Subserous Fibroids Research Articles

8499 Laparoscopic Myomectomy for Symptomatic Pedunculated Fibroid with Degeneration and Subserous Fibroids in Second Trimester of Pregnancy

Study Objective To demonstrate the feasibility of emergency laparoscopic myomectomy for a large pedunculated fibroid (FIGO type 7) with degeneration and multiple subserous fibroids (FIGO type 6) in a patient with pregnancy of 12.4 weeks. Design Stepwise demonstration of laparoscopic myomectomy in a patient with gravid uterus with narrated video footage with sonographic images. Setting Tertiary care hospital. Patients or Participants A 27 years primigravida with 12.4 weeks of gestation presented with severe pain in right lower abdomen and vomiting for three days. Abdominal ultrasound showed gravid uterus with multiple subserous fibroids of size 30 × 30mm, 23 × 26mm, 24 × 21mm and a large avascular lesion showing central degeneration of size 117 × 93 mm in right hypochondriac region separately from uterine fundus suggestive of pedunculated fibroid. Patient counselling was done about the risks and benefits of surgery during pregnancy. Interventions Laparoscopic myomectomy of a large pedunculated myoma and other multiple subserous fibroids was done. The base of pedunculated fibroid ligated with two sutures and rest of fibroids enucleated out. Myometrial walls sutured. Use of vasopressin was avoided during myomectomy. The fibroids were removed by in bag morcellation with morcellator. Measurements and Main Results The myomas were removed with very minimal blood loss of 50 ml. The pedunculated large myoma measured 10 × 12 cm and six subserosal fibroids measured 2 × 2 cm to 2 × 3 cm each. Histopathological reports revealed degeneration in large pedunculated fibroid. The patient had complete resolution of right lower abdominal pain and recovered well post operatively and underwent vaginal delivery at term with healthy baby. Conclusion Laparoscopic myomectomy can be done selectively for patients with only symptomatic pedunculated and subserous fibroids. Minimal handling of the gravid uterus is necessary to minimize the chances of abortion and preterm delivery. Proper selection of patients for this type of surgery during pregnancy is very important and requires surgical expertise. To demonstrate the feasibility of emergency laparoscopic myomectomy for a large pedunculated fibroid (FIGO type 7) with degeneration and multiple subserous fibroids (FIGO type 6) in a patient with pregnancy of 12.4 weeks. Stepwise demonstration of laparoscopic myomectomy in a patient with gravid uterus with narrated video footage with sonographic images. Tertiary care hospital. A 27 years primigravida with 12.4 weeks of gestation presented with severe pain in right lower abdomen and vomiting for three days. Abdominal ultrasound showed gravid uterus with multiple subserous fibroids of size 30 × 30mm, 23 × 26mm, 24 × 21mm and a large avascular lesion showing central degeneration of size 117 × 93 mm in right hypochondriac region separately from uterine fundus suggestive of pedunculated fibroid. Patient counselling was done about the risks and benefits of surgery during pregnancy. Laparoscopic myomectomy of a large pedunculated myoma and other multiple subserous fibroids was done. The base of pedunculated fibroid ligated with two sutures and rest of fibroids enucleated out. Myometrial walls sutured. Use of vasopressin was avoided during myomectomy. The fibroids were removed by in bag morcellation with morcellator. The myomas were removed with very minimal blood loss of 50 ml. The pedunculated large myoma measured 10 × 12 cm and six subserosal fibroids measured 2 × 2 cm to 2 × 3 cm each. Histopathological reports revealed degeneration in large pedunculated fibroid. The patient had complete resolution of right lower abdominal pain and recovered well post operatively and underwent vaginal delivery at term with healthy baby. Laparoscopic myomectomy can be done selectively for patients with only symptomatic pedunculated and subserous fibroids. Minimal handling of the gravid uterus is necessary to minimize the chances of abortion and preterm delivery. Proper selection of patients for this type of surgery during pregnancy is very important and requires surgical expertise.

Laparoscopic Myomectomy Assisted by Hysteroscopy: A Case Report

Study Objective To demonstrate the benefits of laparoscopic myomectomy assisted by hysteroscopy to minimize endometrium damage, therefore providing a better fertility outcome. Design Case report for surgical technique and description of the procedure using video. Setting Tertiary hospital. Patients or Participants A 30-year-old nulliparous woman presents with abnormal uterine bleeding and pelvic pain for a year and a half. She previously tried clinical treatment with Tranexamic Acid and Oral Progesterone without symptoms remission. In the physical examination there weren't any irregular findings. The MRI evidenced multiple nodular formations: a 2 cm submucous fibroid on the fundus with cavity distortion and 8mm of myometrial free margin and others intramural and subserous fibroids measuring up to 1.7cm. Interventions We performed a diagnostic hysteroscopy to locate the submucous fibroid and used the hysteroscope's pressure and light to guide de surgeon on the laparoscopy towards that fibroid. We did a vertical incision and proceeded to enucleate the fibroid. We also excised other subserous and intramural nodules along the surgery. Uterine suture was done with a 2-0 barbed suture in two layers. We finished the procedure with another diagnostic hysteroscopy to evaluate endometrium damage. Measurements and Main Results In the final hysteroscopy we could see little endometrium damage. The patient was discharged on the first postoperative day without significant pain. Conclusion We were able to achieve minimal endometrium damage in a Type 2 FIGO staging fibroid, which would not be possible if we had performed a hysteroscopic myomectomy. On the other hand, if we had done only a laparoscopic procedure, we would have had a significant higher degree of difficulty at finding the fibroid due to its deep placement. Therefore, we reached a favorable outcome regarding the surgical approach in resecting a submucous fibroid in a patient with intention of childbearing. To demonstrate the benefits of laparoscopic myomectomy assisted by hysteroscopy to minimize endometrium damage, therefore providing a better fertility outcome. Case report for surgical technique and description of the procedure using video. Tertiary hospital. A 30-year-old nulliparous woman presents with abnormal uterine bleeding and pelvic pain for a year and a half. She previously tried clinical treatment with Tranexamic Acid and Oral Progesterone without symptoms remission. In the physical examination there weren't any irregular findings. The MRI evidenced multiple nodular formations: a 2 cm submucous fibroid on the fundus with cavity distortion and 8mm of myometrial free margin and others intramural and subserous fibroids measuring up to 1.7cm. We performed a diagnostic hysteroscopy to locate the submucous fibroid and used the hysteroscope's pressure and light to guide de surgeon on the laparoscopy towards that fibroid. We did a vertical incision and proceeded to enucleate the fibroid. We also excised other subserous and intramural nodules along the surgery. Uterine suture was done with a 2-0 barbed suture in two layers. We finished the procedure with another diagnostic hysteroscopy to evaluate endometrium damage. In the final hysteroscopy we could see little endometrium damage. The patient was discharged on the first postoperative day without significant pain. We were able to achieve minimal endometrium damage in a Type 2 FIGO staging fibroid, which would not be possible if we had performed a hysteroscopic myomectomy. On the other hand, if we had done only a laparoscopic procedure, we would have had a significant higher degree of difficulty at finding the fibroid due to its deep placement. Therefore, we reached a favorable outcome regarding the surgical approach in resecting a submucous fibroid in a patient with intention of childbearing.

Can Parasitic Fibroid Present by Intestinal Obstruction? Case Report

Parasitic fibroid is an expression used to indicate a myoma of extrauterine blood supply. Although uterine fibroids are the most common female tumors, parasitic fibroids are considered a rare pathologic entity of unclear explanation. We present a case of a huge parasitic fibroid attached to the jejunum and completely separated from the uterus manifested to emergency department by small intestinal obstruction. The patient also had multiple subserous fibroids that share the same histological features with the mass attached to the small intestine. The patient underwent laparotomy and mass excision with the direct repair of jejunal serosal tears in addition to hysterectomy and bilateral salpingo-oophorectomy. Although parasitic leiomyoma is a rare condition, it should be included in the differential diagnosis in females presenting with pelvic or abdominal masses; pre-operative diagnosis is difficult, and despite careful clinical examination and cross-sectional imaging, sometimes the final diagnosis cannot be made except after laparotomy and histopathological analysis of the specimen.

Miomektomija tokom carskog reza

Myomas (fibroids, leiomyomas) are the most common benign tumors of genital organs in women of reproductive age and represent a significant problem in women's health care. The frequency of cesarean section is higher in women with uterine fibroids. Absolute indications for myomectomy during caesarean section are: fibroids that prevent hysterotomy during caesarean section, impede uterine incision suture, hamper safe fetal extraction and cause uterine torsion. Relative indications for myomectomy during caesarean section are: subserous and pedunculated fibroids, anterior uterine wall fibroids, fibroids that can cause immediate perioperative, and puerperal complications, the patient's desire, fibroids that can cause complications in subsequent pregnancies, and fibroids that can be enucleated without additional hysterotomy. Myomectomy during caesarean section is a complex surgical procedure, associated with the possibility of considerable complications, and defining their actual frequency and risk factors for their occurrence requires further research. Myomectomy during caesarean section is associated with an increased risk of perioperative bleeding. Other perioperative complications of myomectomy during cesarean section are: disseminated intravascular coagulation, paralytic ileus, surgical site infections, sepsis, postoperative febrile morbidity, increased incidence of blood transfusions, and prolonged hospitalization.

Twisting of the uterus, especially of the pregnant uterus

One of the most common reasons for the rotation of the uterus around its axis is the old peri- and parametric exudates, which, wrinkling, can lead to significant displacements of the uterus. The twists, however, rarely reach a significant degree. The latter occurs when large tumors develop in close proximity to the uterus, most often ovarian cysts or subserous fibroids.

Emergency in Fibroids - Acute Abdomen from Myoma Torsion

Study Objective To highlight the rare but possible gynecological emergency due to fibroids. Design Case report using narrated video, for operative technique in a gynecological emergency surgery where the access to the pelvic compartment was impaired by adhesions. Setting Under general anesthesia, in dorsolithotomy position, legs abducted. We used 3 punctures for the robotic arms and one for auxiliar laparoscopic arm and a uterine manipulator. The first auxiliar stands on the left and the second assistant on the manipulator. Patients or Participants A female, 30-years-old patient that arrived at the gynecology emergency room with acute abdominal pain. Referring a previous diagnosis of pedicled fibroid in the posterior uterine wall. On physical exam she presented abdominal pain with signs of peritonitis, palpable mass on the posterior bottom of the vagina. Magnetic resonance: uterus 65ccc, 3 myomas, one anterior intramural, 0.4 cm; other posterior subserous, 1.7 cm; the biggest one was subserous with vascular pedicle, occupying the bottom of posterior pelvic sac, 10.0 cm, with diffuse necrosis. Interventions We have opted to go to a robotic-assisted emergency exploratory laparoscopy. Extensive adhesions lysis from all intestine to uterus and anexus, opening e the blocked pelvis to access the rectum vaginal recess where we could find the detached myoma with signs of ischemia. Myomectomy of posterior subserous fibroids of 2cm. Specimen removal over protection from the bag, through abdominal Pfannenstiel incision for a faster approach. Hemostasis of the uterine posterior wall on fibroids pedicles. Measurements and Main Results Patient had no surgical complications, only mild pain on the first days and was discharged on the third postoperative day. Conclusion Exploratory robotic-assisted laparoscopy done on the emergency was possible due to patient stability, fast room turnover and great preparation by the nursing surgery team and the medical familiarity with the robotic platform.

A.E. Cheremshanskiy. — The first case of removal of subserous fibroids of the uterus through the womb at the Vladivostok Marine Hospital. (Medical Addendum to the Marine Collection, March and April, 1895)

Patient 40 years old, had one childbirth and one miscarriage. Blood with 17 years of age, after 3-4 weeks for 4-5 days. Complaints: abdominal pain, dizziness, headaches, constipation, dysmenorrhea, general weakness, nervousness. The uterus is enlarged, mobile. To the right corner of the uterus a mobile tumor is attached on a wide basis, a little larger than an orange.

2544 Minilaparoscopic Assisted Vaginal Myomectomy: A Novel Technique, Preliminary Study

Study Objective The aim of our study is to perfect technique of vaginal myomectomy and evaluate the safety and efficacy of combined minilaparoscopic and vaginal approach through anterior and posterior cul-de-sac. Design Prospective study. Setting Department of Gynecology, City Hospital. Patients or Participants All women with reproductive plans and symptomatic subserous or intramural fibroids from 4 cm to 7 cm in diameter treated with minilaparoscopic assisted vaginal myomectomy (MiniLAVM) in our department were prospectively followed. Interventions Minilaparoscopic assisted vaginal myomectomy. Measurements and Main Results 19 patients entered the study between January 2016 and December 2018. 17 patients had MiniLAVM through the posterior cul-de-sac and 2 through the anterior one. Age range 31–47 years, mean 42.4 ±5.8 years; parity range 0–4, mean 2.1 ± 1.6). Two patients had a prior history of Cesarean sections, 2 patients had undergone pelvic surgery. The mean duration of hospital stay was 3.2±1.5 days (range, 2–4 days). Mean amount of blood loss was 125±87.2мл (range, 20–550 ml). Mean duration of surgery was 106.49±38.2 мин (range, 60–140 minutes). Mean total myoma size was 7.1 ± 1.4 cm (range, 4. 5–7 cm). The mean number of myomata removed was 1.4 ± 1.1. None of the cases were converted to laparotomy. All uterine and colpotomic defects were repaired vaginally. None of the cases required a blood transfusion. No major complications occurred. Two patients had full term labor, one of them underwent a Cesarean section. Conclusion The MiniLAVM procedure offers advantages over both laparoscopic and abdominal myomectomy such as digital palpation, direct suturing, no morcelation needed, good visualisation for evaluation of abdominal organs and appropriate control for place of surgery, the application of an antiadhesive barrier, minimallyinvasiveness with good cosmetic effect. This is a preliminary study involving a small number of patients; we believe a larger study will be required to further investigate the efficiency and safety of MiniLAVM.

Submucous Fibroids, Fertility, and Possible Correlation to Pseudocapsule Thickness in Reproductive Surgery

Background and Objectives Fibroids are related to infertility. Fibroid pseudocapsule is a neurovascular bundle surrounding leiomyomas rich of neurofibers involved in myometrial biology. Authors evaluated, by a case-control study, the fibroid pseudocapsule (FP) thickness by ultrasound (US) and the histological measurements, according to uterine location of fibroids. Methods 137 consecutive patients undergoing hysterectomy for uterine myomas were enrolled and 200 myomas were evaluated. Before surgery, patients underwent an ultrasound (US) investigation to evaluate the number, the size, and the location of fibroids. After surgery, myoma-pseudocapsule-myometrium specimens were measured and evaluated by a single expert pathologist. Both US and histological data were collected and statistically analyzed. Results Our results confirm the relevant difference of FP thickness, particularly represented under the endometrium for submucous LMs. FPs near the endometrial cavity were considerably thicker than those of both intramural fibroids and subserous fibroids measured by US (P=0.0001) and histology (P=0.0001). A clear cut-off measurement at 2 mm (P=0.0001) was found between endometrial FPs and all other FPs for either US or histology measurements. Conclusion The thickness of FP is considerably higher near the endometrial cavity when compared to those of both intramural and subserous LMs, suggesting a potential role either in fertility or in myometrial healing.

Disseminated Peritoneal Leiomyomatosis and Metastatic GIST: Differential Diagnosis Dilemma Regarding Multiple Nodular Serosal Lesions and Management

We aim to discuss cases with gastrointestinal stromal tumor and leiomatosis peritoneal dissemeniata LPD regarding their diagnosis and surgical management with pitfalls related. We also aim to focus on management of multiple nodular serosal lesions. Two cases are presented. Both were diagnosed as advanced ovarian cancer on CT and ultrasound imaging by multiple nodular peritoneal lesions, omental cake and adnexal masses. Tumor markers were normal in both cases. Both were scheduled for exploratory laparotomy. One patient diagnosed with neurofibromatosis type I. Midline laparotomy was done for one case revealing normal adnexa with multiple fibroid uterus, peritoneal solid masses with large mesenteric and omental masses related to the small intestine. Total hysterectomy with bilateral salpingo-oophorectomy, total omentectomy and resection anastomosis for the small intestine with removal of macroscopic lesions were done. Midline line laparotomy was done for the second case revealing free adnexa with subserous vascular fibroids and omental fibroid solid masses. Total hysterectomy with bilateral salpingo-oophorectomy and total omentectomy and removal of macroscopic peritoneal lesions seen were done. The second case was diagnosed as Disseminated Peritoneal Leiomyomatosis, and the other case was diagnosed with multiple uterine fibroid and metastatic GIST on histopathology. Disseminated Peritoneal Leiomyomatosis and metastatic GIST can be similar on imaging and operative findings. Also they are similar to other lesions especially peritoneal carcinomatosis as in advanced ovarian cancer. These pathologies should be kept on mind when encountering multiple solid nodular masses in the visceral and parietal wall peritoneum and the omentum on imaging and intra-operative especially with normal associated tumor markers of ovarian cancer as serum CA125. Surgical and postoperative management differ according to the pathology. These pathologies should be confirmed by histopathology and immunohistochemistry. Frozen section is highly needed in these cases to optimize management.

Two novel classification systems for uterine fibroids and subsequent uterine reconstruction after myomectomy

Laparoscopic approaches are the gold standard surgical treatment for intramural and subserous fibroids, whereas submucosal myomas can be treated via hysteroscopy. Removal of intramural myomas often requires a subsequent reconstruction of the uterine wall that ranges from single- to multiple-layer sutures to complex reconstructions. Several classification systems are currently used to characterize uterine fibroids, all of which focus on the assessment of submucosal fibroids during hysteroscopic myomectomy. There are no classification systems for the comprehensive localization of fibroids or for uterine reconstruction after myomectomy. Therefore, the aim of this study was to validate a new scoring system developed by our group to classify uterine leiomyoma as well as a standardized assessment scoring system for uterine reconstruction after surgical myomectomy. To validate the uterine fibroid and uterine reconstruction classification systems, a retrospective review of 136 patients undergoing surgical myomectomy and uterine reconstruction at a single tertiary institution was performed. The age of the patient, duration of surgery, number, size, and location of excised fibroids, number of uterine incisions, level of uterine reconstruction, desire for future pregnancies, pre- and postoperative hemoglobin concentrations, duration of postoperative hospitalization, and operating surgeon were obtained by medical chart review. For each patient, a specific fibroid score and the level of uterine reconstruction were determined according to the classification systems. Correlations between the uterine fibroid and reconstruction scores, as well as between the classification scores and perioperative parameters, were analyzed. The newly developed classification system for uterine fibroids incorporates the number, location, and size of myomas, as well as the number of uterine incisions required for myomectomy. The uterine reconstruction scoring system comprises four levels of reconstruction, ranging from no reconstruction to advanced reconstruction. Outcomes from 136 patients showed a correlation between uterine fibroid and uterine reconstructive scores. High fibroid scores were correlated with higher levels of reconstruction. Both scoring systems showed associations with the duration of surgery, intraoperative blood loss, and days of hospitalization. This study presents the first scoring system for uterine fibroids that incorporates all possible fibroid locations and a standardized assessment of uterine reconstruction. Scoring systems were validated in a large cohort, and a correlation was identified between uterine fibroid and uterine reconstruction scores. In daily clinical practice, this scoring system allows a better planning of surgery, specifically of the estimated duration of surgery, blood loss, and time of hospitalization.

Abdominal myomectomy is safe in the first trimester pregnancy: A Case Report

Uterine myoma is the most common gynecological tumor in women of the reproductive age group. The incidence of myoma in pregnancy ranges from 0.3% to 2.6%, of which approximately 10% leads to complications. The management of uterine myoma during pregnancy in most of the cases is expectant, and its surgical removal is generally delayed until after delivery. In the last two decades, there have been increasing reports of successful myomectomy during caesarean section and even fewer cases in the first and second trimester. We report a case of huge uterine fibroids presenting to the booking clinic at approximately 13 weeks of gestation with a large for date uterus and severe lower abdominal pain. She was admitted and managed conservatively for the presumptive diagnosis of red degeneration in pregnancy. She had myomectomy on account of the distressing abdominal pain. She had an uneventful postoperative period and was discharged home on the 7th postoperative day on hematinics. She was eventually delivered a live baby weighing 2.6 kg by an emergency caesarean section following rupture of membranes prematurely at 37 weeks of gestation. We can therefore say that in carefully selected cases, particularly in cases of subserous fibroids, myomectomy in pregnancy may be safer than previously thought.

Comparative Study of Cesarean Myomectomy with Abdominal Myomectomy in Terms of Blood Loss in Single Fibroid.

In this study, we evaluate the safety and feasibility of cesarean myomectomy and compare this procedure with abdominal myomectomy in single fibroid, in terms of blood loss and postoperative complications. Thirty-three patients who underwent cesarean myomectomy from June 2006 to 2012 in Amrita Institute of Medical Sciences, were included in the study. Almost an equal number of patients who underwent abdominal myomectomy (32) in the same period were included. Women are divided into two groups: group 1-cesarean myomectomy, group 2-abdominal myomectomy. Mean age of the women was comparable; mean gestational age in group 1 was 37.97+/-1.57weeks; and 60% were primiparous. Hemoglobin (Hb) drop postoperatively was compared between the groups, and there was no significant difference. Though there was statistically significant difference among the groups regarding the size of fibroids, the main outcome measure of the study, the Hb drop was comparable between group 1 and 2. There is statistically significant difference in the Hb difference with increasing mean diameter of the fibroids. As the size increases, Hb drop also increases indicating the increasing blood loss. The measures used to reduce blood loss such as vasopressin instillation and stepwise devascularization influence the blood loss, and P value shows borderline significance. There was no difference in Hb drop among the groups according to the type of fibroids. But more subserous fibroids were removed in group 1, whereas more intramural fibroids were removed in group 2. Cesarean myomectomy can be safely done in single fibroids and is comparable to abdominal myomectomy in terms of blood loss.

The management of uterine leiomyomas.

The objective of this document is to serve as a guideline to the investigation and management of uterine leiomyomas.The areas of clinical practice considered in formulating this guideline are assessment, medical treatments, conservative treatments of myolysis, selective artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health-care provider.Implementation of this guideline should optimize the decision-making process of women and their health-care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits.English-language articles from MEDLINE, PubMed, and the Cochrane Database were reviewed from 1992 to 2002, using the key words "leiomyoma," "fibroid," "uterine artery embolization," "uterine artery occlusion," "uterine leiomyosarcoma," and "myomectomy." The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.The majority of fibroids are asymptomatic and will not require intervention or further investigations. For the symptomatic fibroid, hysterectomy offers a definitive solution. However, it is not the preferred solution for women who wish to preserve their uterus. The predicted benefits of alternative therapies must be carefully weighed against the possible risks of these therapies. In the properly selected woman with symptomatic fibroids, the result from the selected treatment should be an improvement in the quality of life. The cost of the therapy to the health-care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat treatment modalities.1. Medical management should be tailored to the needs of the woman presenting with uterine fibroids and geared to alleviating the symptoms. Cost and side effects of medical therapies may limit their long-term use. (III-C) 2. In women who do not wish to preserve fertility and who have been counselled regarding the alternatives and risks, hysterectomy may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-A) 3. Myomectomy is an option for women who wish to preserve their uterus, but women should be counselled regarding the risk of requiring further intervention. (II-B) 4. Hysteroscopic myomectomy should be considered as first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (I-B) 5. It is important to monitor ongoing fluid balance carefully during hysteroscopic removal of fibroids. (I-B) 6. Laparoscopic myolysis may present an alternative to myomectomy or hysterectomy for selected women with symptomatic intramural or subserous fibroids who wish to preserve their uterus but do not desire future fertility. (II-B) 7. Uterine artery occlusion may be offered as an alternative to selected women with symptomatic uterine fibroids who wish to preserve their uterus. (I-C) 8. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, and that long-term data regarding efficacy, fecundity, pregnancy outcomes, and patient satisfaction are lacking. (III-C) 9. Removal of fibroids that distort the uterine cavity may be indicated in infertile women, where no other factors have been identified, and in women about to undergo in vitro fertilization treatment. (III-C) 10. Concern of possible complications related to fibroids in pregnancy is not an indication for myomectomy, except in women who have experienced a previous pregnancy with complications related to these fibroids. (III-C) 11. Women who have fibroids detected in pregnancy may require additional fetal surveillance when the placenta is implanted over or in close proximity to hen the placenta is implanted over or in close proximity to a fibroid. (III-C) 12. In women who present with acute hemorrhage related to uterine fibroids, conservative management consisting of estrogens, hysteroscopy, or dilatation and curettage may be considered, but hysterectomy may become necessary in some cases. (III-C) 13. Hormone replacement therapy may cause myoma growth in postmenopausal women, but it does not appear to cause clinical symptoms. Postmenopausal bleeding and pain in women with fibroids should be investigated in the same way as in women without fibroids. (II-B) 14. There is currently no evidence to substantiate performing a hysterectomy for an asymptomatic leiomyoma for the sole purpose of alleviating the concern that it may be malignant. (III-C) VALIDATION: This guideline was reviewed and accepted by the Clinical Practice Gynaecology Committee, and by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.The Society for Obstetricians and Gynaecologists of Canada.

Surgical treatment of fibroids for subfertility.

Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach. To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches. We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and ongoing clinical trials registered online. The final search was in June 2012. Randomised controlled trials examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids. Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions. One study examined the effect of myomectomy on reproductive outcomes and showed no evidence for a significant effect on the clinical pregnancy rate for intramural (OR 1.88, 95% CI 0.57 to 6.14), submucous (OR 2.04, 95% CI 0.62 to 6.66), combined intramural and subserous (OR 2.00, 95% CI 0.40 to 10.09) and combined intramural submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57). Similarly, there was no evidence for a significant effect of myomectomy for any of the described types of fibroids on the miscarriage rate (intramural fibroids OR 0.89 (95% CI 0.14 to 5.48), submucous fibroids OR 0.63 (95% CI 0.09 to 4.40), combined intramural and subserous fibroids OR 0.25 (95% CI 0.01 to 4.73) and combined intramural submucous fibroids OR 0.50 (95% CI 0.03 to 7.99).Two studies compared open versus laparoscopic myomectomy and found no evidence for a significant effect on the live birth rate (OR 0.80, 95% CI 0.42 to 1.50), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04), miscarriage rate (OR 1.31, 95% CI 0.40 to 4.27), preterm labour rate (OR 0.68, 95% CI 0.11 to 4.43) and caesarean section rate (OR 0.59, 95% CI 0.13 to 2.72). There is currently insufficient evidence from randomised controlled trials to evaluate the role of myomectomy to improve fertility. Regarding the surgical approach to myomectomy, current evidence from two randomised controlled trials suggests there is no significant difference between the laparoscopic and open approach regarding fertility performance. This evidence needs to be viewed with caution due to the small number of studies. Finally, there is currently no evidence from randomised controlled trials regarding the effect of hysteroscopic myomectomy on fertility outcomes.

Giant cervical polyp complicating uterine fibroid and masquerading as cervical malignancy

Introduction: Huge cervical polyp causing diagnostic dilemma is rarely encountered in gynecologic practice. The objective of this study is to document a case of huge cervical polyp masquerading as cervical cancer seen and managed in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Case Report: A 39-year-old trader para 5 + 0 who presented at the gynecologic unit with a 7-year history of fleshy mass protruding from the vagina which had been progressively increasing in size but was reducible. Physical examination revealed severe pallor, 16-week sized abdomino-pelvic firm irregular mass, and a huge firm mass protruding through the vagina, measuring 30 cm by 20 cm. The vaginal mass was irregular in shape and occupied the whole of the vagina. The cervix was not reachable. Pelvic ultrasonography revealed features of multiple intramural and subserous fibroids and a right simple cystic adneaxeal mass about 6 cm in diameter. Anemia was corrected, and at examination under anesthesia, a diagnosis of huge cervical polyp (arising from the posterior cervix) with multiple uterine fibroids was made. She had vaginal polypectomy, total abdominal hysterectomy, and bilateral salpingo-ophorectomy using an abdomino-perineal approach. She did well postoperatively and subsequently on follow-up. Histology confirmed cervical fibroid polyp and uterine leiomyoma. Conclusion: Although giant cervical fibroid is rare, it may masquerade as cervical malignancy or uterine inversion. Proper evaluation is needed to make an accurate diagnosis.

The Surgical Treatment of Fibroids for Infertility

Uterine fibroids are a major gynecologic disorder among women and commonly found in the infertile couple. Although numerous surgical techniques exist to destroy or remove these tumors, the role of such surgical procedures in the infertile woman has been heavily debated. The primary reason for this is a lack of evidence of a cause-and-effect relationship between fibroids and subfertility. However, review of the evidence suggests that submucous myomas and possibly intramural myomas both serve to decrease female fertility. A second reason for caution is concern over the impact of surgical treatment on fertility enhancement. For submucous myomas, hysteroscopic myomectomy has proven capable of increasing fertility rates, although this statement may not apply to type 2 submucous myomas. No evidence currently exists for a beneficial effect on fertility of surgical intervention for intramural or subserous fibroids. More randomized treatment trials are clearly needed to clarify the role of myomectomy and other procedures in the infertile woman with type 2 submucous and intramural myomas.

Inevitable Caesarean Myomectomy: A Case Report.

The traditional teaching in obstetrics is to avoid myomectomy during caesarean section because of increased risk of hemorrhage. When a lower segment uterine fibroid is present, a classical incision is prescribed.We present a 32year old booked nullipara who had an emergency classical caesarean section for huge lower segment fibroids, transverse lie and premature rupture of fetal membranes at 37 weeks of gestation and was delivered of a live male baby who weighed 3.6kg with good APGAR scores. The intramural fibroids, enchroaching into the uterine incision, made closure impossible, necessitating a caesarean myomectomy under a high dose oxytocin infusion before successfully closing the incision. She did remarkably well and was discharged home on the 7th post-operative day. Caesarean myomectomy can safely be done in situations where fibroid nodules enchroach on the incision line or in cases of pedunculated subserous fibroids, using good surgical technique and high dose oxytocin infusion.Key words: uterine fibroids, classical incision, inevitable, caesarean myomectomy.

The natural history of fibroids

Fibroids are common, hormone-dependent, benign uterine tumors. They can cause significant morbidity and the symptoms depend largely on their size. The aim of this study was to describe the natural history of fibroids and identify factors that may influence their growth. This was a retrospective longitudinal study of premenopausal women who were diagnosed with uterine fibroids on ultrasound examination. All women underwent at least two transvaginal ultrasound scans, which were all performed by a single operator. Fibroids were measured in three perpendicular planes and the mean diameter was calculated. The size and position of every individual fibroid was assessed and recorded on a computerized database. The volume of each fibroid was calculated using the formula for a sphere. A total of 122 women were included in the study. Their median age at the initial examination was 40 (range, 27-45) years. Seventy-two (59.0%) were nulliparous and 74 (60.7%) had multiple fibroids. The median interval between the initial and final examination was 21.5 (range, 8-90) months. The median fibroid volume increased by 35.2% per year. Small fibroids (< 20 mm mean diameter) grew significantly faster than larger fibroids (P = 0.007). The median increase in size was significantly higher in cases of intramural fibroids (53.2 (interquartile range (IQR), 11.2-217)%) than in subserous fibroids (25.1 (IQR, 1.1-87.1)%) and submucous fibroids (22.8 (IQR, - 11.7 to 48.3)%) (P = 0.012). Multivariate analysis retained only fibroid size at presentation as an independent predictor of fibroid growth. The growth of fibroids in premenopausal women is influenced by the tumor's size at presentation.

Uterine fibroids: impact on fertility and pregnancy loss

Uterine fibroids are the most common tumours of the female genital tract. Depending on their number, location and size, they may distort uterine anatomy and can adversely affect uterine physiology. It is therefore teleologically sound to suppose that fibroids could impede fertility and/or predispose to miscarriage. Their removal and a restoration of normal anatomy could thus be expected to improve fertility and reduce the risk of miscarriage. At present, it is estimated that fibroids may be associated with infertility in 5–10% women and are possibly the sole cause of infertility in 2–3%. There is good research evidence that submucous fibroids are indeed associated with subfertility, and possibly miscarriage, and that hysteroscopic resection results in improved outcomes in both conditions. There is increasing evidence that intramural fibroids may impede success in assisted reproduction technology (ART), and their removal too may improve ART outcomes. Available evidence suggests that purely subserosal fibroids have no impact on fertility or pregnancy loss. Therefore submucous fibroids found in women with subfertility and/or recurrent pregnancy loss should be subjected to hysteroscopic transcervical resection. Careful consideration should be given to myomectomy (laparoscopic or conventional) in women with intramural fibroids of considerable size undergoing ART in whom other causes of the subfertility and/or recurrent pregnancy loss have been eliminated. It is doubtful whether intervention with subserous fibroids would be of any benefit where the only symptoms are subfertility and recurrent pregnancy loss.