IJG-08344; No of Pages 3 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas Hasan O. Topçu ⁎, Can T. İskender, Hakan Timur, Oktay Kaymak, Tuba Memur, Nuri Danışman Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 25 October 2014 Received in revised form 10 March 2015 Accepted 5 May 2015 Keywords: Cesarean Cesarean myomectomy Leiomyoma Myomectomy Pregnancy
a b s t r a c t Objective: To determine whether myomectomy during cesarean delivery is safe and feasible among pregnant women with leiomyomas. Methods: In a retrospective study, data were reviewed from pregnant women with uterine leiomyomas who delivered by cesarean at a center in Turkey between May 1, 2007, and April 30, 2014. Women were divided into two groups: cesarean myomectomy (CM) or cesarean only (CO). Data were analyzed for characteristics of the uterine leiomyomas, hematologic changes occurring between the preoperative and postoperative periods, duration of the operation, and length of hospital stay. Results: Overall, 76 women formed the CM group and 60 formed the CO group. The mean diameter of the leiomyomas did not differ between CM and CO groups (4.6 ± 2.5 cm vs 5.2 ± 2.2 cm; P = 0.175). More patients in the CM group than in the CO group had subserous (24 [31.6%] vs 7 [11.7%]; P = 0.006) and uterine corpus (57 [75.0%] vs 30 [50.0%]; P = 0.003) leiomyomas. Fewer patients in the CM group had intramural (44 [57.9%] vs 49 [81.7%]; P = 0.003) and fundal (15 [19.7%] vs 25 [41.7%]; P = 0.005) leiomyomas. Conclusion: Surgeons were more likely to remove corporal and subserous leiomyomas than other types; size did not seem to affect decision making. CM can be a safe operation for some patients. © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Uterine leiomyomas are the most commonly encountered benign tumor of the female reproductive tract [1]. They are mostly asymptomatic; however, symptomatic cases have various obstetric implications [2–6]. Previous findings have indicated that uterine leiomyomas can be associated with reproductive failure, such as decreased fertility rates and spontaneous abortion, depending on their size and location [3]. Moreover, they have been associated with complications during pregnancy, such as preterm delivery, placental abruption, and dystocia [5,6]. Some of these complications are primarily related to the location of the leiomyoma (e.g. placental abruption when a submucous leiomyoma is located beneath a placental site), whereas others can be related to size (e.g. dystocia) [6]. Additionally, intractable pain and ongoing inflammation as a result of “red degeneration” can cause preterm labor [4,7]. Owing to the significant obstetric complications, it might be tempting to remove leiomyomas encountered during cesarean delivery. Nevertheless, most surgeons avoid myomectomy during cesarean because of the possibility of severe bleeding and subsequent hysterectomy [8]. Recent evidence, however, suggests that myomectomy does not cause
⁎ Corresponding author at: 1549. Cadde, Hardem Apartmanı, B Blok, Daire 12. ÇiğdemÇankaya, Ankara, 06300, Turkey. Tel.: +90 532 635 95 38; fax: +90 312 306 59 17. E-mail address: [email protected] (H.O. Topçu).
additional morbidity apart from a slightly increased drop in hemoglobin levels [9]. The aim of the present study was to determine, first, whether myomectomy during cesarean is a safe and feasible procedure and, second, the factors that can affect the decision to perform myomectomy.
2. Materials and methods In a retrospective study, data were reviewed from women with leiomyomas who attended the Perinatology Division of Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey—a tertiary teaching referral hospital with an annual delivery rate of 20 000 neonates—between May 1, 2007, and April 30, 2014. The study was approved by the Ethics and Educational Issues Coordinating Committee of the hospital. All patients provided written consent for the use of their data, which was anonymized and de-identified before analysis. Pregnant women with leiomyomas who delivered via cesarean during the study period were identified from hospital records and divided into two groups: those who underwent myomectomy formed the cesarean myomectomy (CM) group, and those who did not undergo myomectomy formed the cesarean only (CO) group. There was no defined algorithm for performing CM. The decision about whether to perform CM was made intraoperatively by the surgeon. Maternal request, fetal distress, cephalopelvic disproportion, previous uterine surgery,
http://dx.doi.org/10.1016/j.ijgo.2015.03.035 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Topçu HO, et al, Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.035
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H.O. Topçu et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Table 1 Characteristics of the study patients.a
Table 3 Comparison of outcomes between the study groups.a
Characteristics
CM group (n = 76)
CO group (n = 60)
P value
Outcomes
CM group (n = 76)
CO group (n = 60)
P value
Age, y Length of pregnancy, wk Nulliparous Previous spontaneous abortions Regional anesthesia Diameter of leiomyoma, cm Planned cesarean
32.3 ± 4.2 38.3 ± 2.6 42 (55.3) 0.2 ± 0.5 57 (75.0) 4.6 ± 2.5 27 (35.5)
31.1 ± 3.2 38.6 ± 1.0 35 (58.3) 0.2 ± 0.4 50 (83.3) 5.2 ± 2.2 19 (31.7)
0.532 0.403 0.724 0.906 0.239 0.175 0.637
Mean preoperative hemoglobin, g/L Mean postoperative hemoglobin, g/L Mean change in hemoglobin, g/L Intraoperative hemorrhage Blood transfusion Postoperative fever Duration of operation, min Length of hospital stay, d
125 ± 11 111 ± 12 14 ± 9 5 (6.6) 7 (9.2) 5 (6.6) 51.6 ± 13.5 2.2 ± 0.9
121 ± 11 107 ± 14 14 ± 11 5 (8.3) 5 (8.3) 7 (11.7) 42.1 ± 8.7 2.1 ± 0.7
0.065 0.062 0.087 0.749 0.858 0.299 0.032 0.359
Abbreviations: CM, cesarean myomectomy; CO, cesarean only. a Values are given as mean ± SD or number (percentage), unless indicated otherwise.
Abbreviations; CM, cesarean myomectomy; CO, cesarean only. a Values are given as mean ± SD or number (percentage), unless indicated otherwise.
malpresentation, failure to progress, cordon prolapse, and suspected macrosomia were the indications for a cesarean delivery. There is no specific definition of an emergency cesarean [10]. For the present study, therefore, emergency cesarean was defined as the delivery of a neonate in 10 minutes via a laparotomy. Non-emergency deliveries were subdivided into planned versus unplanned procedures: a planned cesarean was defined as the delivery of a neonate via a laparotomy on a planned schedule, and an unplanned cesarean as the delivery of a neonate before the planned schedule (e.g. for a pregnant woman with previous surgery who had regular contractions before the expected date or when an active phase of delivery began in a pregnant woman with malpresentation). For the present analysis, information on maternal and neonatal features—including maternal age, gravida, and gestational age at delivery—and data regarding the size and location of leiomyomas, operative time, intraoperative and postoperative complications, and preoperative and postoperative hemoglobin levels were retrieved from patient records. Statistical analyses were performed with SPSS version 17 (SPSS Inc, Chicago, IL, USA). Student t tests were used to compare parametric variables between groups, and χ2 tests to compare non-parametric variables. P b 0.05 was considered significant.
The frequency of subserous leiomyomas was significantly higher in the CM group than in the CO group (P = 0.006), whereas the frequency of intramural leiomyomas was higher in the CO group (P = 0.003) (Table 2). The frequency of uterine corpus leiomyomas was significantly higher in the CM group than in the CO group (P = 0.003), but the frequency of fundal leiomyomas was higher in the CO group (P = 0.005). In each group, the rates of leiomyomas located in lower uterine segment were similar (P = 0.507) (Table 2). In the CM group, the indications for cesarean delivery were maternal request (1 [6.7%] of 15 patients), fetal distress (2 [13.3%]), cephalopelvic disproportion (1 [6.7%]), previous uterine surgery (5 [33.3%]), malpresentation (5 [33.3%]), and cord prolapse (1 [6.7%]). The mean operating time was significantly longer in the CM group than in the CO group (P = 0.032) (Table 3). No other perioperative or outcome variables differed between groups, including the rate of substantial intraoperative bleeding, change in hemoglobin after surgery, frequency of postoperative fever, and mean duration of hospital stay (Table 3). The rate of significant intraoperative bleeding, change in hemoglobin after surgery, and mean length of hospital stay did not differ between groups according to leiomyoma diameter (Table 4).
3. Results
The present results indicate that myomectomy during cesarean is a safe and feasible procedure. The difference between preoperative and postoperative hemoglobin, incidence of perioperative hemorrhage, frequency of blood transfusion, incidence of postoperative fever, and mean duration of hospital stay were similar between the CM and CO groups. The duration of the operation was the only delivery variable that
During the study period, 136 patients with leiomyomas underwent cesarean delivery, of whom 76 (55.9%) underwent myomectomy during cesarean and 60 (44.1%) underwent cesarean only. The leiomyomas had been identified prenatally for 51 (67.1%) patients in the CM group and 42 (70.0%) in the CO group. All other cases were diagnosed intraoperatively. Maternal age, gestational age, frequency of nulliparity, previous spontaneous abortion, and mean diameter of leiomyomas were similar in the two groups (Table 1). There were five emergency cases across both groups. The indications were cord prolapse (two patients) and fetal distress (three patients). The number of emergency cases was insufficient to compare between the two groups. The rate of planned cesarean deliveries was similar across groups (P = 0.637) (Table 1). Table 2 Leiomyoma characteristics between the study groups.a Myoma characteristics Location Fundus Corpus Lower segment Classification Subserous Submucous Intramural
CM group (n = 76)
CO group (n = 60)
P value
15 (19.7) 57 (75.0) 4 (5.3)
25 (41.7) 30 (50.0) 5 (8.3)
0.005 0.003 0.507
24 (31.6) 8 (10.5) 44 (57.9)
7 (11.7) 4 (6.7) 49 (81.7)
0.006 0.431 0.003
Abbreviations: CM, cesarean myomectomy; CO, cesarean only. a Values are given as number (percentage) unless indicated otherwise.
4. Discussion
Table 4 Comparison of outcomes between study groups among patients with leiomyomas of a similar size.a Outcomes
Mean change in hemoglobin, g/L b3 cm ≥3 to b6 cm ≥6 cm Frequency of blood transfusion b3 cm ≥3 to b6 cm ≥6 cm Mean length of hospital stay, d b3 cm ≥3 to b6 cm ≥6 cm
CM group (n = 76)
CO group (n = 60)
P value
No. of patients
Value
No. of patients
Value
17 39 20
11 ± 9 14 ± 8 15 ± 10
11 24 25
7±1 13 ± 10 18 ± 14
0.071 0.679 0.491
17 39 20
0 1 (2.6) 6 (30.0)
11 24 25
0 0 5 (20)
– N0.99 0.50
17 39 20
2.0 ± 0.4 2.4 ± 1.1 2.2 ± 0.6
11 24 25
2.0 ± 0.9 2.0 ± 0.6 2.0 ± 0.6
0.345 0.156 0.389
Abbreviations: CM, cesarean myomectomy; CO, cesarean only. a Values are given as number, mean ± SD, or number (percentage), unless indicated otherwise.
Please cite this article as: Topçu HO, et al, Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.035
H.O. Topçu et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
differed between the groups. The numbers of corporal and subserous leiomyomas were significantly higher in the CM group than in the CO group, although the diameters of the leiomyomas did not differ between groups. Because the study hospital is a tertiary referral center, the use of regional anesthesia might be lower than expected, possibly due to the heavy workload. However, this was not specific to the CM group. The reported incidence of leiomyomas in pregnancy varies between 1.6% and 10.7% [2,11,12]. Leiomyomas in pregnancy are increasing in frequency because women are waiting until they are older before childbearing [9]. Although surgeons are encountering leiomyomas in pregnancy more frequently, many are hesitant to remove them during a cesarean procedure because of possible perioperative complications. However, one study [13] showed that approximately one-third of leiomyomas that were left in place increased in volume after delivery. Moreover, additional surgery was required in 9 of 22 patients during a follow-up period of 38.5 months [13]. Several management options have been used to control blood loss in myomectomies during cesarean, such as uterine artery ligation [14,15], use of tourniquets [14–16], and high-dose oxytocin [16]. In the present study, the incidence of hemorrhage was not significantly higher in the CM group than in the CO group, consistent with previous reports [8, 14,15,17–19]. These results could reflect the surgeons’ choices: a surgeon might choose to intervene with leiomyomas that are relatively easy to remove in terms of their classification and location. The proportion of corporal and subserous leiomyomas was significantly higher in the CM group than in the CO group in the present study, indicating that these leiomyomas were preferred for removal. It has been recommended that leiomyomas that are readily accessible—e.g. subserous or pedunculated leiomyomas—should be removed during a cesarean procedure [15,20]. Kim et al. [21] found higher rates of complication in an intramural CM group than in a subserous CM group; however, all their participants underwent myomectomy during cesarean. In the present study, CM and CO groups were compared. The size of leiomyomas alone did not seem to have a significant impact on hemorrhage since the mean hemoglobin change and frequency of blood transfusions were similar in patients with or without myomectomy when they were grouped by leiomyoma size of leiomyoma. It seems that only one previous study [14] has previously compared the location and classification of leiomyomas in CM and CO groups, showing no difference between the groups. Previous studies comparing the length of hospital stay and duration of operation between CM and CO groups have reported longer hospital stays in the CM group [17–19] or no difference [8,15]. In the present analysis, there was no difference in the length of hospital stay between the two groups. The duration of the operation was longer in the CM group than in the CO group in several previous studies [14,17–19], although Roman et al. [6] reported similar operation times between the groups. In the present study, the operating time was significantly higher in the CM group than in CO group, consistent with most previous studies. The present study investigated whether leiomyoma size affected the change in hemoglobin, frequency of blood transfusions, and length of hospital stay, finding no differences between the CM and CO groups for any leiomyoma size. Roman et al. [15], Kaymak et al. [17], and Park et al. [8] compared the incidence of hemorrhage among patients with similarly sized leiomyomas and found no difference among the groups. Park et al. [8] also compared other variables, such as frequency of blood transfusion and operation time, reporting that the duration of the operation was longer for leiomyomas of 6 cm or more in the CM group than in the CO group [8]. It was expected that the number of leiomyomas in the lower segment would be higher in the CM group than in the CO group, because no hysterotomies additional to the one made for cesarean are necessary.
3
However, the number of leiomyomas in the lower segment was similar in both groups. Previous studies might have been affected by various biases. For example, there were no specific rules regarding the decision to remove or leave the leiomyomas in some studies. The present study seems to show this bias statistically: surgeons might prefer to remove leiomyomas that are readily accessible and good candidates for less blood loss. Prospective randomized trials would be required to obtain robust data, but such trials might have ethical problems. It must be kept in mind that myomectomy during cesarean can result in severe blood loss or hysterectomy. In conclusion, myomectomy during cesarean was found to be safe among the patients who underwent this procedure. Additionally, corporal and subserous leiomyomas were removed significantly more frequently. The results of the present study could encourage investigators to make objective classifications of leiomyomas—including preoperative and intraoperative evaluations of the locations and types of leiomyoma—that can be removed during cesarean procedures. Conflict of interest The authors have no conflicts of interest. References [1] Lippman SA, Warner M, Samuels S, Olive D, Vercellini P, Eskenazi B. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertil Steril 2003; 80(6):1488–94. [2] Strobelt N, Ghidini A, Cavallone M, Pensabene I, Ceruti P, Vergani P. Natural history of uterine leiomyomas in pregnancy. J Ultrasound Med 1994;13(5):399–401. [3] Boynton-Jarrett R, Rich-Edwards J, Malspeis S, Missmer SA, Wright R. A prospective study of hypertension and risk of uterine leiomyomata. Am J Epidemiol 2005; 161(7):628–38. [4] Phelan JP. Myomas and pregnancy. Obstet Gynecol Clin North Am 1995;22(4): 801–5. [5] Kolankaya A, Arici A. Myomas and assisted reproductive technologies: when and how to act? Obstet Gynecol Clin North Am 2006;33(1):145–52. [6] Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol 2008;198(4):357–66. [7] Kwon SY, Lee G, Kim YS. Management of severely painful uterine leiomyoma in a pregnant woman with epidural block using a subcutaneous injection port. Acta Obstet Gynecol Scand 2014;93(8):839. [8] Park BJ, Kim YW. Safety of cesarean myomectomy. J Obstet Gynaecol Res 2009; 35(5):906–11. [9] Song D, Zhang W, Chames MC, Guo J. Myomectomy during cesarean delivery. Int J Gynecol Obstet 2013;121(3):208–13. [10] Schauberger CW, Chauhan SP. Emergency cesarean section and the 30-minute rule: definitions. Am J Perinatol 2009;26(3):221–6. [11] Laughlin SK, Baird DD, Savitz DA, Herring AH, Hartmann KE. Prevalence of uterine leiomyomas in the first trimester of pregnancy: an ultrasound-screening study. Obstet Gynecol 2009;113(3):630–5. [12] Exacoustòs C, Rosati P. Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obstet Gynecol 1993;82(1):97–101. [13] AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994;171(3):694–700. [14] Lin JY, Lee WL, Wang PH, Lai MJ, Chang WH, Liu WM. Uterine artery occlusion and myomectomy for treatment of pregnant women with uterine leiomyomas who are undergoing cesarean section. J Obstet Gynaecol Res 2010;36(2):284–90. [15] Roman AS, Tabsh KM. Myomectomy at time of cesarean delivery: a retrospective cohort study. BMC Pregnancy Childbirth 2004;4(1):14. [16] Umezurike CC. Caesarean myomectomy in Aba, southeastern Nigeria. Trop Doct 2008;38(3):189–90. [17] Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L. Myomectomy during cesarean section. Int J Gynecol Obstet 2005;89(2):90–3. [18] Tinelli A, Malvasi A, Mynbaev OA, Barbera A, Perrone E, Guido M, et al. The surgical outcome of intracapsular cesarean myomectomy. A match control study. J Matern Fetal Neonatal Med 2014;27(1):66–71. [19] Hassiakos D, Christopoulos P, Vitoratos N, Xarchoulakou E, Vaggos G, Papadias K. Myomectomy during cesarean section: a safe procedure? Ann N Y Acad Sci 2006; 1092:408–13. [20] Kwawukume EY. Caesarean myomectomy. Afr J Reprod Health 2002;6(3):38–43. [21] Kim YS, Choi SD, Bae DH. Risk factors for complications in patients undergoing myomectomy at the time of cesarean section. J Obstet Gynaecol Res 2010;36(3):550–4.
Please cite this article as: Topçu HO, et al, Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.035
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas Hasan O. Topçu ⁎, Can T. İskender, Hakan Timur, Oktay Kaymak, Tuba Memur, Nuri Danışman Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 25 October 2014 Received in revised form 10 March 2015 Accepted 5 May 2015 Keywords: Cesarean Cesarean myomectomy Leiomyoma Myomectomy Pregnancy
a b s t r a c t Objective: To determine whether myomectomy during cesarean delivery is safe and feasible among pregnant women with leiomyomas. Methods: In a retrospective study, data were reviewed from pregnant women with uterine leiomyomas who delivered by cesarean at a center in Turkey between May 1, 2007, and April 30, 2014. Women were divided into two groups: cesarean myomectomy (CM) or cesarean only (CO). Data were analyzed for characteristics of the uterine leiomyomas, hematologic changes occurring between the preoperative and postoperative periods, duration of the operation, and length of hospital stay. Results: Overall, 76 women formed the CM group and 60 formed the CO group. The mean diameter of the leiomyomas did not differ between CM and CO groups (4.6 ± 2.5 cm vs 5.2 ± 2.2 cm; P = 0.175). More patients in the CM group than in the CO group had subserous (24 [31.6%] vs 7 [11.7%]; P = 0.006) and uterine corpus (57 [75.0%] vs 30 [50.0%]; P = 0.003) leiomyomas. Fewer patients in the CM group had intramural (44 [57.9%] vs 49 [81.7%]; P = 0.003) and fundal (15 [19.7%] vs 25 [41.7%]; P = 0.005) leiomyomas. Conclusion: Surgeons were more likely to remove corporal and subserous leiomyomas than other types; size did not seem to affect decision making. CM can be a safe operation for some patients. © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Uterine leiomyomas are the most commonly encountered benign tumor of the female reproductive tract [1]. They are mostly asymptomatic; however, symptomatic cases have various obstetric implications [2–6]. Previous findings have indicated that uterine leiomyomas can be associated with reproductive failure, such as decreased fertility rates and spontaneous abortion, depending on their size and location [3]. Moreover, they have been associated with complications during pregnancy, such as preterm delivery, placental abruption, and dystocia [5,6]. Some of these complications are primarily related to the location of the leiomyoma (e.g. placental abruption when a submucous leiomyoma is located beneath a placental site), whereas others can be related to size (e.g. dystocia) [6]. Additionally, intractable pain and ongoing inflammation as a result of “red degeneration” can cause preterm labor [4,7]. Owing to the significant obstetric complications, it might be tempting to remove leiomyomas encountered during cesarean delivery. Nevertheless, most surgeons avoid myomectomy during cesarean because of the possibility of severe bleeding and subsequent hysterectomy [8]. Recent evidence, however, suggests that myomectomy does not cause
⁎ Corresponding author at: 1549. Cadde, Hardem Apartmanı, B Blok, Daire 12. ÇiğdemÇankaya, Ankara, 06300, Turkey. Tel.: +90 532 635 95 38; fax: +90 312 306 59 17. E-mail address: [email protected] (H.O. Topçu).
additional morbidity apart from a slightly increased drop in hemoglobin levels [9]. The aim of the present study was to determine, first, whether myomectomy during cesarean is a safe and feasible procedure and, second, the factors that can affect the decision to perform myomectomy.
2. Materials and methods In a retrospective study, data were reviewed from women with leiomyomas who attended the Perinatology Division of Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey—a tertiary teaching referral hospital with an annual delivery rate of 20 000 neonates—between May 1, 2007, and April 30, 2014. The study was approved by the Ethics and Educational Issues Coordinating Committee of the hospital. All patients provided written consent for the use of their data, which was anonymized and de-identified before analysis. Pregnant women with leiomyomas who delivered via cesarean during the study period were identified from hospital records and divided into two groups: those who underwent myomectomy formed the cesarean myomectomy (CM) group, and those who did not undergo myomectomy formed the cesarean only (CO) group. There was no defined algorithm for performing CM. The decision about whether to perform CM was made intraoperatively by the surgeon. Maternal request, fetal distress, cephalopelvic disproportion, previous uterine surgery,
http://dx.doi.org/10.1016/j.ijgo.2015.03.035 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Topçu HO, et al, Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.035
2
H.O. Topçu et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Table 1 Characteristics of the study patients.a
Table 3 Comparison of outcomes between the study groups.a
Characteristics
CM group (n = 76)
CO group (n = 60)
P value
Outcomes
CM group (n = 76)
CO group (n = 60)
P value
Age, y Length of pregnancy, wk Nulliparous Previous spontaneous abortions Regional anesthesia Diameter of leiomyoma, cm Planned cesarean
32.3 ± 4.2 38.3 ± 2.6 42 (55.3) 0.2 ± 0.5 57 (75.0) 4.6 ± 2.5 27 (35.5)
31.1 ± 3.2 38.6 ± 1.0 35 (58.3) 0.2 ± 0.4 50 (83.3) 5.2 ± 2.2 19 (31.7)
0.532 0.403 0.724 0.906 0.239 0.175 0.637
Mean preoperative hemoglobin, g/L Mean postoperative hemoglobin, g/L Mean change in hemoglobin, g/L Intraoperative hemorrhage Blood transfusion Postoperative fever Duration of operation, min Length of hospital stay, d
125 ± 11 111 ± 12 14 ± 9 5 (6.6) 7 (9.2) 5 (6.6) 51.6 ± 13.5 2.2 ± 0.9
121 ± 11 107 ± 14 14 ± 11 5 (8.3) 5 (8.3) 7 (11.7) 42.1 ± 8.7 2.1 ± 0.7
0.065 0.062 0.087 0.749 0.858 0.299 0.032 0.359
Abbreviations: CM, cesarean myomectomy; CO, cesarean only. a Values are given as mean ± SD or number (percentage), unless indicated otherwise.
Abbreviations; CM, cesarean myomectomy; CO, cesarean only. a Values are given as mean ± SD or number (percentage), unless indicated otherwise.
malpresentation, failure to progress, cordon prolapse, and suspected macrosomia were the indications for a cesarean delivery. There is no specific definition of an emergency cesarean [10]. For the present study, therefore, emergency cesarean was defined as the delivery of a neonate in 10 minutes via a laparotomy. Non-emergency deliveries were subdivided into planned versus unplanned procedures: a planned cesarean was defined as the delivery of a neonate via a laparotomy on a planned schedule, and an unplanned cesarean as the delivery of a neonate before the planned schedule (e.g. for a pregnant woman with previous surgery who had regular contractions before the expected date or when an active phase of delivery began in a pregnant woman with malpresentation). For the present analysis, information on maternal and neonatal features—including maternal age, gravida, and gestational age at delivery—and data regarding the size and location of leiomyomas, operative time, intraoperative and postoperative complications, and preoperative and postoperative hemoglobin levels were retrieved from patient records. Statistical analyses were performed with SPSS version 17 (SPSS Inc, Chicago, IL, USA). Student t tests were used to compare parametric variables between groups, and χ2 tests to compare non-parametric variables. P b 0.05 was considered significant.
The frequency of subserous leiomyomas was significantly higher in the CM group than in the CO group (P = 0.006), whereas the frequency of intramural leiomyomas was higher in the CO group (P = 0.003) (Table 2). The frequency of uterine corpus leiomyomas was significantly higher in the CM group than in the CO group (P = 0.003), but the frequency of fundal leiomyomas was higher in the CO group (P = 0.005). In each group, the rates of leiomyomas located in lower uterine segment were similar (P = 0.507) (Table 2). In the CM group, the indications for cesarean delivery were maternal request (1 [6.7%] of 15 patients), fetal distress (2 [13.3%]), cephalopelvic disproportion (1 [6.7%]), previous uterine surgery (5 [33.3%]), malpresentation (5 [33.3%]), and cord prolapse (1 [6.7%]). The mean operating time was significantly longer in the CM group than in the CO group (P = 0.032) (Table 3). No other perioperative or outcome variables differed between groups, including the rate of substantial intraoperative bleeding, change in hemoglobin after surgery, frequency of postoperative fever, and mean duration of hospital stay (Table 3). The rate of significant intraoperative bleeding, change in hemoglobin after surgery, and mean length of hospital stay did not differ between groups according to leiomyoma diameter (Table 4).
3. Results
The present results indicate that myomectomy during cesarean is a safe and feasible procedure. The difference between preoperative and postoperative hemoglobin, incidence of perioperative hemorrhage, frequency of blood transfusion, incidence of postoperative fever, and mean duration of hospital stay were similar between the CM and CO groups. The duration of the operation was the only delivery variable that
During the study period, 136 patients with leiomyomas underwent cesarean delivery, of whom 76 (55.9%) underwent myomectomy during cesarean and 60 (44.1%) underwent cesarean only. The leiomyomas had been identified prenatally for 51 (67.1%) patients in the CM group and 42 (70.0%) in the CO group. All other cases were diagnosed intraoperatively. Maternal age, gestational age, frequency of nulliparity, previous spontaneous abortion, and mean diameter of leiomyomas were similar in the two groups (Table 1). There were five emergency cases across both groups. The indications were cord prolapse (two patients) and fetal distress (three patients). The number of emergency cases was insufficient to compare between the two groups. The rate of planned cesarean deliveries was similar across groups (P = 0.637) (Table 1). Table 2 Leiomyoma characteristics between the study groups.a Myoma characteristics Location Fundus Corpus Lower segment Classification Subserous Submucous Intramural
CM group (n = 76)
CO group (n = 60)
P value
15 (19.7) 57 (75.0) 4 (5.3)
25 (41.7) 30 (50.0) 5 (8.3)
0.005 0.003 0.507
24 (31.6) 8 (10.5) 44 (57.9)
7 (11.7) 4 (6.7) 49 (81.7)
0.006 0.431 0.003
Abbreviations: CM, cesarean myomectomy; CO, cesarean only. a Values are given as number (percentage) unless indicated otherwise.
4. Discussion
Table 4 Comparison of outcomes between study groups among patients with leiomyomas of a similar size.a Outcomes
Mean change in hemoglobin, g/L b3 cm ≥3 to b6 cm ≥6 cm Frequency of blood transfusion b3 cm ≥3 to b6 cm ≥6 cm Mean length of hospital stay, d b3 cm ≥3 to b6 cm ≥6 cm
CM group (n = 76)
CO group (n = 60)
P value
No. of patients
Value
No. of patients
Value
17 39 20
11 ± 9 14 ± 8 15 ± 10
11 24 25
7±1 13 ± 10 18 ± 14
0.071 0.679 0.491
17 39 20
0 1 (2.6) 6 (30.0)
11 24 25
0 0 5 (20)
– N0.99 0.50
17 39 20
2.0 ± 0.4 2.4 ± 1.1 2.2 ± 0.6
11 24 25
2.0 ± 0.9 2.0 ± 0.6 2.0 ± 0.6
0.345 0.156 0.389
Abbreviations: CM, cesarean myomectomy; CO, cesarean only. a Values are given as number, mean ± SD, or number (percentage), unless indicated otherwise.
Please cite this article as: Topçu HO, et al, Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.035
H.O. Topçu et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
differed between the groups. The numbers of corporal and subserous leiomyomas were significantly higher in the CM group than in the CO group, although the diameters of the leiomyomas did not differ between groups. Because the study hospital is a tertiary referral center, the use of regional anesthesia might be lower than expected, possibly due to the heavy workload. However, this was not specific to the CM group. The reported incidence of leiomyomas in pregnancy varies between 1.6% and 10.7% [2,11,12]. Leiomyomas in pregnancy are increasing in frequency because women are waiting until they are older before childbearing [9]. Although surgeons are encountering leiomyomas in pregnancy more frequently, many are hesitant to remove them during a cesarean procedure because of possible perioperative complications. However, one study [13] showed that approximately one-third of leiomyomas that were left in place increased in volume after delivery. Moreover, additional surgery was required in 9 of 22 patients during a follow-up period of 38.5 months [13]. Several management options have been used to control blood loss in myomectomies during cesarean, such as uterine artery ligation [14,15], use of tourniquets [14–16], and high-dose oxytocin [16]. In the present study, the incidence of hemorrhage was not significantly higher in the CM group than in the CO group, consistent with previous reports [8, 14,15,17–19]. These results could reflect the surgeons’ choices: a surgeon might choose to intervene with leiomyomas that are relatively easy to remove in terms of their classification and location. The proportion of corporal and subserous leiomyomas was significantly higher in the CM group than in the CO group in the present study, indicating that these leiomyomas were preferred for removal. It has been recommended that leiomyomas that are readily accessible—e.g. subserous or pedunculated leiomyomas—should be removed during a cesarean procedure [15,20]. Kim et al. [21] found higher rates of complication in an intramural CM group than in a subserous CM group; however, all their participants underwent myomectomy during cesarean. In the present study, CM and CO groups were compared. The size of leiomyomas alone did not seem to have a significant impact on hemorrhage since the mean hemoglobin change and frequency of blood transfusions were similar in patients with or without myomectomy when they were grouped by leiomyoma size of leiomyoma. It seems that only one previous study [14] has previously compared the location and classification of leiomyomas in CM and CO groups, showing no difference between the groups. Previous studies comparing the length of hospital stay and duration of operation between CM and CO groups have reported longer hospital stays in the CM group [17–19] or no difference [8,15]. In the present analysis, there was no difference in the length of hospital stay between the two groups. The duration of the operation was longer in the CM group than in the CO group in several previous studies [14,17–19], although Roman et al. [6] reported similar operation times between the groups. In the present study, the operating time was significantly higher in the CM group than in CO group, consistent with most previous studies. The present study investigated whether leiomyoma size affected the change in hemoglobin, frequency of blood transfusions, and length of hospital stay, finding no differences between the CM and CO groups for any leiomyoma size. Roman et al. [15], Kaymak et al. [17], and Park et al. [8] compared the incidence of hemorrhage among patients with similarly sized leiomyomas and found no difference among the groups. Park et al. [8] also compared other variables, such as frequency of blood transfusion and operation time, reporting that the duration of the operation was longer for leiomyomas of 6 cm or more in the CM group than in the CO group [8]. It was expected that the number of leiomyomas in the lower segment would be higher in the CM group than in the CO group, because no hysterotomies additional to the one made for cesarean are necessary.
3
However, the number of leiomyomas in the lower segment was similar in both groups. Previous studies might have been affected by various biases. For example, there were no specific rules regarding the decision to remove or leave the leiomyomas in some studies. The present study seems to show this bias statistically: surgeons might prefer to remove leiomyomas that are readily accessible and good candidates for less blood loss. Prospective randomized trials would be required to obtain robust data, but such trials might have ethical problems. It must be kept in mind that myomectomy during cesarean can result in severe blood loss or hysterectomy. In conclusion, myomectomy during cesarean was found to be safe among the patients who underwent this procedure. Additionally, corporal and subserous leiomyomas were removed significantly more frequently. The results of the present study could encourage investigators to make objective classifications of leiomyomas—including preoperative and intraoperative evaluations of the locations and types of leiomyoma—that can be removed during cesarean procedures. Conflict of interest The authors have no conflicts of interest. References [1] Lippman SA, Warner M, Samuels S, Olive D, Vercellini P, Eskenazi B. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertil Steril 2003; 80(6):1488–94. [2] Strobelt N, Ghidini A, Cavallone M, Pensabene I, Ceruti P, Vergani P. Natural history of uterine leiomyomas in pregnancy. J Ultrasound Med 1994;13(5):399–401. [3] Boynton-Jarrett R, Rich-Edwards J, Malspeis S, Missmer SA, Wright R. A prospective study of hypertension and risk of uterine leiomyomata. Am J Epidemiol 2005; 161(7):628–38. [4] Phelan JP. Myomas and pregnancy. Obstet Gynecol Clin North Am 1995;22(4): 801–5. [5] Kolankaya A, Arici A. Myomas and assisted reproductive technologies: when and how to act? Obstet Gynecol Clin North Am 2006;33(1):145–52. [6] Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol 2008;198(4):357–66. [7] Kwon SY, Lee G, Kim YS. Management of severely painful uterine leiomyoma in a pregnant woman with epidural block using a subcutaneous injection port. Acta Obstet Gynecol Scand 2014;93(8):839. [8] Park BJ, Kim YW. Safety of cesarean myomectomy. J Obstet Gynaecol Res 2009; 35(5):906–11. [9] Song D, Zhang W, Chames MC, Guo J. Myomectomy during cesarean delivery. Int J Gynecol Obstet 2013;121(3):208–13. [10] Schauberger CW, Chauhan SP. Emergency cesarean section and the 30-minute rule: definitions. Am J Perinatol 2009;26(3):221–6. [11] Laughlin SK, Baird DD, Savitz DA, Herring AH, Hartmann KE. Prevalence of uterine leiomyomas in the first trimester of pregnancy: an ultrasound-screening study. Obstet Gynecol 2009;113(3):630–5. [12] Exacoustòs C, Rosati P. Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obstet Gynecol 1993;82(1):97–101. [13] AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994;171(3):694–700. [14] Lin JY, Lee WL, Wang PH, Lai MJ, Chang WH, Liu WM. Uterine artery occlusion and myomectomy for treatment of pregnant women with uterine leiomyomas who are undergoing cesarean section. J Obstet Gynaecol Res 2010;36(2):284–90. [15] Roman AS, Tabsh KM. Myomectomy at time of cesarean delivery: a retrospective cohort study. BMC Pregnancy Childbirth 2004;4(1):14. [16] Umezurike CC. Caesarean myomectomy in Aba, southeastern Nigeria. Trop Doct 2008;38(3):189–90. [17] Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L. Myomectomy during cesarean section. Int J Gynecol Obstet 2005;89(2):90–3. [18] Tinelli A, Malvasi A, Mynbaev OA, Barbera A, Perrone E, Guido M, et al. The surgical outcome of intracapsular cesarean myomectomy. A match control study. J Matern Fetal Neonatal Med 2014;27(1):66–71. [19] Hassiakos D, Christopoulos P, Vitoratos N, Xarchoulakou E, Vaggos G, Papadias K. Myomectomy during cesarean section: a safe procedure? Ann N Y Acad Sci 2006; 1092:408–13. [20] Kwawukume EY. Caesarean myomectomy. Afr J Reprod Health 2002;6(3):38–43. [21] Kim YS, Choi SD, Bae DH. Risk factors for complications in patients undergoing myomectomy at the time of cesarean section. J Obstet Gynaecol Res 2010;36(3):550–4.
Please cite this article as: Topçu HO, et al, Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.035
