CEASAREAN DELIVERY POST MYOMECTOMY. pptx

This to share a case presentation on mode of delivery post myomectomy

1. CESAREAN DELIVERY POST MYOMECTOMY Dr NIYONSENGA ANTOINE SUPERVISOR:DR BALKACHEW NIGATU

2. OBJECTIVES CASE PRESENTATION LITERATURE REVIEW ABOUT THE MODE OF DELIVERY AFTER MYOMECTOMY

3. Name : U.M.A ID number : 65795 Age : 39 Y.O Admission date : 05/09/2024 Diagnosis : Full term pregnancy on B/G of myomectomy Discharge date : 08/09/2024 IDENTIFICATION CHIEF COMPLAINT Scheduled for C/S

4. HPI She was followed here for routine ANC and she was scheduled for c/s. ROS : No headache; no fever ; no pv bleeding; no pv fluid leakage, FMV+ ATCD : LMP : unknown . EDD 39W0D G1P0: PMH : She had 18 month hx of inability to conceive No known chronic disease reported, HIV Neg BG:A+ No known allergy Surgical : Hx of myomectomy in July 2023 the myoma was submucosa

5. PHYSICAL EXAMINATION General status : Stable VS BP 117/70, HR: 103 , RR:18, T:36.7, SPO2: 97% CNS : Fully awake, GCS:15/15 , RS : No RD , clear lungs. CVS : warm extremities, S1&S2 are audible ; no added sounds ABD : Gravid Uterus, SFH:35cm, No palpable uterine contraction MSK : normal U/S : SIUP, cephalic presentation, FHR: 139bpm, anterofundic placenta, SDP:5 cm , EFW 3.5 kg

6. INVESTIGATIONS WBC 7.07 Na 132 Hgb 13.3 K 4.2 Plt 229 Urea 1.8 Bgp A +ve Creat 51 mmol/L RBS 90 mg/dL Hep B Neg Hep C Neg

7. Management Admitted the patient Sign consent form Anesthesia visit Prepare the patient for surgery On 6 th Sept C/S was done with good maternal fetal out come On 8 th Sept she was discharged home.

8. INTRODUCTION leiomyomas are benign smooth muscle neoplasms that typically originate from the myometrium. They are often referred to as uterine myomas, and they are colloquially called fibroids. Fibroids are the commonest benign tumour of the female genital tract, affecting up to 80% of women (Baird et al., 2003). They are symptomatic in 25- 30% of women and most symptomatic women seek treatment prior to pregnancy From 1998 to 2005, 27 percent of inpatient gynecologic admissions were for uterine leiomyoma care. williams-gynecology-3e-true-pdf-3rd-edition

9. INTRODUCTION Con’t Uterine leiomyomas are estrogen and progesterone sensitive tumors. Consequently, they develop during the reproductive years. After menopause, leiomyomas generally shrink, and new tumor development is infrequent. Uterine rupture after TOLAM is around (0.7-1)% Women who suffer uterine rupture, the majority do so before the onset of labour . the success of vaginal delivery after myomectomy, which can be as high as 90% without uterine rupture or severe maternal morbidity. ( Gambacorti-Passerini et al., 2016)

10. UTERINE FIBROIDS FIGO CLASSIFICATION

11. williams-gynecology-3e-true-pdf-3rd-edition

12. Symptoms are classified into three categories Heavy or prolonged menstrual bleeding Bulk-related symptoms, such as pelvic pressure and pain Reproductive dysfunction (i.e. infertility, miscarriage, obstetric complications) www.uptodate.com,uterine fibroids(leiomyomas) issues in pregnancy

13. MODE OF DELIVERY IF THE PATIENT HAS HAD MYOMECTOMY IN WHICH extensive intramyometrial complete transmyometrial dissection is required for removal of one or several intramural or submucosal fibroids of appreciable size, followed by extensive uterine reconstruction. D eliver y at 36+0 to 37+0 weeks of gestation since they appear to be at risk for preterm labor. Patients who underwent substantial but less extensive myometrial surgery may be delivered by cesarean as late as 38+6 weeks. www.uptodate.com,uterine fibroids(leiomyomas) issues in pregnancy

14. MODE OF DELIVERY For patients who have had minimal myometrial surgery that was unlikely to have significantly compromised the myometrium t rial of labor is suggested but C ontinuous intrapartum fetal monitoring E arly access to obstetric anesthesia T he ability to perform an emergency cesarean birth, if it becomes necessary www.uptodate.com,uterine fibroids(leiomyomas) issues in pregnancy.

15. Factors that could affect the risk of rupture after a myomectomy Number of fibroids removed The number of uterine incisions The size of the fibroids removed The location of the fibroids removed

16. Abnormal fetal heart rate (FHR Abdominal pain Vaginal bleeding  – Vaginal bleeding may occur but is not a cardinal symptom as it may be modest or even absent despite major intraabdominal hemorrhage. Loss of station  – Loss of station can result from partial extrusion of the fetus through the rupture, or possibly from myometrial relaxation. SIGNS OF UTERINE RUPTURE Uptodate.com-uterine rupture clinical manifestation.

17. SIGNS OF UTERINE RUPTURE Hematuria –  A rupture that extends into the bladder may cause hematuria. Hemodynamic instability  – Intraabdominal hemorrhage from the site of rupture can lead to rapid maternal hemodynamic deterioration (hypotension and tachycardia). Changes in contraction patterns   Uptodate.com-uterine rupture clinical manifestation.

18. Vaginal birth after prior myomectomy Gambacorti-Passerini , Z.M. et al. Abstract Objective The aim of this retrospective cohort study was to evaluate the obstetrical and perinatal outcomes of vaginal birth in case of pregnancies achieved after prior myomectomy. We also analyzed how operative characteristics at the time of surgery might influence the choice of obstetricians about mode of delivery. Study design We analyzed retrospectively all women who underwent laparoscopic (LPS) or laparotomic (LPT) myomectomy between January 2002 and December 2014, in a network of three Institutions belonging to the University of Milano Bicocca, Italy. Women were contacted by phone interview and only cases with available follow-up data and who had a subsequent pregnancy were included. Operative characteristics and subsequent obstetrical outcomes were recorded and analyzed. Results 469 women who underwent myomectomy were contacted by phone interview, and 152 pregnancies were achieved after surgery, 96 after LPS and 56 after LPT. A total of 110 pregnancies ended in deliveries at ≥24 weeks. Seventy-three (66.4%) women had trial of labor after myomectomy (TOLAM), while 24 (21.8%) had a planned cesarean delivery (CD). Sixty-six (90.4%) of the TOLAM cases successfully accomplished vaginal delivery. No cases of uterine rupture (UR) were reported, and all deliveries ended in live births. The incidence of Neonatal Intensive Care Unit admission was 14.5% (16/110), with no cases of perinatal death. Comparing the surgical details at the time of myomectomy, the incidence of uterine cavity entered was significantly higher in planned CD group compared to TOLAM cases (p < 0.001). No other significant difference between the two groups was reported. Conclusions A successful vaginal delivery was accomplished by 90.4% of women who had TOLAM, without any case of UR or severe maternal and perinatal complications. TOLAM may be considered and offered as feasible and relatively safe option. Obstetricians’ attitude toward mode of delivery after prior myomectomy seems to be influenced by the reported entry into the uterine cavity at the time of surgery. European Journal of Obstetrics and Gynecology and Reproductive Biology, Volume 231, 198 - 203

19. Trial of labor after myomectomy and uterine rupture: a systematic review Gambacorti-Passerini Z, Gimovsky AC, Locatelli A, Berghella V. Trial of labor after myomectomy and uterine rupture: a systematic review. Abstract Introduction:  There is concern about the risk of uterine rupture in the subsequent pregnancy after myomectomy. This risk is reported in literature to be around 0.7-1%. The aim of this study was to evaluate the incidence of uterine rupture and associated risk factors in women who had a trial of labor after prior myomectomy. Material and methods:  A systematic review of the literature was performed including all cohort studies with at least five cases reporting outcomes of pregnancies after prior myomectomy. The terms "myomectomy", "pregnancy", "trial of labor" and "uterine rupture" were used in PubMed and EMBASE searches for identification purposes. Every reference was reviewed for possible inclusion and all eligible cases of uterine rupture were considered. Results:  Twenty-three studies with at least five cases of pregnancy after myomectomy were identified, with an overall incidence of uterine rupture of 0.6% (0.3-1.1%) (n = 11/1825). Of these 23 studies, 11 studies reported detailed data about trial of labor after myomectomy and related pregnancy outcomes, including 1034 pregnancies and 756 viable (≥24 weeks) deliveries. The overall incidence of uterine rupture after myomectomy in the included studies was 0.93% (0.45-1.92%) (n = 7/756); specifically, it was 0.47% (0.13-1.70%) (n = 2/426) in women undergoing trial of labor after myomectomy, and 1.52% (0.65-3.51%) (n = 5/330) in women before the onset of labor. Of the seven uterine ruptures, five (71%) occurred within 36 weeks (range 24-40 weeks). Conclusions:  Trial of labor after myomectomy is associated with a 0.47% risk of uterine rupture. There were no identified risk factors among the variables studied. The present systematic review of the literature revealed that uterine rupture after prior myomectomy occurred mainly before 36 weeks and before labor. Department of Obstetrics and Gynecology, University of Milan Bicocca, Milan, Italy. 

20. Pregnancy and delivery after laparoscopic myomectomy Kumakiri , Jun et al. Study objective: To assess the factors influencing pregnancy outcome and evaluate vaginal birth after laparoscopic myomectomy (VBALM). Design : Retrospective study (Canadian Task Force classification II-2). RESULT: Vaginal birth after LM was managed in accordance with the standard management of vaginal birth after cesarean section (VBAC) in our hospital. Delivery after LM was accomplished in 32 pregnancies. Vaginal birth after laparoscopic myomectomy was attempted in 23 pregnancies (71.9%) and vaginal birth successful in 19 (82.6%) of these 23 pregnancies. Vaginal birth after LM was unsuccessful in four patients, as labor did not occur during more than 2 weeks after the expected date of delivery in two patients, and cesarean section was performed to prevent fetal asphyxia during the course of delivery in two patients. Journal of Minimally Invasive Gynecology, Volume 12, Issue 3, 241 - 246

21. Abstract Objective: Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy. Methods: We conducted a survey of 49 practicing obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy. Results: Overall, the inter-respondent agreement was fair (kappa 0.3; P < 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour . There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins. Conclusion: Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach. Weibel, H. S., Jarcevic , R., Gagnon, R., & Tulandi , T. (2014). Journal of Obstetrics and Gynaecology Canada ,

22. TAKE HOME MESSAGE There is high success of vaginal delivery after myomectomy. C/s can be planned depending on the kind of myomectomy done

23. DISCUSSION Was the patient a candidates for C/S or TOLAM?

24. References Vaginal birth after prior myomectomy Gambacorti-Passerini , Z.M. et al. European Journal of Obstetrics and Gynecology and Reproductive Biology, Volume 231, 198 – 203 Pregnancy and delivery after laparoscopic myomectomy Kumakiri , Jun et al. Journal of Minimally Invasive Gynecology, Volume 12, Issue 3, 241 – 246 Gambacorti-Passerini Z, Gimovsky AC, Locatelli A, Berghella V. Trial of labor after myomectomy and uterine rupture: a systematic review. Acta Obstet Gynecol Scand. 2016 Jul;95(7):724-34. doi : 10.1111/aogs.12920. Epub 2016 May 25. PMID: 27154306. Williams gynecology 3rdedition www.uptodate.com,uterine fibroids(leiomyomas) issues in pregnancy Caesarean section in women following an abdominal . (n.d.). , R., & Tulandi , T. (2014). Perspectives of Obstetricians on Labour and Delivery After Abdominal or Laparoscopic Myomectomy. Journal of Obstetrics and Gynaecology Canada.

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