depended on the skill and experience
of the surgeon involved and the conditions in the hospital. The center where our study
was conducted is not a tertiary center but a gynecology and pediatric hospital. It
had no intensive care unit, but the intensive care facilities of a state hospital
in the same city were available, although this would require the transportation of
the patient. The hospital also did not have specific surgical technologies which would
be useful to control bleeding. As it was thought that small myoma diameters would
reduce the power of our study, cases with myoma diameters of 5 cm or above were also
examined. 66 cases in the non-myomectomy group and 31 patients in the cesarean myomectomy
group had a myoma with a diameter of 5 cm or more. When these two groups were compared,
the drop in hemoglobin levels, rate of complications and transfusion requirements
were similar in both groups (p > 0.05).
Various methods have been recommended to prevent bleeding during cesarean myomectomy.
The majority of studies in the literature have reported using high-dose oxytocin intraoperatively
and in the postoperative period [17]. Uterine tourniquet, electrocautery, bilateral uterine artery ligation and other
intraoperative techniques are also useful in reducing the amount of bleeding [10], [25], [26], [27]. Bilateral uterine ligation has been reported to be effective to reduce bleeding,
especially if applied before removing large diameter myomas [23], [28]. In a study of 9 cases, the myomectomy was successfully completed without excessive
bleeding following previous uterine artery ligation [29]. However, only 1 case in that study treated a myoma with a large diameter, and ligation
was applied to the descending uterine artery branches in 2 cases with lower segment
localization [29]. Tinelli et al. described an intracapsular myomectomy technique during cesarean
myomectomy [30]. They reported that bleeding was not higher compared to the control group [30]. Similarly, Lee et al. [31] showed that the purse-string suture technique could be useful in controlling bleeding.
Both devascularization and the intracapsular approach are important myomectomy techniques
because they depend entirely on the surgeon, which is especially important in areas
which have few centers with high-level technological infrastructure or intensive care
units. In non-tertiary centers, the use of these techniques to control bleeding can
be effective without incurring additional costs. In the present study, control of
bleeding was achieved by suturing the myoma bed, and oxytocin was used intraoperatively
and postoperatively for all patients. A total of 17 patients developed uterine atony
and bleeding occurred in 4 patients; hypogastric artery ligation was performed in
8 of these patients.
This study is important because of the large number of cases and the separate analysis
of cases with myoma diameters of 5 cm and above. In non-tertiary centers or centers
with limited facilities, knowledge of the above-mentioned techniques is valuable to
control bleeding. Cesarean myomectomy is a safe option in the hands of skilled, experienced
surgeons and where the appropriate facilities are available. The main limitations
of our study are its retrospective nature and the lack of follow-up data for patients.
Financial Disclosure
The authors state that this study received no financial support.
