29092024 Caesarean Myomectomy MOGS A2S Conference.pptx

Dear Friends and Colleagues,

This is a link to my Keynote address on Caesarean Myomectomy at the recently concluded MOGS A2S Conference held at ITC Grand Hotel, Parel, Mumbai, India on 29th September 2024.

The presentation explore’s the indications, surgical technique, risks, and postoperative management of Caesarean Myomectomy. It offers valuable insights into the combined approach of fibroid removal during cesarean section, with a focus on clinical outcomes and case studies.

It will provide a comprehensive overview of the current best practices on approach on Ceasrean Myomectomy.

YouTube link: https://youtu.be/V7HH62wxNkQ?si=E980TRUIXT15eYzm
Kindly do comment, like and share.

Dr. Niranjan Chavan.

1. Cesarean Myomectomy MOGS A2S Conference 29 th September, Mumbai.

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital President, MOGS (2022-2023) Joint Treasurer, FOGSI (2021-2025) Organising Secretary, AICOG Mumbai 2025 Treasurer, AFG (2023-2024) Member Oncology Committee, SAFOG (2021-2023) Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses Editor-in-Chief, FEMAS , JGOG & TOA Journal 87 publications in International and National Journals with 213 C itations National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-202 2 ) Chair & Convener, FOGSI Cell Violence Against Doctors (2015 - 16) Member, Oncology Committee AOFOG (2013-2015) Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at L.T.M.G.H (2010-16) Member, Managing Committee IAGE (2013-17), (2018-20) , (2022-2023) Editorial Board, European Journal of Gynaec. Oncology (Italy) Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS) at LTMGH (2018-19) DR. NIRANJAN CHAVAN MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP, DIPLOMA IN ENDOSCOPY (USA)

3. introduction Uterine fibroids are the most common benign tumors of the female reproductive system, with an incidence in pregnancy ranging from 0.1 to 10.7% and increasing with maternal age. Key factors influencing morbidity during pregnancy include, Number Size Location of the fibroids Their relationship to placental position

4. Changes such as degeneration can complicate fibroids, leading to varying degrees of abdominal pain, from mild discomfort to acute abdomen. Fibroids are associated with antepartum, intrapartum, and postpartum complications, occurring in 10–40% of pregnant patients .

5. It is a common benign tumour . Prevalence is increasing in pregnancy due to, - Delay in childbearing - Better imaging technique 0.37-12% There are no clear guidelines regarding tackling these myomas during cesarean section. Management depends on the size, position of the fibroid, and surgeon’s expertise.

6. Effect of pregnancy on myoma - 60-70% of fibroids do not have any change in size - 20-25% increase in size mainly occurs in the first and early second trimesters In puerperium -The majority of fibroids show changes - 5-10% reduce in size

7. DIAGNOSIS Clinically, it is difficult to diagnose a fibroid during pregnancy without foreknowledge of its existence. Marked softening and alteration in the shape (flattening) make it difficult to differentiate from the pregnant uterus.

8. Sonography confirms the diagnosis with certainty. Color Doppler is helpful in some cases. MRI is more accurate for diagnosis and to know the dimensions, location and relation to placental implantation. “In early months, the fibroid is diagnosed but pregnancy is missed whereas in later months, pregnancy is diagnosed but the fibroid is missed.”

9. Sir Victor Bonney ( 1872-1953) The pioneer in myomectomy He wrote: "It is tempting for the adventurous and sympathetic surgeon to condense the operation of caesarean section and myomectomy into one undertaking and so to save his patient the ordeal of a second admission to hospital. We heartily deprecate this misguided policy."

10. TO DO OR NOT TO DO ? Caesarean Myomectomy

11. Doing Nothing Is Easy That’s Why So Many People Do It.

12. Leave it Caesarean myomectomy was practically absent from the 1. Obstetric literature until the last decade 2. Myomectomy is discouraged in all the leading textbooks despite the lack of any direct evidence supporting the approach Reasons Hemorrhage Difficulty in securing haemostasis Need for blood transfusion Hysterectomy Operative morbidity WHAT TO DO?

13. What happens if you leave it? This is not safe 1. PPH 2. Inversion of uterus 3. Spontaneous expulsion 4. Intramyometrial haemorrhage - Involution of the uterus compresses the venous drainage. Blood sequestration into the tumour- Hypovolaemia and shock 5. Sepsis

14. REMOVAL/CAESAREAN MYOMECTOMY INDICATIONS: 1. Large or symptomatic fibroids Large fibroids that obstruct the uterine cavity or lower uterine segment, impeding the delivery of the baby. Fibroids causing significant pain, discomfort, or pressure symptoms during pregnancy.

15. 2. Lower uterine segment fibroids 3. Subserosal or pedunculated fibroids 4. Degenerating fibroids 5. Multiple or rapidly growing fibroids 6. Preoperative planning - Saves the time and cost

16. PRE-REQUISITES FOR myomectomy during caesarean Experience and skill person Well-equipped tertiary institution Better anaesthesia and available blood Full consent and counselling High Hb level Size and site of myoma Good assistant

17. Procedure Delivery of baby before attempting myomectomy In rare situation Where Myoma in the lower segment in the incision line - Myomectomy first then caesarean section -Classical caesarean section or upper segment incision

18. 2 . Closing the uterine incision first then myomectomy.

19. 3. Myomectomy by sharp dissection. Enucleation of myoma easy because of loose tissue More muscle damage during pregnancy Less healing due to contraction of uterine muscle during puerperium Weak scar Rupture uterus Dead space obliteration by meticulous suturing in three laye rs

20. 4. Haemorrhage can be reduced by Uterotonic agent Step-wise devascularisation Local vasoconstrictor -Vasopressin -Noradrenaline -Tourniquets

21. - Myomectomy Clamp -Liberal use of diathermy -Tranexamic acid - Gelatin matrix -Kept intraperitoneal drain in situ Multiple myoma in multiparous- Hysterectomy Prophylactic antibiotics Analgesics Postoperative period stormy

22. The recurrence of uterine fibroids It is likely to be higher than after myomectomy in the non-pregnant state.

23. Future fertility The future fertility and/or subsequent pregnancy outcome was unaffected by caesarean myomectomy .

24. complications Massive blood loss Peripartum hysterectomy Blood transfusion Admission in ICU Adhesion formation Scar integrity in subsequent pregnancy

25. Key to success Careful case selection Detail counselling and consent Well-equipped set Blood transfusion facilities Skilled surgeon Technical secret Build up antenatal HB% Incision on contracted uterus Control blood loss

26. CONCLUSION Caesarean myomectomy can be safely done by an experienced surgeon even in large myomas with no increase in intra and post-operative complications. Future fertility and subsequent pregnancy outcomes were unaffected by caesarean myomectomy. Should be done by an experienced obstetrician preferably in superficial subserosal fibroid.

27. Summary Is not absolutely contraindicated Decision depends on Location Size Number Preoperative counselling and consent Individualised Management in tertiary set-up

28. It is the time to change as Charlie Chaplin rightly said " Nothing is permanent in this world not even our troubles "

29. Caesarean myomectomy is no longer a far fetched job in modern obstetrics We have to be prepared! JUST DO IT !

30. A good assistant is a good surgeon, and not vice versa. Niranjan Chavan