Previous Myomectomy Research Articles

Uterine artery embolisation for symptomatic fibroids: the University of Malaya Medical Centre experience.

Background:Transcatheter uterine artery embolisation (UAE) for the treatment of symptomatic fibroids has been performed in several centres in the United States, Western Europe and Asia with promising results. This study reports the authors' experience with UAE at the University Malaya Medical Centre.Method:Fifty women with symptomatic uterine fibroids who declined surgery were treated by transcatheter UAE. The uterine arteries were selectively catheterised and embolised with polyvinyl alcohol particles. Post-procedure analgesia was administered via patient-controlled analgesic pump. The patients were followed up at an interval of 6/12 clinically and with MRI.Results:Transcatheter UAE was performed on all 50 patients with no major complications. 49 patients had both uterine arteries embolised while 1 patient had only the right uterine artery embolised on account of hypoplasia of the left uterine artery due to previous myomectomy. The mean hospital stay was 3.5 days (range, 2 to 7). At a mean follow-up of 24/52, all patients reported improvements in their presenting symptoms. Objective improvement in terms of reduction of uterine and fibroid sizes was determined on MRI. One patient, who initially responded with a decrease in uterine and dominant fibroid size, became symptomatic (menorrhagia) after 6 months and subsequent endometrial sampling revealed cystic glandular hyperplasia for which total abdominal hysterectomy was performed. Two other patients had no change in symptoms and after hysterectomy, the pathology revealed concurrent adenomyosis. Another 2 patients with cervical fibroids were treated with hysterectomy as there was no gross reduction in the size of fibroid following UAE. Overall, 90% of the patients had dramatic improvement of anaemia and symptoms at 1 year follow-up.Conclusion:Out of the 50 patients, 17 patients had total disappearance of their fibroids and 28 patients had more than 50% reduction in the size of fibroids after 1 year. 5 patients ended up with total abdominal hysterectomy. These results suggest that UAE is an appealing alternative to hysterectomy or myomectomy for many women with symptomatic fibroids.

Spontaneous uterine rupture during a second trimester pregnancy with a history of laparoscopic myomectomy

Uterine rupture is one of the most feared obstetric complications, carrying an increased risk of maternal and perinatal morbidity and mortality. Here, we present a case of spontaneous uterine rupture during the first half of pregnancy. The patient did not report any recent trauma, however she had a history of laparoscopic myomectomy conducted three years earlier. The uterine rupture was 6-7 cm in length, located at the fundal level and was thought to originate from the previous myomectomy scar. In this report, we discuss the importance of choosing the right surgical technique and suturing method in patients undergoing myomectomy who desire to conceive in the future, and how obscure the findings of uterine rupture during pregnancy can be.

Vaginal delivery after myomectomy: challenges and opportunities

A 33-year-old patient was booked for antenatal care at 6 weeks during her Wrst pregnancy. She had a previous abdominal myomectomy 6 years earlier for heavy periods that made her anaemic. She had a hospital report indicating that the Wbroid was located in the lower posterior uterine wall, encroaching on the cervix and measured 8 £ 7 £ 6 cm. It distorted the uterine cavity and obliterated the pouch of Douglas. The incision was made over the Wbroid, through the posterior wall of the uterus. An opening of half a centimeter was made into the uterine cavity during the operation and the patient was advised to have an elective section. The uterine wall was closed with vicryl, and the peritoneum was closed with prolene. She was counseled about the risk of uterine scar rupture and was oVered an elective caesarean section, which she declined and requested a trial of vaginal delivery. Her pregnancy progressed uneventfully and repeat ultrasound scans showed no signiWcant change in the size of her Wbroids or any thinning of her uterine wall. She was admitted in spontaneous labour 9 days after her due date. A venXon was inserted, blood taken for group and save, and an epidural sited. She was kept under continuous cardiotocography monitoring. She progressed from 5 cm cervical dilatation to 9 cm in 4 h. The patient then took 4 h to reach full dilatation, as the vertex rotated from occiptoposterior position to right occiptoanterior position. There was no progress, despite an hour of pushing and the patient was counseled again regarding the need for emergency section, but insisted on continuing the trial. There was no progress despite an hour of pushing and the patient was counseled regarding the need for emergency section, but insisted on continuing the trial. The consultant was called in and agreed to a trial of instrumental delivery in theatre. The vertex was presenting in the right occiptoanterior position at 0 station. Nivelle Barns forceps were applied and the head was delivered after three pulls, with a right mediolateral episiotomy performed. A 4.220 kg active term male baby was born and the placenta was removed manually. The patient sustained a third degree tear, which was repaired alongside the episiotomy. She lost 1,500 ml of blood and was started on oral iron, alongside antibiotics and laxatives for the third degree tear. The patient recovered well and had no problems with anal incontinence when seen for postnatal check. She was keen on vaginal delivery in a subsequent pregnancy.

Frequency of uterine rupture at delivery and accompanying risks for the mother and the newborn

Uterine rupture at delivery is a severe lifethreatening complication for both mather and the newborn. The aim of the study was to determine the frequency of total number uterine rupture within the deliveries, to perceive circumstances and causes that lead to rupture, to establish perinatal and maternal mortality and to present our therapeutic procedure. In the group of 37 ruptures at 59 660 deliveries from the period 1991-2000 included in this retrospective study we analyzed age, level of education, gestational age, parity, previous caesarian section and other operations on uterus, time of diagnosing rupture, grade and place of rupture, use of Syntocinon and Prostaglandin at delivery, perinatal and maternal mortality, as well as therapeutic procedures at rupture that occurred. The highest influence on uterine rupture in our group had been exerted by previous caesarian section and myomectomy in relation 33 : 4. Incomplete uterine ruptures were more frequent, 26 (70.27%), in relation to complete ones, 11 (29.75%). The most frequent place of uterine rupture was the front wall, 34 (91.89%), two ruptures occurred on the fundus and one on the back wall. The most frequently applied therapeutic procedures were rupture suture in 31 (83.78%) cases, and in six (16.22%) cases hysterectomy. Perinatal mortality was three times higher than average (17.78%) in that period and was 51.28%. We emphasize that rupture frequency in the total number of deliveries was one rupture at 1 612 deliveries, whereas rupture frequency on the intact uterus was 1 : 17 269, and frequency of uterine rupture after caesarian section was one rupture at 245 deliveries. Our research as well as researches of other authors, showed that a previous caesarian section is the most frequent cause for the occurrence of uterine rupture. Therefore, caesarian section should be avoided whenever possible, not just because of a potential rupture, but also because of more frequent hysterectomy that interrupts woman's reproductive ability.

Parasitic myomas after laparoscopic myomectomy: case report

To report a case of a woman who presented with parasitic myomas 27 months after laparoscopic myomectomy. Case report. University medical center. A 31-year-old G0 woman who had a previous history significant for laparoscopic myomectomy with morcellation 27 months before. Repeat laparoscopic myomectomy and review of video footage from previous myomectomy. Pathology report. Repeat laparoscopic examination revealed two pedunculated and two parasitic myomas. Review of video footage from initial surgery revealed pieces of myoma dispersed within pelvis during morcellation. Pieces of initial myoma dispersed within the pelvis during morcellation may have developed into parasitic myomas.

Parasitic leiomyoma in the abdominal wall after laparoscopic myomectomy

To report a case of parasitic leiomyoma of the abdominal wall after laparoscopic myomectomy. Case report. Large medical center. A 31-year-old woman with a newly developed palpable mass in the abdominal wall near the trocar site of a previous laparoscopic myomectomy. Excision of the mass. Histopathologic examination of the mass. A mass measuring 3.2 x 2.2 x 2.0 cm was excised. The lesion was located in the subfascial area of the abdominal wall, near the trocar site of a previous laparoscopic myomectomy. Histopathologic examination confirmed leiomyoma. This result shows that myoma fragments sometimes are found to be scattered in the abdominal cavity after laparoscopic myomectomy, suggesting that all myoma fragments, however small they may be, must be completely removed.

Staircase sign: A newly described uterine contraction pattern seen in rupture of unscarred gravid uterus

Although extremely rare, rupture of an unscarred gravid uterus poses significant morbidity and mortality to both fetus and mother. In the past, loss of uterine contraction was thought to be characteristic of uterine rupture, while recent evidence shows that uterine contraction pattern is not associated with uterine rupture. We report two cases of rupture in the unscarred term uterus. Both patients were multiparous and denied any past medical complications, previous cesarean delivery or myomectomy. Uterine rupture occurred in the latent phase of labor at 1 cm dilation (Case 1) and during an intravenous oxytocin infusion after three doses of intravaginal misoprostol (Case 2). Case 2 required cesarean hysterectomy and blood transfusion. Case 1 was monitored with an external tocodynamometer, while Case 2 was monitored with an internal pressure transducer. External monitoring demonstrated the classic sign of complete loss of uterine tone. In contrast, internal monitoring demonstrated an increase in uterine resting tone. Both techniques revealed a stepwise gradual decrease in contraction amplitude followed by sudden onset of profound and prolonged fetal bradycardia (staircase sign). In cases of uterine rupture, differing baseline characteristics between contraction patterns were dependent on uterine monitoring technique. In both techniques a stepwise gradual decrease in contraction amplitude was followed by prolonged fetal bradycardia.

Cesarean Delivery and Peripartum Hysterectomy

To estimate the national incidence of peripartum hysterectomy and quantify the risk associated with cesarean deliveries and other factors. A population-based, matched case-control study using the United Kingdom Obstetric Surveillance System, including 318 women in the United Kingdom who underwent peripartum hysterectomy between February 2005 and February 2006 and 614 matched control women. The incidence of peripartum hysterectomy was 4.1 cases per 10,000 births (95% confidence interval [CI] 3.6-4.5). Maternal mortality was 0.6% (95% CI 0-1.5%). Previous cesarean delivery (odds ratio [OR] 3.52, 95% CI 2.35-5.26), maternal age over 35 years (OR 2.42, 95% CI 1.66-3.58), parity of three or greater (OR 2.30, 95% CI 1.26-4.18), previous manual placental removal (OR 12.5, 95% CI 1.17-133.0), previous myomectomy (OR 14.0, 95% CI 1.31-149.3), and twin pregnancy (OR 6.30, 95% CI 1.73-23.0) were all risk factors for peripartum hysterectomy. The risk associated with previous cesarean delivery was higher with increasing numbers of previous cesarean deliveries (OR 2.14 with one previous delivery [95% CI 1.37-3.33], 18.6 with two or more [95% CI 7.67-45.4]). Women undergoing a first cesarean delivery in the current pregnancy were also at increased risk (OR 7.13, 95% CI 3.71-13.7). Peripartum hysterectomy is strongly associated with previous cesarean delivery, and the risk rises with increasing number of previous cesarean deliveries, maternal age over 35 years, and parity greater than 3. II.

Laparoscopic subtotal hysterectomy using the plasma kinetic and lap loop systems: An alternative approach in the surgical management of women with uterine fibroids

Objective To evaluate the safety and applicability of laparoscopic subtotal hysterectomy (LSH) using the plasma kinetic (PK) and lap loop systems as an alternative surgical approach in the management of uterine fibroids in women who have completed their families. Study design Sixty-two consecutive LSH were performed during this prospective study from March 2003 to March 2005 at Princess Royal University Hospital, Kent, UK. Results All study patients had menorrhagia resistant to at least one form of therapy, with a mean duration of symptoms of 3.5 years. In addition, four patients had previous myomectomy. The mean number of fibroids removed was 2.7. The mean weight of the uterus was 141.9 g. The mean operative time was 46.8 min, and the mean blood loss was 126.6 mL. The overall perioperative complication rate was 4.8% with no visceral injury, or return to theatre. At follow-up, all patients were satisfied with surgery. Conclusion The study describes the first application of the PK and Lap Loop systems in LSH for the surgical management of uterine fibroids in women in whom fertility is not an issue, and its findings suggest that this minimally invasive technique is a safe, and valid alternative. Larger adequately-powered studies are however still required.

Do uterine fibroids affect IVF outcomes?

The effect of myomectomy on implantation and pregnancy rates prior to assisted reproduction treatments is controversial. This study was designed to assess clinical outcomes of IVF cycles in women with uterine fibroids. A retrospective single-centre assessment of clinical outcomes of IVF/intracytoplasmic sperm injection (ICSI) treatments in infertile women in a 4-year span was carried out. All patients underwent detailed transvaginal ultrasound and hysteroscopy to precisely identify presence, location and intracavitary growth of uterine fibroids. Cumulative pregnancy, ongoing pregnancy and live birth rates were considered primary outcome measurements. Fifty-one women with fibroids (97 treatment cycles), 63 patients with previous myomectomy (127 cycles), and 106 infertile women who did not demonstrate fibroids anywhere in the uterus (215 cycles) were considered for the analysis. No significant difference was found for pregnancy and live birth rates between groups. Women with fibroids >4 cm required an increased number of cycles to obtain an ongoing pregnancy, compared with the other groups. The data do not support pre-IVF myomectomy in women with small-to-moderate uterine fibroids, regardless of their location. This represents valuable information in the counselling of women with fibroids before reproductive assisted cycles.

Induction of labor with misoprostol or oxytocin in Tanzania

The aim of this study is to compare the safety efficacy and cost effectiveness of vaginal misoprostol and intravenous oxytocin in induction of labor. A randomized trial was performed in 142 women requiring labor induction in Muhimbili National Hospital Dar es Salaam Tanzania from June to December 2004. Inclusion criteria were singleton vertex presentation; gestational age >36 weeks. Exclusion criteria were previous myomectomy uteroplasty or cesarean section. Sequential sealed envelopes generated by computer were used. Patients were assigned to receive either oxytocin or 25 mcg 4-hourly vaginal misoprostol (Continental pharma Inc Belgium; maximum dose 100 mcg). If contractions were not established 4 h after the insertion of the fourth misoprostol induction was considered a failure and the patient was managed according to hospital protocols. In the oxytocin group infusion of 5 I in 500 ml of 5% dextrose (10 mU/ ml) was started (maximum dosage 40 mU/min). If labor was not established within 12 h induction was regarded as a failure and the patient was managed according to hospital protocols. (excerpt)

Accuracy of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta

The incidence of placenta accreta has increased dramatically over the last three decades, in concert with the increase in the cesarean delivery rate. Optimal management requires accurate prenatal diagnosis. The purpose of this study was to determine the precision and reliability of ultrasonography and magnetic resonance imaging (MRI) in diagnosing placenta accreta. A historical cohort study was performed with information gathered from our obstetric, radiologic, and pathology databases. Records from January 2000 to June 2005 were reviewed to identify patients with a diagnosis of placenta previa, low-lying placenta with a prior cesarean delivery, or history of a myomectomy to determine the accuracy of pelvic ultrasonography in the diagnosis of placenta accreta. The records of those considered to be suspicious for placenta accreta and subsequently referred for additional confirmation by MRI were also analyzed. The sonographic and MRI diagnoses were compared with the final pathologic or operative findings or with both. Of the 453 women with placenta previa, previous cesarean delivery and low-lying anterior placenta, or previous myomectomy, 39 had placenta accreta confirmed by pathological examination. Ultrasonography accurately predicted placenta accreta in 30 of 39 of women and correctly ruled out placenta accreta in 398 of 414 without placenta accreta (sensitivity 0.77, specificity 0.96). Forty-two women underwent MRI evaluation because of findings suspicious or inconclusive of placenta accreta by ultrasonography. Magnetic resonance imaging accurately predicted placenta accreta in 23 of 26 cases with placenta accreta and correctly ruled out placenta accreta in 14 of 14 (sensitivity 0.88, specificity 1.0). A two-stage protocol for evaluating women at high risk for placenta accreta, which uses ultrasonography first, and then MRI for cases with inconclusive ultrasound features, will optimize diagnostic accuracy.

Influence of Uterine Myomas on Course and Outcome of Pregnancy

Purpose and Introduction: Uterine myomas are present in 1.4 % of all pregnancies. They increase incidence of spontaneous abortions, preterm labor and fetal malpresentation, as well as degeneration and infection of myomas. Some of them must be operated and removed before or during the pregnancy and during the cesarean section. Our study shows how uterine myomas influence the course of pregnancy or the way of its termination. We paid special attention to the group of patients who previously had myomectomy. We seeked for an answer if myomectomy should be an indication for operative delivery or not. Materials and Method: We analyzed 122 pregnancies which were followed and terminated in the Institute for Gynecology and Obstetrics in two years' interval. The patients were divided in 3 groups. Group 1: 23 patients who previously had myomectomy and had normal ultrasound finding during the actual pregnancy. Group 2: 10 patients who previously had myomectomy and had new myomas. Group 3: 89 patients who had one or more myomas and had no operations before. Results and Discussion: Vaginal delivery was performed in 23.7 % cases, they were all spontaneous. Operative deliveries were performed in 76.3 % pregnancies. In group 1 this percentage was 87 % and in group 2 even 90 % due to previous myomectomy. During the cesarean section we performed myomectomy in 33.6 %. There were no significant intrapartal or postpartal hemorrhages. In group 2 we found 2 incomplete uterus ruptures during the elective cesarean sections. Conclusion: We suggest to take special care of patients with previous myomectomy and new myomas because they are at great risk to develop uterine rupture in pregnancy and labor with great danger for fetus and mother.

Subserosal pregnancy in a previous myomectomy site: A variant of intramural pregnancy

A 35-year-old woman with a history of myomectomy underwent in vitro fertilization and became pregnant. Transvaginal ultrasound revealed a gestational sac within the subserosal area of the posterior uterine wall. The patient was treated successfully with conservative surgery, and the pathologic evaluation of the excised mass demonstrated chorionic villi involving myometrium. Early in a subsequent pregnancy, placental invasion through the sinus tract was detected. However, the pregnancy outcome was uneventful. This constitutes the first report of subserosal implantation in the uterine body. Our findings suggest that the probable pathogenesis of this rare variant of intramural pregnancy is implantation through a sinus tract made during a previous uterine surgery.

High Recurrence Rate of Uterine Fibroids on Transvaginal Ultrasound after Abdominal Myomectomy in Japanese Women

Aim: To evaluate the recurrence rate of uterine fibroids (UF) after abdominal myomectomy and the risk factors for recurrences. Methods: In aretrospective study, transvaginal ultrasound examinations were performed in 135 women after abdominal myomectomy. The main outcome measures were cumulative UF recurrence rates after abdominal myomectomy. The Kaplan-Meier survival analysis was used to estimate the cumulative recurrence rate, and log-rank tests were applied to compare survival curves among different categorical groups of potential risk factors for recurrences. Results: The cumulative UF recurrence rates at 12 and 24 months after abdominal myomectomy were 12.4 and 46.0%, respectively. Women who had a history of previous myomectomy had a higher hazard of UF recurrence than women without such a history (hazard ratio 4.1, 95% confidence interval 1.20–13.6). The women having four or more UFs had a higher hazard than those who had less than four UFs (hazard ratio 3.7, confidence interval 1.41–9.88). After adjusting these variables to each other, the hazard ratio remained similar. Conclusions: The UF recurrence rate detected by transvaginal ultrasound after abdominal myomectomy was high, but did not require any additional surgery. Physicians need to consider the timing of the myomectomy, taking into account complications of pregnancy and infertility due to UF recurrence.

Multiple peritoneal parasitic myomas after laparoscopic myomectomy and morcellation

We describe multiple parasitic myomas visualized on laparoscopy in a woman who had a previous laparoscopic myomectomy. Location of the myomas suggests morcellation as a contributing factor.

Failure of uterine fibroid embolization

To assess the outcomes of patients who underwent uterine fibroid embolization (UFE) and to evaluate factors associated with failure of UFE. Retrospective study. University teaching hospital. Two hundred thirty-three consecutive patients who underwent UFE from November 1997 to February 2004. Uterine fibroid embolizations were performed by three interventional radiologists using 355-500-mu polyvinyl alcohol particles. Hysterectomy rate, myomectomy rate, and repeat UFE rate. With a mean follow-up of 13 months, a total of 22 patients underwent surgery after UFE (9.4%); 16 had hysterectomies (6.9%), and 6 had myomectomies (2.6%). This included 3 patients who underwent repeat UFE and subsequently required surgical intervention. The mean (+/- SEM) time interval between UFE and subsequent treatment was 12.5 +/- 2.0 months. Among patients who required surgery, 13 (59.1%) presented with recurrent menorrhagia, and 5 (22.7%) complained of persistent abdominal pain. Histopathologic examination revealed concomitant findings of adenomyosis in 25% of hysterectomy specimens. Patients who failed UFE were more likely to have had a previous myomectomy (13% vs. 2.4%) and significant reduction in the uterine size 6 months after UFE (57.1% vs. 25.2%). The overall failure rate of UFE is 9.4%. Failure is mainly due to persistent menorrhagia and abdominal pain. Shrinkage of the uterus after UFE does not necessarily correlate with long-term success of UFE.

Reducing blood loss at open myomectomy using triple tourniquet: a randomised controlled trial

isremarkable and would be a useful addition to the armamentar-ium for minimising blood loss during myomectomy. However, of171 patients who were assessed for eligibility, only 30 of thesewomen (18%) were recruited. This challenges the assertion thattheir results from the tourniquet technique are ‘as generalisable aspossible’. It is unfortunate that they do not say why 101 womenwith moderately enlarged fibroids were not eligible for surgery,and why an additional 40 women were not eligible for open myo-mectomy. Our own experience is that access, especially to thearea of the internal os, would be a frequent problem.The authors also suggest that the inclusion of five women,who had had previous laparotomy, including myomectomy, alsosupports the generalisability of their findings but do not sayhow many of these had had a previous myomectomy, or a sim-pler procedure.A Roeder knot was left in situ at the level of the internal os withthe intention of tightening it laparoscopically in the event of post-operative bleeding. One wonders if this is wise. Surely, if bleedingis severe enough to warrant a return to theatre, attempting totighten a knot laparoscopically under a general anaesthetic in apatient with a fresh laparotomy wound may not be the safestapproach.We recently reported on the use of pre-myomectomy uterineartery embolisation (UAE) for minimising blood loss at surgery,

Leiomiomas uterinos e gravidez

OBJETIVO: avaliar a evolução da gestação e o prognóstico materno-fetal em gestantes com leiomiomas uterinos. MÉTODOS: análise retrospectiva descritiva de 75 prontuários de gestantes com leiomiomas atendidas em hospital terciário, no período de janeiro de 1992 a janeiro de 2002. RESULTADOS: foram identificadas 75 gestantes com leiomiomas numa população de 34.467 gestantes atendidas neste período (incidência de 0,2%). Dezoito pacientes (24%) tiveram os diagnósticos feitos previamente à gestação, 41 (54,6%) tiveram os diagnósticos durante a gestação e 16 (21,3%) durante a cesariana, das quais apenas seis não haviam sido submetidas à ultra-sonografia durante o pré-natal. Foram observados 10 partos com feto pré-termo e cinco casos de rotura prematura das membranas. Quarenta e sete pacientes (75,8%) foram submetidas à cesariana, sendo as indicações diretamente relacionadas aos leiomiomas em 38,3% delas (apresentação anômala, obstrução do canal de parto ou cicatriz uterina por miomectomia prévia). Foram diagnosticados quatro casos de necrose central do leiomioma, dois casos de degeneração hialina e um caso com potencial de malignidade nas pacientes submetidas à miomectomia ou histerectomia após a gestação. Sessenta e um recém-nascidos (98,4%) tiveram índices de Apgar maior que 7 no 5º minuto, e a cirurgia para miomectomia, quando realizada durante a gestação, não piorou o prognóstico materno-fetal. CONCLUSÕES: a incidência de leiomiomas na gestação foi de 0,2% no período, tendo a ultra-sonografia falhado no diagnóstico em 10 pacientes. A cesariana foi freqüentemente indicada neste grupo de pacientes, mas a presença de leiomiomas na gestação não comprometeu o índice de Apgar dos recém-nascidos.

Intrapartum posterior uterine wall rupture in lower segment cesarean section scarred uterus

Intrapartum uterine rupture is a well-documented complication of labor that fortunately is a rare event. The majority of these cases arise in women with scarred uteri secondary to some event such as previous cesarean section myomectomy deep cornual resection metroplasty tubo-cornual anastomosis iatrogenic or traumatic uterine rupture. Vaginal birth after cesarean (VBAC) is now a safe and well-accepted procedure of conduct in women with one previous lower segment cesarean section (LSCS). Uterine rupture in such women commonly involves the anteriorly placed scar. Posterior rupture in women in whom VBAC was attempted has also been reported although only twice in the literature. Here we report a similar case of posterior uterine rupture in a woman in labor with a previous LSCS to add further data to this rare and isolated complication. (excerpt)