Chauhan AR

Fibroids in pregnancy are increasingly common due to factors like delayed childbearing and advances in infertility treatment, and are more often diagnosed due to better imaging techniques.  They may remain asymptomatic, or complicate pregnancy in any trimester; miscarriage, increase in size of fibroid, pain due to red degeneration, malpresentation, preterm labor, obstructed labor and postpartum hemorrhage (PPH) may occur in 10 - 30 % of these patients. The incidence of cesarean section (CS) in patients with fibroids is as high as 73 %, however surgical removal of the myoma has traditionally been discouraged due to the high risk of PPH and postoperative morbidity. Cesarean myomectomy (CM) is the term used to describe myomectomy at cesarean section. Previously CM was resorted to only when the fibroid was obstructing the lower uterine segment or line of incision, or inadvertent entry into the fibroid when the placenta was implanted over it, or when closure of the uterus was not possible without its removal. This article examines recent literature on the safety of CM.

The safety and efficacy of CM was evaluated by Hassiakos in 47 women who underwent simultaneous CS and myomectomy, compared with 94 women with fibroids who underwent only CS. He found that myomectomy added only 15 minutes to the operative time, no patients required blood, no patient required hysterectomy, and length of hospital stay was similar. Pre- and postoperative hemoglobin fall was statistically significant but did not differ among the two groups. He concluded that despite a traditional reluctance to do two procedures simultaneously, myomectomy at CS could be recommended.
Similar findings have been shown by Park, where he retrospectively studied 97 women who had CM as compared to 60 women with fibroids who had only CS. There were no differences in intra or postoperative morbidity; when the size of the fibroid was more than 6 cm, the operative time was longer in the CM group. Kwon studied the safety of CM in large myomas and found no differences in operative outcomes in patients with myomas > 5 cm as compared to those with smaller ones.
In a meta- analysis of available data, Song et al reviewed 9 case - control studies which included more than 1000 women with fibroids, of whom 41 % underwent CM and 59 % underwent CS alone. They found no major differences in safety parameters like intra-operative blood loss, need for transfusion, surgical time or postoperative morbidity. However they concluded that though CM is a reasonable option for some women, no definite conclusions can be drawn as the data was of low quality.  
Principles of myomectomy that are routinely followed apply for CM as well: intracapsular myomectomy, sharp dissection or use of electrocautery, careful attention to hemostasis, obliteration of dead spaces to prevent postoperative hematoma in the myoma bed, good approximation of the myometrium with 2 or 3 layered closure with delayed absorbable sutures. Additional techniques to prevent blood loss like stepwise devascularization and preoperative placement of balloons in the uterine arteries have also been described.
Two interesting recent articles in 2015 looked at surgical decision -making. Sparic analyzed the  intraoperative decision to perform CM in 102 of 185 women with myomas who underwent CS, and found that CM was mostly performed in younger women, and usually by experienced surgeons. The decision was based more on type and location of the fibroid rather than number or size; myomectomy was done more often when the fibroids were subserous or pedunculated.  Topcu in his retrospective series of 76 women who underwent CM compared to 60 women who had CS alone, also found that surgeons were more likely to remove subserous fibroids and that size of the myoma did not affect the decision process. Both authors concluded that CM is a safe procedure.  
Turgal evaluated postoperative adhesion formation between uterus and omentum, adnexal adhesions, incision site adhesions and adhesions causing surgical difficulty in women who had previously undergone CM for small subserosal, pedunculated or intramural fibroids, and were undergoing repeat CS 1 to 5 years later. He found no statistical difference in the adhesions between these patients and controls who had not undergone myomectomy during their previous CS.   
So, is it time to rethink CM in low - resource settings? In a recent 2013 review of CM in Africa, Awoleke supports the argument for CM citing that it could eliminate multiple surgeries for both indications. He emphasises that careful selection of the patient, thorough preoperative counselling especially when patient requests removal of previously diagnosed fibroids at CS, an experienced surgeon and facilities for postoperative management, will increase the safety of the procedure. However he cautions that large RCTs are required before any recommendations. Similarly, Mumtaz from Kerala and Ramesh Kumar from Karnataka have published their experience of CM in 26 and 21 cases respectively with encouraging results. Both authors cite potential advantages of CM as: avoiding a second surgical procedure or "interval myomectomy" with its attendant risks of anesthesia and surgical difficulties due to previous CS, better obstetric outcome in subsequent pregnancies as known complications of pregnancy with fibroids will be negated, increased chances of VBAC in subsequent pregnancies, and cost saving by combining two surgeries. 

Sir Victor Bonney, the father of myomectomy, cautioned the bold surgeon against a "misguided policy" of combining CS with myomectomy. Even today, only a small number of surgeons practice CM and most of the published data is a retrospective analysis of cases; more robust data and larger studies are needed before advocating CM as standard practice. This issue of the journal carries two vastly different reports of fibroid in pregnancy which we hope will be of interest to our readers.