Myomectomy or conservative management of uterine fibroids: effects on reproductive potential

Abstract

AIM: The aim of this study was to analyze reproductive function, pregnancy and labor in women after laparoscopic myomectomy and in women with unoperated myoma.

MATERIALS AND METHODS: The main group consisted of 60 patients aged 25-46 years with a scar on the uterus who had laparoscopic myomectomy. Inclusion criteria were full-term pregnancy, uterine scar after laparoscopic myomectomy for subserosal or intramural uterine myoma (3-10 cm), and myomatous nodules (one to three). The comparison group included 30 women aged 25-46 years who were not surgically treated. Inclusion criteria were full-term pregnancy, subserosal or intramural uterine myoma (3-10 cm), and myomatous nodules (one to three). All patients in the main group underwent laparoscopic myomectomy. In all cases, the myomatous nodule was removed intracapsularly, leaving the leiomyoma pseudocapsule, which, with a deep arrangement of the transmural myomatous nodules, avoided opening the uterine cavity; myomatous nodule morcellation being used. With a deep intramural arrangement of the leiomyoma, the myometrial defect was sutured layer by layer with the application of several rows of endosutures.

RESULTS: Six months after myomectomy, the patients underwent MRI of their pelvic organs with contrast. In 95% of cases, the uterine scar had no anatomical insolvency. In assessing the anamnesis, gynecological diseases occurred two times more often in women in the main group: 22 (36.7%) patients resorted to the use of the in vitro fertilization method for pregnancy, while among the patients in the comparison group, there were only two (6.7%) of them (χ² = 12.8; р < 0.001). In the main group, moderate preeclampsia and gestational diabetes mellitus were twice as common. In the main group, all patients were delivered by caesarean section, of which 83.3% were planned and 16.7% were emergency. In the comparison group, 73.3% of patients were delivered through the natural birth canal and 26.7% by caesarean section (χ² = 149, p < 0.0001). The most unfavorable signs predisposing to obstetric complications and operative delivery were the presence of multiple nodules (OR = 5.96 (1.09-32.72), p < 0.05), the location of the nodule or scar in the uterine bottom (OR = 2.52 (1.00-6.33), p < 0.05), and their combination with IVF (OR = 9.09 (2.42-34.07), р < 0.01).

CONCLUSIONS: In 95% of women, the scar on the uterus after myomectomy was consistent, but all these pregnant women were delivered by cesarean section, mainly for combined indications. However, they carried out the pregnancy safely, with a good outcome for the fetus. In women with uterine myoma and its conservative management, there was a lower rate of aggravated gynecological history and obstetric complications, and 73.3% of them were delivered through the natural birth canal. Despite the increased risk of caesarean section, the presence of uterine fibroids, even of a large size (more than 4 cm), should not be considered as a contraindication to vaginal delivery.

Keywords

uterine fibroids / myomectomy / pregnancy / delivery

References

[1] Savelyeva GM, Kurtser MA, Breusenko VG, et al. Endoscopic myomectomy: pro and con. Voprosy ginekologii, akusherstva i perinatologii. 2007;6(1):57−60. (In Russ.)

[2] Савельева Г.М., Курцер М.А., Бреусенко В.Г. и др. Эндоскопическая миомэктомия: за и против // Вопросы гинекологии, акушерства и перинатологии. 2007. Т. 6. № 1. С. 57−60.

[3] Mioma matki. Klinicheskie rekomendacii. 2020. [cited 12 Aug 21]. Available from: http: //www.chelsma.ru/files/misc/kr_miomamatki.pdf. (In Russ.)

[4] Миома матки. Клинические рекомендации. 2020. [дата обращения 12.08.21]. Доступ по ссылке: http://www.chelsma.ru/files/misc/kr_miomamatki.pdf

[5] Mioma matki: diagnostika, lechenie i reabilitacija. Klinicheskie rekomendacii (protokol lechenija). Akusherstvo i ginekologija. 2016;4(Supl):3−42. (In Russ.)

[6] Миома матки: диагностика, лечение и реабилитация. Клинические рекомендации (протокол лечения) // Акушерство и гинекология. 2016. № 4. (Приложение). С. 3−42.

[7] Ajlamazjan JeK, Rjabceva IT, Jakovlev VG. Ginekologija: uchebnik dlja medicinskih vuzov. Saint Petersburg: SpecLit; 2013. (In Russ.)

[8] Айламазян Э.К., Рябцева И.Т., Яковлев В.Г. Гинекология: учебник для медицинских вузов. 2-е изд. Санкт-Петербург: СпецЛит, 2013.

[9] Tskhay VB, Schtoh EA. Uterine fibroids and women’s reproductive function. Communication uterine fibroids with infertility. Akusherstvo, ginekologija i reprodukcija. 2014;8(4):42−47. (In Russ.)

[10] Цхай В.Б., Штох Е.А. Миома матки и репродуктивная функция женщины. Связь миомы матки с бесплодием // Акушерство, гинекология и репродукция. 2014. Т. 8. № 4. С. 42−47.

[11] Kozachenko AV, Revazova ZV, Adamyan LV, et al. Hormonal assessment for surgical treatment of patients of reproductive age with uterine myoma. Meditsinskiy sovet = Medical Council. 2019;(13):29−35. (In Russ.). DOI: 10.21518/2079-701X-2019-13-29-35

[12] Козаченко А.В., Ревазова З.В., Адамян Л.В. и др. Гормональная подготовка к хирургическому лечению больных миомой матки репродуктивного возраста // Медицинский совет. 2019. № 13. C. 29−35. DOI: 10.21518/2079-701Х-2019-13-29-35

[13] Goncharova MA, Petrov YuA. Uterine myoma: modern directions of surgical treatment. Mezhdunarodnyj zhurnal prikladnyh i fundamental’nyh issledovanij. 2019;(11):70−74. (In Russ.)

[14] Гончарова М.А., Петров Ю.А. Миома матки: современные направаления хирургического лечения // Международный журнал прикладных и фундаментальных исследований. 2019. № 11. С. 70−74.

[15] Fagherazzi S, Borgato S, Bertin M, et al. Pregnancy outcome after laparoscopic myomectomy. Clin Exp Obstet Gynecol. 2014;41(4):375−379.

[16] Fagherazzi S., Borgato S., Bertin M. et al. Pregnancy outcome after laparoscopic myomectomy // Clin. Exp. Obstet. Gynecol. 2014. Vol. 41. No. 4. P. 375−379.

[17] Sancho JM, Delgado VSC, Valero MJN, et al. Hysteroscopic myomectomy outcomes after 3-month treatment with either Ulipristal Acetate or GnRH analogues: a retrospective comparative study. Eur J Obstet Gynecol Reprod Biol. 2016;198:127−130. DOI: 10.1016/j.ejogrb.2016.01.014

[18] Sancho J.M., Delgado V.S.C., Valero M.J.N. et al. Hysteroscopic myomectomy outcomes after 3-month treatment with either Ulipristal Acetate or GnRH analogues: a retrospective comparative study // Eur. J. Obstet. Gynecol. Reprod. Biol. 2016. Vol. 198. P. 127−130. DOI: 10.1016/j.ejogrb.2016.01.014

[19] Cervikal’naja intrajepitelial’naja neoplazija, jerozija i jektropion shejki matki. Klinicheskie rekomendacii. 2020. [cited 12 Aug 21]. Available from: https://www.dzhmao.ru/spez/klin_recom/akushGinekol/2020/KR_597_CINeoplaziyaMatki.pdf

[20] Цервикальная интраэпителиальная неоплазия, эрозия и эктропион шейки матки. Клинические рекомендации. 2020. [дата обращения 12.08.21]. Доступ по ссылке: https://www.dzhmao.ru/spez/klin_recom/akushGinekol/2020/KR_597_CINeoplaziyaMatki.pdf

[21] Dodkhoeva MF, Pirmatova DA. Gestational diabetes mellitus: a modern view on the actual problem. Vestnik Avitsenny [Avicenna Bulletin]. 2018;20(4):455−461. (In Russ.). DOI: 10.25005/2074-0581-2018-20-4-455-461

[22] Додхоева М.Ф., Пирматова Д.А. Гестационный сахарный диабет: современный взгляд на актуальную проблему // Вестник Авиценны. 2018. Т. 20. № 4. С. 455−461. DOI: 10.25005/2074-0581-2018-20-4-455-461

[23] Krasnopol’skiy VI, Dolgieva LU. The rate of caesarian section at delivery ofwomen with monocyesis after IVF. Journal of Obstetrics and Women’s Diseases. 2010;(5):103−109. (In Russ.)

[24] Краснопольский В.И., Долгиева Л.У. Место кесарева сечения при родоразрешении женщин с одноплодной беременностью после ЭКО // Журнал акушерства и женских болезней. 2010. № 5. С. 103−109.

[25] Sidorova IS, Ageev MB. The clinical and morphological features of simple and proliferating uterine myoma. Rossiyskiy vestnik akushera-ginekologa. 2013;13(6):34−38. (In Russ.)

[26] Сидорова И.С., Агеев М.Б. Клинико-морфологические особенности простой и пролиферирующей миомы матки // Российский вестник акушера-гинеколога. 2013. Т. 13. № 6. С. 34−38.

[27] Ivanova MA, Vorihanov AV. Complications in pregnancy and childbirth and their relationship with extragenital pathology. Current problems of health care and medical statistics. 2015;(2):30−40. (In Russ.)

[28] Иванова М.А., Ворыханов А.В. Осложнения в периоде беременности и родов и их взаимосвязь с экстрагенитальной патологией // Современные проблемы здравоохранения и медицинской статистики. 2015. № 2. С. 30−40.

RIGHTS & PERMISSIONS

Eсо-Vector