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Tackling Myoma During Caesarean Section
- 1. Prof. Rokeya Beguum Prof and Advisor Dept of OBG/ GYNAE USTC Director Surgiscope fertility centre Chittagong, Bangladesh Tackling of Myoma During Caesarean Section
- 2. World wide caesarean sections are on rise 1. It is common benign tumour 2. Prevalence is increasing due - Delay in child bearing - Better imaging technique 0.37-12% There is no clear guideline regarding tackling these myoma during caesarean section. There is dilemma and debate.
- 3. Effect of pregnancy on myoma 60-70% fibroid do not have any change in size 20-25% increase in size mainly occurs in first and early second trimester In puerperium Majority of fibroids shows on changes 5-10% reduce in size
- 5. Sir Victor Bonney 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. This kindly and misguided policy we heartily deprecate.”
- 6. Caesarean myomectomy have the life threatening complications- - Massive blood loss - Peripartum hysterectomy - Blood transfusion - Admission in ICU - Adhesion formation - Scar integrity in subsequent pregnancy
- 7. Doing Nothing is easy that’s why many people do it
- 8. What to do 1. Leave it 2. Leave it with uterine artery ligation (UAL)
- 9. 1.Leave it Caesarean myomectomy was practically absent from the- 1. Obstetric literature until the last decade. 2. Myomectomy discouraged in all the leading text book despite the lack of any direct evidence supporting the approach. Reasons Hemorrhage Difficulty in securing haemostasis Need for blood transfusion Hysterectomy Operative morbidity
- 10. What happens if leave it . This is not safe 1. PPH 2. Inversion of uterus 3. Spontaneous expulsion 4. Intramyometrial haemorrhage - Involution of uterus compresses the venous drainage - Blood sequestration into the tumour - Hypovolaemia and shock 5. Sepsis
- 11. 2. Leave it with UAL Uterine artery ligation promising method for treating pregnant women with myoma. - Reduce blood loos - Reduce blood supply - Minimize necessity for future surgery • Lactation • Puerperium • Reduce size
- 12. Removal/Caesarean myomectomy Reasons: - Avoid repeat surgery - Relieves symptom - Reduce postpartum complications - Save cost and time
- 13. Caesarean myomectomy after baby delivery
- 14. Type Selective Routine - All myoma - Particular
- 15. Removal of pedunculated fibroid only. Removal of pedunculated anterior subserous lower uterine segment fibroid. Removal of all anterior uterine fibroids without post, cervical and cornual Removal of all fibroid Size more than 5 cm Selective removal of fibroids
- 16. Main principles of myomectomy during caesereen Experience and skill person Well equipped tertiary institution Better aneasthesia and available blood Full consent and counselling High Hb level Size and site of myoma Good assistant
- 17. Procedure 1. Delivery of baby before attempting myomectomy Rare situation Myoma in lower segment in the incision line - Myomectomy first then C/S - Classical C/S or upper segment incision
- 18. Procedure 2. Closing the uterine wound first then myomectomy. Endometrial myomectomy Submucous Posterior wall myoma Intramural myoma Endometrial myomectomy causes endometrial synaechiae due to endometrial suture. Evidence Rapid involution of uterus diminishes the dead space and suture sites therefore endometrial scarring is minimized automatically and no chance of Asherman,s syndrome. Less chance of intraperitoneal adhesion
- 20. Serosal myomectomy Adhesion Reduce future fertility Minimized by - Single incision Smaller incision Apposition Base ball suture Antiadhesive agent
- 21. 3. Myomectomy by sharp dissection. Enucluation 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 Evidence is scanty
- 22. Dead space obliteration by meticulous suturing in three layers.
- 23. 4. Excessive bleeding ultimately peripartum hysterectomy. Haemorrhage can be reduce by - Uterotonic agent Step wise devascularisation Local vasoconstrictor Vasopressin Noradrenaline - Jungle juice
- 24. Tourniquets Myomectomy Clamp Liberal use of diathermy Tranexamic acid Gelatin matrix Kept intraperitoneal drain insitu Multiple myoma in multiparous – Hysterectomy Prophylactic antibiotics Analgesics Postoperative period stormy
- 25. The recurrence of uterine fibroids It is likely to be higher than after myomectomy in the non pregnant state.
- 26. Future fertility The future fertility and/or subsequent pregnancy outcome was unaffected by caesarean myomectomy.
- 27. Key to success Careful case section 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.
- 28. Consensus • Caesarean myomectomy can be safely done by experience surgeon even in large myoma with no increase in intra and post operative complications. (Evidence level IIa) • Future fertility and subsequent pregnancy outcome was unaffected by caesarean myomectomy. (Evidence level III) • Should be done by experienced obstetrician preferably in superficial subserosal fibroid.
- 29. Is not absolutely contraindicated Decision depends on Location, size, number Preoperative counselling and consent Individualized Management in tertiary set up Summary
- 30. It is the time to change as Charlie Chaplin rightly said “Nothing is permanent in this wicked world – not even our troubles”
- 31. Caesarean myomectomy no longer a fer fetched job in modern obstetrics We have to prepare.