2. 23y G1
37 weeks
Chief complain : LP

3. Last sono:
S/breech/post/Nl/37+2/36+2/36+5
In ant fundal myometr two myoma is seen (60*50) (55*70)

4. Surgery:
Cesarean and myomectomy
(two intramural myoma in size of 9 and 10 cm)

5. Uterine leiomyomas (also referred to as fibroids or myomas) are the most common pelvic tumor in women

6. They are benign monoclonal tumors arising from the smooth muscle cells of the myometrium. They arise in reproductive-age women and typically present with symptoms of abnormal uterine bleeding and/or pelvic pain/pressure

7. RISK FACTORS
Race
The etiology of the increased incidence of leiomyomas in black women is unknown
Differences in genetic factors, diet, lifestyle, psychosocial stress, and environmental exposures between black and white women are thought to contribute this disparity

8. Although the growth of fibroids is responsive to gonadal steroids,
Reproductive and endocrine factors
Although the growth of fibroids is responsive to gonadal steroids,
these hormones are not necessarily responsible for the genesis of the tumors

9. Parity
Parity (having one or more pregnancies extending beyond 20 weeks of gestation) decreases the chance of fibroid formation
older age at first birth was also associated with a decreased risk compared with younger age at first birth and a longer interval since last birth with an increased risk

10. Early menarche
Early menarche (<10 years old) is associated with an increased risk of developing fibroids Menarche is associated with increase of estradiol to postpubertal levels which can plausibly lead both to increased fibroid growth and early fusion of the long bone epiphyses leading to decreased height.

11. Hormonal contraception
Use of standard or lower dose oral contraceptives (≤35 mcg ethinyl estradiol/day) do not appear to cause fibroids to grow; therefore, administration of these drugs is not contraindicated in women with fibroids

12. One possible exception was reported by the Nurses' Health Study, which suggested OC use was associated with an increased risk of leiomyomas in women with early exposure to OCs (13 to 16 years old)

13. Prenatal exposure to diethylstilbestrol is associated with an increased risk of fibroids, supporting the role of early hormonal exposure in pathogenesis There are isolated reports of leiomyoma enlargement in women treated with clomiphene

14. Obesity
Most studies show a relationship between fibroids and increasing body mass index (BMI)

15. Diet
Significant consumption of beef and other reds meats (1.7-fold) or ham (1.3-fold) is associated with an increased relative risk of fibroids
and consumption of green vegetables (0.5-fold) and fruit (especially citrus fruit) with a decreased risk

16. Increases in dietary glycemic index or load are associated with a small increase in fibroid risk in some women
Dietary consumption of carotenoids is not associated with a change in risk for uterine leiomyoma
Dietary vitamin A from animal sources may also be associated with decreased fibroid risk
There is increasing evidence that vitamin D deficiency or insufficiency, which is more prevalent among black women, is linked to fibroid risk .The major source of vitamin D is from synthesis from a prohormone when sunlight hits the skin, and this is inhibited by the higher levels of melanin in darker skin. This relationship is especially interesting because it is a biologically plausible explanation for the increased fibroid risk in black women that lends itself to prevention trials.
Caffeine consumption is generally not a risk factor for fibroids, except for weak associations in women under age 35 with high consumption of coffee or caffeine intake

17. Alcohol
Consumption of alcohol, especially beer, appears to be associated with an increased risk of developing fibroids

18. Early studies showed that smoking
Decreased
the risk of having fibroids, possibly through the inhibition of aromatase

19. Hypertension is associated with an increased leiomyoma risk
Hypertension is associated with an increased leiomyoma risk. The risk is related to increased duration or severity of hypertension

20. Symptoms ●Heavy or prolonged menstrual bleeding
●Bulk-related symptoms, such as pelvic pressure and pain
●Reproductive dysfunction (ie, infertility or obstetric complications)

21. Heavy or prolonged menstrual bleeding
Heavy and/or prolonged menses is the typical bleeding pattern with leiomyomas and the most common fibroid symptom

22. ●Submucosal myomas that protrude into the uterine cavity (eg, types 0 and 1) (figure 3) are most frequently related to significant heavy menstrual bleeding .
●Intramural myomas are also commonly associated with heavy or prolonged menstrual bleeding, but subserosal fibroids are not considered a major risk for heavy menstrual bleeding.
●Cervical fibroids that are close to the endocervical canal may be related to AUB

23. Pelvic pressure or pain
pelvic discomfort is common in women with fibroids but less common than AUB
chronic
intermittent
dull

24. Venous compression Very large uteri may compress the vena cava and lead to an increase in thromboembolic risk Urinary tract or bowel issues

25. Painful menses — Painful menses is reported by many women with fibroids. This pain in many women appears to be correlated with heavy menstrual flow and/or passage of clots.
Painful intercourse — It is controversial whether women with fibroids are more likely to experience painful intercourse than women without fibroids . However, among women with fibroids, anterior or fundal fibroids are the most likely to be associated with deep pain with intercourse. Number and size of fibroids do not appear to influence the incidence or intensity of painful intercourse

26. Fibroid degeneration or torsion
Fibroid degeneration typically results in pelvic pain and may be associated with a low-grade fever, uterine tenderness on palpation, elevated white blood cell count, or peritoneal signs. The discomfort resulting from degenerating fibroids is self-limited, lasting from days to a few weeks, and usually responds to nonsteroidal antiinflammatory drugs

27. DIAGNOSIS

28. Step one: Pelvic ultrasound
Transvaginal ultrasound has high sensitivity (95 to 100 percent) for detecting myomas in uteri less than 10 gestational weeks' size
calcification in a fibroid generally implies that it has degenerated. These calcifications can be seen on plain film as "popcorn" calcifications in the pelvis. On ultrasound, the calcifications may appear as clumps or rim-like calcifications within a mass

30. Step two: Evaluate the uterine cavity
Saline infusion sonography (sonohysterography) is an imaging study in which pelvic ultrasound is performed while saline is infused into the uterine cavity. Use of this technique allows identification of submucosal lesions (some of which may not be seen on routine ultrasonography) and intramural myomas that protrude into the cavity and characterizes the extent of protrusion into the endometrial cavity

32. Hysteroscopy
When the entire fibroid is visualized arising from a pedicle, or has a broad base, the lesion is hysteroscopically classified as intracavitary. However, when the fibroid abuts the endometrium or protrudes into the myometrium, the depth of penetration cannot be ascertained hysteroscopically. Additionally, hysteroscopy less accurately predicts the size of the myoma compared with ultrasound and sonohysterography

33. Magnetic resonance imaging
Magnetic resonance imaging (MRI) is the most effective modality for visualizing the size and location of all uterine myomas and can distinguish among leiomyomas, adenomyosis, and adenomyomas

34. TREATMENT

35. Relief of symptoms (eg, abnormal uterine bleeding, pain, pressure) is the major goal in management of women with significant symptoms

36. EXPECTANT MANAGEMENT
given data that fibroids can shrink substantially and that there is substantial regression during the postpartum period, expectant management appears to be a reasonable option for some women

37. After an initial evaluation, we perform annual pelvic exams and, in patients with anemia or menorrhagia, check a complete blood count. If symptoms or uterine size are increasing, we proceed with further evaluation and patient counseling regarding treatment options.

38. MEDICAL THERAPY
Anecdotal data suggest medical therapy provides adequate symptom relief in some women, primarily in situations where bleeding is the dominant or only symptom.

39. Hormonal therapies
Combined hormonal contraceptives and progestational agents are commonly prescribed to regulate abnormal uterine bleeding, but appear to have limited efficacy in the treatment of uterine leiomyomas

40. These drugs can be useful in some women with heavy menstrual bleeding, particularly those with coexisting problems (eg, dysmenorrhea or oligoovulation); but they do not appear to be effective in decreasing bulk symptoms.

41. Estrogen-progestin contraceptives
therapeutic trial may be appropriate before proceeding to more invasive therapies. The purported mechanism of action is via endometrial atrophy.

42. Levonorgestrel-releasing intrauterine system
Observational studies and systematic reviews have shown a reduction in uterine volume and bleeding, and an increase in hematocrit after placement of this IUS

43. The presence of intracavitary leiomyomas amenable to hysteroscopic resection is a strong relative contraindication to use.

44. Progestin implants, injections, and pills
progestin-only contraceptives cause endometrial atrophy and thus provide relief of menstrual bleeding-related symptoms.

45. Gonadotropin-releasing hormone agonists
Gonadotropin-releasing hormone (GnRH) agonists are the most effective medical therapy for uterine myomas.

46. Most women will develop amenorrhea, improvement in anemia (if present), and a significant reduction (35 to 60 percent) in uterine size within three months of initiating this therapy, thus achieving improvement in both categories of myoma symptomatology there is rapid resumption of menses and pretreatment uterine volume after discontinuation of GnRH agonists

47. Because of the rapid rebound in symptoms and side effects, GnRH agonists are primarily used selectively as preoperative therapy. GnRH agonists are approved for administration for three to six months prior to leiomyoma-related surgery in conjunction with iron supplementation to facilitate the procedure and enable correction of anemia

48. The side effects of long-term GnRH agonist administration can be minimized during therapy by giving add-back therapy with low dose estrogen-progestin after the initial phase of downregulation.

49. Low dose estrogen-progestin therapy, such as used for menopausal replacement (equivalent to mg of conjugated estrogen and 2.5 of medroxyprogesterone acetate or 5 mg norethindrone acetate) maintains amenorrhea and the reduction in uterine volume, while preventing significant hypoestrogenic side effects (eg, osteoporosis, vasomotor symptoms)

50. Gonadotropin-releasing hormone antagonists
The advantage of antagonists over agonists is the rapid onset of clinical effects without the characteristic initial flare-up observed with GnRH agonist treatment.

51. Ulipristal acetate
Ulipristal acetate is a progesterone receptor modulator (PRM) that inhibits ovulation, but has little impact on serum estradiol levels. The drug is approved for three months of preoperative therapy outside the US

52. Mifepristone
The antiprogestin mifepristone (RU-486) is the most widely studied PRM and reduces uterine volume by 26 to 74 percent in women with leiomyomas, comparable to the reduction observed with GnRH agonists Regrowth occurs slowly following cessation of the drug

53. Danazol and gestrinone
Since it induces amenorrhea and has been shown to have a direct effect on endometriosis implants, danazol likely inhibits autologous endometrium. Danazol may control anemia related to leiomyoma-related menorrhagia, but it does not appear to reduce uterine volume.

54. SURGERY Abnormal uterine bleeding or bulk-related symptoms
Infertility or recurrent pregnancy loss

55. Hysterectomy
We suggest hysterectomy for: (1) women with acute hemorrhage who do not respond to other therapies; (2) women who have completed childbearing and have current or increased future risk of other diseases (cervical intraepithelial neoplasia, endometriosis, adenomyosis, endometrial hyperplasia, or increased risk of uterine or ovarian cancer) that would be eliminated or decreased by hysterectomy; (3) women who have failed prior minimally invasive therapy for leiomyomas; (4) women who have completed childbearing and have significant symptoms, multiple leiomyomas, and a desire for a definitive end to symptomatology.

56. Myomectomy
Myomectomy is an option for women who have not completed childbearing or otherwise wish to retain their uterus. Although myomectomy is an effective therapy for menorrhagia and pelvic pressure, the disadvantage of this procedure is the risk that more leiomyomas will develop from new clones of abnormal myocytes.

57. Endometrial ablation
In women who have completed childbearing, endometrial ablation, either alone or in combination with hysteroscopic myomectomy, is an option for management of bleeding abnormalities. Since intramural and subserosal leiomyomas are not affected by this procedure, bulk or pressure symptoms are unlikely to improve.

58. Myolysis
Myolysis refers to laparoscopic thermal, radiofrequency, or cryoablation (cryomyolysis) of leiomyoma tissue . This technique is easier to master than myomectomy, which requires suturing. However, localized tissue destruction without repair may increase the chance of subsequent adhesion formation or rupture during pregnancy

59. Uterine artery occlusion
Occlusion of uterine vessels either via laparoscopy or a vaginally-placed clamp has been proposed as an alternative to uterine artery embolization (UAE), but experience is limited

60. Treatment with uterine artery embolization

61. RELEVANT ANATOMY
The majority of the blood supply to the uterus derives from the uterine arteries, and there is also collateral perfusion from the ovarian arteries. The uterine arteries originate from the anterior division of the internal iliac arteries in the retroperitoneum . They may share a common origin with the obliterated umbilical artery, internal pudendal, or vaginal artery. The ovarian arteries arise from the abdominal aorta. The right ovarian vein returns to the inferior vena cava while the left ovarian vein returns to the left renal vein.

63. PATIENT SELECTION
Uterine artery embolization (UAE) is a treatment option for women with symptomatic uterine leiomyomas.
There are many treatment options for uterine fibroids and the clinician must guide the patient through this choice.

64. Ideal candidates for UAE include women with all of the following characteristics :
●Heavy menstrual bleeding or dysmenorrhea caused by intramural fibroids
●Premenopausal
●No desire for future pregnancy

65. If bulk-related symptoms (eg, sensation of pressure in the lower abdomen, nocturia, urinary frequency, and urinary incontinence) are the only symptoms, the efficacy of UAE is questionable

66. Prognostic factors
•Predictors of a greater improvement in symptom score following the procedure include a presenting symptom of heavy menstrual bleeding (rather than other symptoms), smaller leiomyoma size, and submucosal location .
•Hypervascular fibroids, detected with contrast-enhanced imaging, before UAE predict a high regrowth-free interval . In our practice, we use magnetic resonance imaging, but Doppler ultrasound or contrast enhanced ultrasound may also be used.
•Larger fibroids and more numerous fibroids predict higher symptom recurrence

67. Contraindications ●Asymptomatic fibroids ●Pregnancy
●Pelvic inflammatory disease
●Uterine malignancy

68. Location – Subserosal or submucosal fibroids that are pedunculated and have a narrow stalk (stalk <50 percent in diameter in comparison with the largest diameter fibroid) are considered a relative contraindication because these fibroids may detach either intraperitoneally or within the uterine cavity; submucosal fibroids that detach may be expelled vaginally .Detachment may be associated with sterile peritonitis or intrauterine infection.

69. Size or number of fibroids – The volume of necrosis after UAE in a large fibroid uterus can be substantial with a proportionate level of postprocedural pain and risk of infection. However, no clear threshold for the size of the uterus or size or number of fibroids has been established as a contraindication. The only study to address this question was a case series of women with a dominant fibroid of >10 cm and/or a uterine volume of >700 cm that found no increase in the risk of serious complications

71. OUTCOMES

73. Heavy menstrual bleeding
It has been shown that most patients (73 to 90 percent) reported improvement or disappearance of heavy menstrual bleeding symptoms up to 10 years after treatment

74. Pelvic pain or dysmenorrhea
The effect of UAE on lower abdominal pain or dysmenorrhea has also been described and shows an improvement in up to 80 percent of patients.

75. Pelvic pressure or bulk-related symptoms
The effect of UAE on bulk and pressure complaints is less well studied, but in large cohort studies, up to 90 percent of patients reported improved bulk complaints

76. Uterine artery embolization versus surgery
UAE had a shorter hospital stay and a faster resumption of daily activities and work compared with hysterectomy or myomectomy in a meta-analysis of seven randomized trials

77. Pregnancy in women with uterine leiomyomas (fibroids)

78. Pregnancy-related increases in estrogen and progesterone levels, uterine blood flow, and possibly human chorionic gonadotropin levels, are believed to affect fibroid growth. Most studies that have sonographically monitored the size of fibroids across pregnancy have refuted the commonly held belief that fibroids increase in size throughout gestation ,although there are exceptions
It appears that fibroid size remains stable (<10 percent change) across gestation in 50 to 60 percent of cases, increases in 22 to 32 percent, and decreases in 8 to 27 percent

79. Most pregnant women with fibroids do not have any complications during pregnancy related to the fibroids . When complications occur, painful degeneration is the most common complication

80. Degeneration and torsion
pain is one of the most common symptoms of fibroids in pregnant women and is typically due to fibroid degeneration or, rarely, torsion. Rapid growth of fibroids can result in a relative decrease in perfusion, leading to ischemia and necrosis (red degeneration) and release of prostaglandins . Pedunculated fibroids are at risk of torsion and necrosis, but this is much less common than degeneration.

81. Miscarriage
In some patients, submucosal fibroids appear to adversely affect implantation, placentation, and ongoing pregnancy. The effects of intramural fibroids are more controversial, while fibroids that are primarily subserosal or pedunculated are unlikely to cause adverse outcomes. The risk of pregnancy loss may be higher when there are multiple fibroids

82. Preterm labor and birth
Characteristics reported to increase this risk include multiple fibroids, placentation adjacent to or overlying the fibroid ,and size greater than 5 cm

83. Antepartum bleeding and placental abruption
Numerous studies have reported that antepartum bleeding is more common in pregnancies with fibroids The location of the fibroid in relation to the placenta appears to be an important determinant and implies that bleeding is related to abruption. Pooled cumulative data suggest the risk of abruption is increased threefold in women with fibroids

84. Submucosal and retroplacental fibroids and fibroids with volumes >200 mL (corresponding to 7 to 8 cm diameter) are associated with the highest risk of abruption

85. Malpresentation
Müllerian anomalies are associated with an increased risk of malpresentation, presumably because they distort the shape of the uterine cavity [

86. Dysfunctional labor
fibroids in the myometrium may decrease the force of uterine contractions or disrupt the coordinated spread of the contractile wave, thereby leading to dysfunctional labor Higher rates of tachysystole (defined as >5 contractions in 10 minutes) have also been reported

87. Cesarean delivery
The proposed increase in cesarean delivery rate is likely due to such factors as an increased risk of malpresentation

88. Postpartum hemorrhage
especially if the fibroids are large (>3 cm) and located behind the placenta or the delivery is by cesarean

89. Fetal anomalies
. Case reports have described fetal anomalies including limb reduction defects, congenital torticollis, and head deformities in pregnancies with large submucosal fibroids

90. Preterm premature rupture of membranes
the greatest risk of preterm premature rupture of membranes appears to be when the fibroid is in direct contact with the placenta

91. Placenta previa
Most studies that account for maternal age and prior uterine surgery failed to show any association between fibroids and placenta previa

92. Fetal growth restriction
large fibroids (greater than 200 mL) may be associated with delivery of small-for-gestational age infants (<10th percentile for gestational age)

93. PRECONCEPTIONAL PLANNING
We suggest that women with leiomyomas not postpone pregnancy for a prolonged period of time, if possible. Our rationale is that fertility naturally declines with age, especially after age 35 years, and leiomyomas may impair fertility and adversely affect pregnancy outcome

94. we suggest not performing prophylactic myomectomy to prevent pregnancy complications. Myomectomy can be considered in selected patients with a history of obstetrical complications that appear related to the presence of leiomyomas

95. Indications for myomectomy during pregnancy or at delivery
Given the potential for harm (hemorrhage, uterine rupture, miscarriage or preterm delivery), myomectomy is avoided during pregnancy and at delivery, especially if an intramyometrial incision is required, unless the procedure cannot be safely delayed

96. Painful fibroids
Short-term use of opioids in standard doses or a course of nonsteroidal anti-inflammatory drugs (NSAIDs) can be given when pain is not controlled by these measures. First trimester opioid use has been associated with an increased risk of congenital anomalies in some studies, but the data are weak and do not justify withholding these medications when needed to control pain.

97. Pain may be managed with a short course of ibuprofen
Pain may be managed with a short course of ibuprofen . Indomethacin 25 mg orally every 6 hours for up to 48 hours is another NSAID that has been effective . Therapy should be limited to pregnancies less than 32 weeks of gestation because of the possibility of inducing premature closure of the ductus arteriosus, neonatal pulmonary hypertension, oligohydramnios, and fetal/neonatal platelet dysfunction

98. Fibroids prolapsing into the vagina
The need for resection should be assessed on a case-by-case basis. Clinically significant bleeding, excessive pain, urinary retention, and (rarely) infection during pregnancy due a prolapsed fibroid are reasonable indications for resection.

99. The aim of the present study was to assess the safety of myomectomy for intramural fibroids during caesarean section. A retrospective study of 63 women who underwent myomectomy during caesarean section and 63 women who underwent caesarean delivery without myomectomy was conducted. The study group was divided into subgroups according to the volume of fibroids and total incision count. The volume of fibroids, the preoperative and postoperative haemoglobin values and the difference between them, incidence of haemorrhage and blood transfusion, duration of operation and postoperative fever of patients were investigated. Duration of operation was longer (p < .001) and haemoglobin loss was higher (p = .01) in the myomectomy group. There was no difference between one incision and two incisions subgroups in terms of mean haemoglobin change (p = .068). Haemoglobin loss was higher in volume >50 cm3 group than volume <50 cm3 and control groups. These differences were statistically significant (p = .02; p = .001, respectively). Although intramural fibroids can be safely removed during caesarean section, large fibroids and extra incisions for myomectomy are risk factors for haemorrhage.
Myomectomy for intramural fibroids during caesarean section: A therapeutic dilemma.
Akbas M1, Mihmanli V1, Bulut B1, Temel Yuksel I1, Karahisar G1, Demirayak G1.

100. Outcome and risk factors of cesarean delivery with and without cesarean myomectomy in women with uterine myomatas.
Arch Gynecol Obstet Jan;295(1): doi: /s Epub 2016 Aug 24.

101. AIM: To evaluate the outcome of a cesarean myomectomy (CM) versus a cesarean delivery (CD) alone in women with uterine myomas and the risk factors for adverse outcomes. METHODS: A retrospective cohort study of all women undergoing CDs with uterine leiomyomatas and singleton pregnancies was performed. Patients with known risk factors for hemorrhage were excluded. Measured adverse outcome parameters included estimated blood loss, drop in hemoglobin levels (pre/postoperatively), operation time, and the use of additional uterotonics. Outcome parameters of women with CM were compared to women with CD alone. Possible risk factors for adverse outcomes were analyzed in a multivariate regression analysis. Evaluated risk factors for CM were according to localization and type of myomatas, the myoma size, BMI ≥30 kg/m2, age ≥40 years, fetal weight ≥4 kg, repeat CD, and unplanned CD in the first stage of labor. The influence of localization and myoma type were further analyzed in a subgroup analysis. RESULTS: Of the 162 women with uterine myomatas during CD, 48 underwent CM and were analyzed. Overall, CM was not associated with adverse outcomes. Independent of a concomitant myomectomy, a large myoma size of ≥5 cm was associated with an increased blood loss of ≥500 ml (adj. OR 2.7 CI 95 % , p = 0.02), and women ≥40 years of age had a significant postoperative drop in hemoglobin (adj. OR 2.4 CI 95 % , p = 0.04). In the univariate subgroup analysis, CM of multiple myomatas was associated with an increased blood loss and an increased operation time compared to women with multiple myomatas and CD alone. Prolonged operation times were also observed in women with pedunculated and subserosal myomatas with concomitant myomectomy. There were no cases of hysterectomy or blood transfusions. CONCLUSION: CM performed by an experienced obstetrician can be safe in selected patients who are without additional preexisting risk factors. Risk factors that are associated with increased blood loss in women with uterine leiomyomatas include a larger size of the leiomyoma (≥5 cm) and a maternal age of ≥40 years.

102. Comparative Study of Cesarean Myomectomy with Abdominal Myomectomy in Terms of Blood Loss in Single Fibroid.
J Obstet Gynaecol India Aug;66(4): doi: /s x. Epub 2015 Mar 15.

103. OBJECTIVE: 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. METHODS: 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. RESULTS: Mean age of the women was comparable; mean gestational age in group 1 was / weeks; 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. CONCLUSION: Cesarean myomectomy can be safely done in single fibroids and is comparable to abdominal myomectomy in terms of blood loss.

104. Safety of cesarean myomectomy with huge myoma compared with uncomplicated cesarean section in Indian scenario

105. Background: Myomectomy with cesarean section has traditionally been discouraged due to risk of intractable hemorrhage and increased post-operative morbidity. In recent years, many studies have demonstrated safety of performing myomectomy with cesarean section even for large fibroids. The aim of this study was to find out the safety and clinical outcome of cesarean myomectomy in case of large myoma to encourage routine combination of both procedures.
Methods: 15 term women undergoing cesarean myomectomy constituted the study group and were compared with control group of 15 pregnant women matched on basis of gestational age and parity without myoma or any other high risk factor. Outcomes studied were duration of surgery, change in hemoglobin from pre-operative to post-operative period, need for blood transfusion, and duration of hospital stay, post-operative complications and follow up of patients up to 6 weeks postpartum.
Results: Mean age was higher in study group than control group which could be attributed to increased incidence of fibroids with increasing age. Both the groups were comparable for pre-operative hemoglobin, post-operative hemoglobin, change in hemoglobin, neonatal outcome, post-operative complications, duration of hospital stay and follow up to 6 weeks postpartum. Duration of surgery was significantly increased in study group as compared to control group. Blood transfusion was required only in study group.
Conclusions: Myomectomy may be done with cesarean section safely even for large fibroids by expert person in tertiary care setting.

106. A study of outcome of caesarean myomectomy in a tertiary care hospital

107. Background: Uterine leiomyoma (i. e
Background: Uterine leiomyoma (i.e. fibroid or myoma) are benign clonal tumours arising from the muscle cell of the uterus .Uterine myomas are the commonest tumour over the age of 30 years and seen in 2% pregnant women. The impact of uterine myomas on pregnancy depends on the size, number and location of myoma. Myomectomy is a surgery to remove one or more fibroids. Recently, it has been suggested that caesarean myomectomy is a safe surgical modality if is performed in carefully selected patients. The aim of the study was to assess the safety and feasibility of performing myomectomy during caesarean section.
Methods: This prospective observational study was conducted in the Postgraduate Department of Gynaecology and Obstetrics for a period of one and a half year in Government Lalla Ded Hospital – an associated hospital of Government Medical College, Srinagar which is the sole tertiary care referral centre in the valley.
Results: A total of 54 patients were taken for caesarean myomectomy. Majority of the patients were in the age group of 26-30years and were of para-1 or 2. Mean blood loss was ≤500 ml during surgery. Most common intraoperative complication was haemorrhage and post-operative complication was fever.
Conclusions: From the present study, it is concluded that with the advent of better anaesthesia and availability of blood, caesarean myomectomy is no longer a dreaded job in the hands of an experienced surgeon and in a well-equipped tertiary institution.