Minimally Invasive Therapy & Allied Technologies
ISSN: 1364-5706 (Print) 1365-2931 (Online) Journal homepage: http://www.tandfonline.com/loi/imit20
Uncertainties about laparoscopic myomectomy during pregnancy: A lack of evidence or an inherited misconception? A critical literature review starting from a peculiar case Carlo Saccardi, Silvia Visentin, Marco Noventa, Erich Cosmi, Pietro Litta & Salvatore Gizzo To cite this article: Carlo Saccardi, Silvia Visentin, Marco Noventa, Erich Cosmi, Pietro Litta & Salvatore Gizzo (2015) Uncertainties about laparoscopic myomectomy during pregnancy: A lack of evidence or an inherited misconception? A critical literature review starting from a peculiar case, Minimally Invasive Therapy & Allied Technologies, 24:4, 189-194 To link to this article: http://dx.doi.org/10.3109/13645706.2014.987678
Published online: 15 Dec 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imit20 Download by: [University of Cambridge]
Date: 05 November 2015, At: 23:57
Minimally Invasive Therapy. 2014;24:189–194
REVIEW ARTICLE
Downloaded by [University of Cambridge] at 23:57 05 November 2015
Uncertainties about laparoscopic myomectomy during pregnancy: A lack of evidence or an inherited misconception? A critical literature review starting from a peculiar case
CARLO SACCARDI, SILVIA VISENTIN, MARCO NOVENTA, ERICH COSMI, PIETRO LITTA & SALVATORE GIZZO Department of Woman and Child Health, University of Padua, Padua, Italy
Abstract Objective: The aim of this report was to perform a critical review of the literature about feasibility, safety, limitations and contraindications of laparoscopic myomectomy during pregnancy starting from a peculiar case of a 15-weeks pregnant woman affected by a symptomatic large myoma. Case report: A 35 year-old Caucasian-nulliparous-woman was referred to our unit at nine weeks of gestation for abdominal heaviness and constipation. The ultrasound examination revealed the presence of a 24 cm pedunculated myoma. The initial management was conservative until the achievement of 15 gestational weeks, when the worsening of abdominal pain led to the need of a laparoscopic myomectomy. Intraoperative blood-loss was 600 ml and operating-time was 150 minutes (70 minutes were required for the morcellement); the postoperative course was normal. The pregnancy evolved regularly and, at 41 weeks, the patient delivered by urgent caesarean section (because intrapartum fetal heart rate abnormalities) a healthy male baby weighing 4460 gr. Both post-partum and puerperium period had a regular course. Conclusion: Laparoscopic myomectomy is feasible and safe during pregnancy for both mother and fetus and vaginal delivery should not be contraindicated. Evidence from our and other reported cases suggests that, during pregnancy, laparoscopic myomectomy should be considered the best surgical choice when subserous peduncolated myomas are symptomatic.
Key words: Laparoscopic myomectomy, myoma complicated pregnancy, surgical approach, procedure safety, maternal-fetal wellbeing, evidence-based guidelines
Introduction Uterine myomas are benign monoclonal, estrogendependent uterine tumors. Prevalence ranges from 10% to >50%, but it is still difficult to determine the real frequency in the general population (1). It is commonly accepted that myomas are more frequent in the black than in the caucasian population, and that their incidence increases with age, especially after 30 years. Estrogen and progesterone play an important role in the development and growth of myomas, but in the last years this concept has been questioned. Several factors, such as genetic and epigenetic mechanism, growth factors, cytokines and disorganization of extracellular matrix components have shown to interact in their pathogenesis (2). Only a minority
of myomas are symptomatic, and discomfort depends to their localization, size and number. Women affected by myomas usually report symptoms of menstrual bleeding, pelvic pain, pelvic heaviness and history of miscarriage. The laparoscopic approach to myomectomy is widely accepted because it avoids abdomen opening, requires small incisions, decreases postoperative pain comporting shorter hospitalization and convalescence time and a faster return to normal activities. Some concerns remain about the quality of the uterine scar and the consequent risk of dehiscence or uterine rupture during pregnancy or delivery, but the improvement of technologies and techniques has reduced the risks (3). The prevalence of uterine myomas during pregnancy varies between 2 and 10%, and only 10% of these could lead to pregnancy
Correspondence: S. Gizzo, Dipartimento di Salute della Donna e del Bambino, U.O.C. di Ginecologia e Ostetricia, Via Giustiniani 3, 35128 Padova, Italy. Fax: +39 049 8211785. E-mail: [email protected] ISSN 1364-5706 print/ISSN 1365-2931 online 2014 Informa Healthcare DOI: 10.3109/13645706.2014.987678
Downloaded by [University of Cambridge] at 23:57 05 November 2015
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C. Saccardi et al.
complications, such as pelvic pain, intrauterine growth restriction, placenta previa or accreta, placental abruption, dystocia and postpartum hemorrhage (4,5). Surgeons are usually reluctant to perform myomectomy during pregnancy because in this clinical condition both the increased uterine blood flow and volume raise the potential risk of hemorrhagic complications, while the uterine manipulation can determine an adverse outcome of pregnancy. In rare cases surgery is inevitable: Severe abdominal pain due to degeneration or torsion (associated with necrosis) of pedunculated myomas, abdominal discomfort and the bulk of the mass could potentially negatively affect the course of pregnancy. Although laparotomic myomectomy during pregnancy has been reported as a safe approach since the end of the nineteenth century (6,7), nowadays evidence about laparoscopic myomectomy in pregnancy is poor and represented only by case reports and series. The aim of this report is to perform a critical review of the English literature about feasibility, safety, limitations and contraindications of laparoscopic myomectomy during pregnancy starting from the peculiar case of a 15-weeks pregnant woman affected by a symptomatic large myoma.
Case report A 35 year-old Caucasian nulliparous woman was referred to our unit at nine weeks of gestation for abdominal heaviness and constipation. She did not have any significant medical or surgical history and the pregnancy had occurred spontaneously. At first clinical evaluation the uterus was bigger than expected for the gestational age and she reported significant abdominal discomfort. The transabdominal ultrasound examination revealed the presence of a 24 cm pedunculated myoma with an implantation base of 5 cm. There were no apparent signs of myoma degeneration or necrosis. An intrauterine singleton pregnancy corresponding to gestational age was found. The initial management was conservative, consisting of bed rest, analgesics administration (paracetamol), and diet enriched with fluid and fibers intake. The pregnancy continued with a slow but steady increase in symptoms until the achievement of 15 gestational weeks, when the worsening of abdominal pain led to the need of a laparoscopic myomectomy. Pneumoperitoneum was performed with the Optyview technique (Endopath, Xcel. Bladeless trocars, Ethicon Endo-S, LLC, Guaynabo, Cincinnati, OH, USA) after placement of the trocar 3 cm above the transverse umbilical line, until an intra-abdominal pressure of 10 mmHg was reached. Carbon dioxide
pressure was maintained
ISSN: 1364-5706 (Print) 1365-2931 (Online) Journal homepage: http://www.tandfonline.com/loi/imit20
Uncertainties about laparoscopic myomectomy during pregnancy: A lack of evidence or an inherited misconception? A critical literature review starting from a peculiar case Carlo Saccardi, Silvia Visentin, Marco Noventa, Erich Cosmi, Pietro Litta & Salvatore Gizzo To cite this article: Carlo Saccardi, Silvia Visentin, Marco Noventa, Erich Cosmi, Pietro Litta & Salvatore Gizzo (2015) Uncertainties about laparoscopic myomectomy during pregnancy: A lack of evidence or an inherited misconception? A critical literature review starting from a peculiar case, Minimally Invasive Therapy & Allied Technologies, 24:4, 189-194 To link to this article: http://dx.doi.org/10.3109/13645706.2014.987678
Published online: 15 Dec 2014.
Submit your article to this journal
Article views: 30
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imit20 Download by: [University of Cambridge]
Date: 05 November 2015, At: 23:57
Minimally Invasive Therapy. 2014;24:189–194
REVIEW ARTICLE
Downloaded by [University of Cambridge] at 23:57 05 November 2015
Uncertainties about laparoscopic myomectomy during pregnancy: A lack of evidence or an inherited misconception? A critical literature review starting from a peculiar case
CARLO SACCARDI, SILVIA VISENTIN, MARCO NOVENTA, ERICH COSMI, PIETRO LITTA & SALVATORE GIZZO Department of Woman and Child Health, University of Padua, Padua, Italy
Abstract Objective: The aim of this report was to perform a critical review of the literature about feasibility, safety, limitations and contraindications of laparoscopic myomectomy during pregnancy starting from a peculiar case of a 15-weeks pregnant woman affected by a symptomatic large myoma. Case report: A 35 year-old Caucasian-nulliparous-woman was referred to our unit at nine weeks of gestation for abdominal heaviness and constipation. The ultrasound examination revealed the presence of a 24 cm pedunculated myoma. The initial management was conservative until the achievement of 15 gestational weeks, when the worsening of abdominal pain led to the need of a laparoscopic myomectomy. Intraoperative blood-loss was 600 ml and operating-time was 150 minutes (70 minutes were required for the morcellement); the postoperative course was normal. The pregnancy evolved regularly and, at 41 weeks, the patient delivered by urgent caesarean section (because intrapartum fetal heart rate abnormalities) a healthy male baby weighing 4460 gr. Both post-partum and puerperium period had a regular course. Conclusion: Laparoscopic myomectomy is feasible and safe during pregnancy for both mother and fetus and vaginal delivery should not be contraindicated. Evidence from our and other reported cases suggests that, during pregnancy, laparoscopic myomectomy should be considered the best surgical choice when subserous peduncolated myomas are symptomatic.
Key words: Laparoscopic myomectomy, myoma complicated pregnancy, surgical approach, procedure safety, maternal-fetal wellbeing, evidence-based guidelines
Introduction Uterine myomas are benign monoclonal, estrogendependent uterine tumors. Prevalence ranges from 10% to >50%, but it is still difficult to determine the real frequency in the general population (1). It is commonly accepted that myomas are more frequent in the black than in the caucasian population, and that their incidence increases with age, especially after 30 years. Estrogen and progesterone play an important role in the development and growth of myomas, but in the last years this concept has been questioned. Several factors, such as genetic and epigenetic mechanism, growth factors, cytokines and disorganization of extracellular matrix components have shown to interact in their pathogenesis (2). Only a minority
of myomas are symptomatic, and discomfort depends to their localization, size and number. Women affected by myomas usually report symptoms of menstrual bleeding, pelvic pain, pelvic heaviness and history of miscarriage. The laparoscopic approach to myomectomy is widely accepted because it avoids abdomen opening, requires small incisions, decreases postoperative pain comporting shorter hospitalization and convalescence time and a faster return to normal activities. Some concerns remain about the quality of the uterine scar and the consequent risk of dehiscence or uterine rupture during pregnancy or delivery, but the improvement of technologies and techniques has reduced the risks (3). The prevalence of uterine myomas during pregnancy varies between 2 and 10%, and only 10% of these could lead to pregnancy
Correspondence: S. Gizzo, Dipartimento di Salute della Donna e del Bambino, U.O.C. di Ginecologia e Ostetricia, Via Giustiniani 3, 35128 Padova, Italy. Fax: +39 049 8211785. E-mail: [email protected] ISSN 1364-5706 print/ISSN 1365-2931 online 2014 Informa Healthcare DOI: 10.3109/13645706.2014.987678
Downloaded by [University of Cambridge] at 23:57 05 November 2015
190
C. Saccardi et al.
complications, such as pelvic pain, intrauterine growth restriction, placenta previa or accreta, placental abruption, dystocia and postpartum hemorrhage (4,5). Surgeons are usually reluctant to perform myomectomy during pregnancy because in this clinical condition both the increased uterine blood flow and volume raise the potential risk of hemorrhagic complications, while the uterine manipulation can determine an adverse outcome of pregnancy. In rare cases surgery is inevitable: Severe abdominal pain due to degeneration or torsion (associated with necrosis) of pedunculated myomas, abdominal discomfort and the bulk of the mass could potentially negatively affect the course of pregnancy. Although laparotomic myomectomy during pregnancy has been reported as a safe approach since the end of the nineteenth century (6,7), nowadays evidence about laparoscopic myomectomy in pregnancy is poor and represented only by case reports and series. The aim of this report is to perform a critical review of the English literature about feasibility, safety, limitations and contraindications of laparoscopic myomectomy during pregnancy starting from the peculiar case of a 15-weeks pregnant woman affected by a symptomatic large myoma.
Case report A 35 year-old Caucasian nulliparous woman was referred to our unit at nine weeks of gestation for abdominal heaviness and constipation. She did not have any significant medical or surgical history and the pregnancy had occurred spontaneously. At first clinical evaluation the uterus was bigger than expected for the gestational age and she reported significant abdominal discomfort. The transabdominal ultrasound examination revealed the presence of a 24 cm pedunculated myoma with an implantation base of 5 cm. There were no apparent signs of myoma degeneration or necrosis. An intrauterine singleton pregnancy corresponding to gestational age was found. The initial management was conservative, consisting of bed rest, analgesics administration (paracetamol), and diet enriched with fluid and fibers intake. The pregnancy continued with a slow but steady increase in symptoms until the achievement of 15 gestational weeks, when the worsening of abdominal pain led to the need of a laparoscopic myomectomy. Pneumoperitoneum was performed with the Optyview technique (Endopath, Xcel. Bladeless trocars, Ethicon Endo-S, LLC, Guaynabo, Cincinnati, OH, USA) after placement of the trocar 3 cm above the transverse umbilical line, until an intra-abdominal pressure of 10 mmHg was reached. Carbon dioxide
pressure was maintained
