Myoma after cesarean section. Modern approaches to delivery of women with fibroids

Review of indications, contraindications and techniques for performing myomectomy during cesarean section, possible complications and methods of preventing them.

A. I. Ishchenko, V. I. Lanchinsky, A. V. Murashko State Educational Institution of Higher Professional Education First Moscow State Medical University named after. I.M.Sechenov Ministry of Health of the Russian Federation

Rresume

Uterine fibroids are one of the most common benign tumors female reproductive system, which can complicate pregnancy. Issues of tactics for managing pregnancy and childbirth in women with uterine fibroids remain relevant, given the expansion of the boundaries of reproductive age, the increase in the number of primigravidas after 30 years and the tendency for tumors to appear at older ages. at a young age.

This review talks about the indications, contraindications and techniques for performing myomectomy during cesarean section, possible complications and methods of preventing them.

Key words: pregnancy, uterine fibroids, delivery, cesarean section.

Cesarean section and myomectomy A.I.Ishenko, V.I.Lanchinskiy, A.V.Murashko Summary

Uterine fibroids are most often found in reproductive age women which could complicate pregnancy. But there are many controversial questions about pregnancy management and delivery of patients with uterine myoma especially considering extension of reproductive age, increase of late reproductive age patients, and trend to myoma development in younger women.

Indications, contraindications, and precise myomectomy techniques in combination with cesarean section are presented in survey.

Key words: pregnancy, uterine fibroids, delivery, caesarean section.

Ishchenko Anatoly Ivanovich – dr med. Sciences, prof., head. department obstetrics and gynecology, medical faculty No. 1 First Moscow State Medical University them. I.M.Sechenova

Lanchinsky Viktor Ivanovich – Dr. med. Sciences, doctor of the gynecological department of the university clinical hospital No. 2 of the First Moscow State Medical University named after. I.M.Sechenova

Murashko Andrey Vladimirovich – Dr. med. sciences, prof. department Obstetrics and Gynecology, Faculty of Medicine No. 1, First Moscow State Medical University named after. I.M. Sechenov. Email: [email protected]

Issues of tactics for managing pregnancy and childbirth in women with uterine fibroids remain relevant. Moreover, their relevance increases as the incidence of this disease increases.

Currently, uterine fibroids are detected in 20% of women over 30 years of age. Growing interest in the combination of uterine fibroids and pregnancy is dictated by both the expansion of the boundaries of reproductive age, the increase in the number of primiparas after 30 years, and the tendency for the tumor to appear at a younger age.

If it is necessary to remove a myomatous node, it was generally accepted to perform a supravaginal amputation or hysterectomy after a cesarean section. The only exceptions were pedunculated nodes and small fibroid nodes along the uterine incision line, and in these cases myomectomy was allowed. However, the young age of many women giving birth raises the question of the most careful approach to thisthe contingent of patients and preservation of the uterus.

Attitudes towards myomectomy during cesarean section in Russia have undergone certain changes: in the 1950s–60s, as a rule, removal of myomatous nodes was performed or, in the presence of large fibroids, hysterectomy.

In the 1970s and 80s, myomectomy during cesarean section was not recommended due to large quantity postoperative complications: uterine hypotension, peritonitis, septic conditions.

Question about the possibility of myomectomy during pregnancy and childbirth long time remained controversial. In the late 1980s, myomectomy during cesarean section began to be widely used again. The reduction in the number of complications is associated with improved quality of suture material, the introduction of broad-spectrum antibiotics into obstetric practice, and improved anesthesia. G.S. Shmakov (1997) argued the expediency of active surgical tactics with expansion of indications for myomectomy during cesarean section. He noted that the incidence of postoperative complications after myomectomy during cesarean section depends on surgical tactics, antibiotic prophylaxis and antibiotic therapy, as well as the type of synthetic suture material used. Compliance with optimal conditions makes it possible to reduce the number of postoperative intestinal paresis from 11.1% (in 1979) to isolated cases (in 1991–1995), and the number of purulent-inflammatory complications from 14.6 to 4.4% with isolated cases wound infection V last years.

Preoperative preparation for delivery of women with uterine fibroids and indications for cesarean section and myomectomy.

Planned hospitalization and preparation of pregnant women with uterine fibroids to determine labor management tactics should be carried out at 36–37 weeks of pregnancy.

Along with traditional clinical and laboratory methods, special attention is paid to functional research methods. During the ultrasound examination(ultrasound) requires the presence of a surgeon who will perform the operation. At the same time, the size, number, location of fibroid nodes and their relationship to the vascular bundles of the uterus are determined, and indications for cesarean section and surgical treatment are formed.

Myomas removed during cesarean section with a diameter of 10 to 14 cm are considered large nodes, and fibroids with a diameter of 15 or more (25–30 cm) are considered giant. In the pregnant uterus intraoperatively, subserous, subserous-interstitial and interstitial nodes, as well as their localization along the anterior and posterior walls of the uterus (less often - in the fundus and along the side wall), are detected with approximately equal frequency. Sometimes myomatous nodes are localized in the lower segment, preventing natural childbirth.

The histological examination of fibroid nodes corresponds to ultrasound data, which is evidence of the reliability of the echographic characteristics of the node’s architecture during dystrophic and necrotic changes in fibroids.

When comparing ultrasound data performed in early and late dates pregnancy, there was no pronounced dynamics of node growth in 47.4% of patients; in 42.1% there was a moderate increase in nodes (by 3–4 cm in diameter). Only 10.5% of primigravidas had fast growth fibroids: from 2–3 cm in diameter at the beginning of pregnancy to 12–14 cm at full-term gestation, reaching 18 cm in one observation.

When studying data from a histological study of removed myomatous nodes, necrotic changes were noted in the area of ​​the nodes, often accompanied by either leukocyte infiltration or hyalinosis and calcification. In other observations, leiomyoma was combined with edema, hemorrhages and foci of leukocyte infiltration. In all cases, in the presence of giant fibroid nodes, necrotic changes occurred in the remote node. However, in the presence of a large-diameter tumor, it is not possible toIt is possible to detect a connection between the size of a node and the degree of secondary changes in it. So, for example, oneIn one of the patients, three nodes with a diameter of 9, 5, 3 cm were removed during the operation, while in the smaller nodes pronounced areas of necrosis were noted, and the structure big knot was a leiomyoma without secondary changes.

Functional examinations before the operation should include an assessment of the intrauterine condition of the fetus (carditocography, Doppler analysis of the vessels of the uterus, umbilical cord and fetal aorta) according to generally accepted methods.

Studies of the microflora of the vagina and cervical canal are mandatory, since when the uterine cavity is opened during a cesarean section, infection may enter the abdominal cavity, which leads to complications both in the early and late postoperative period.

When deciding on the method of delivery in patients with uterine fibroids, the woman’s age, obstetric history, the nature and location of the fibroid node, as well as the course of the pregnancy and the condition of the fetus are taken into account. The presence of uterine fibroids in pregnant women is relatively rarely the only indication for cesarean section.

Ababsolute indications for caesarean section for uterine fibroids

Large fibroids, the localization of which prevents delivery through the vaginal genital tract.
The presence of large fibroids with a submucosal location of the node.
Degeneration of fibroid nodes established before birth.
Torsion of the base (pedicle) of the subserous node of the fibroid with the development of peritonitis.
Uterine fibroids, accompanied by severe dysfunction related bodies.
Suspicion of malignancy of the fibroid node.
The patient's age is more than 35 years.
Uterine fibroids in women with a uterine scar who have previously undergone a cesarean section, myomectomy, or uterine perforation.
The presence of additional unfavorable factors: gestosis, severe illness, partial placenta previa, large fetus, etc.

ABOUTrelative indications for caesarean section for uterine fibroids

Multiple uterine fibroids in “elderly” pregnant women (primigravidas, multiparous women with a burdened obstetric history).
Uterine fibroids and placental insufficiency (hypoxia and fetal malnutrition).
Fibroids and a history of long-term reproductive dysfunction (induced pregnancy, prolonged infertility, unfavorable outcomes of previous pregnancies).
Malformations of the internal genital organs.

Indications for myomectomy during cesarean section

Subserous nodes on a thin base in any accessible place of the uterus.
Broad-based subserous nodes (excluding those located on vascular bundles and in the lower segment of the uterus).
The presence of no more than 5 large nodes (more than 10 cm).
Myoma nodes located intramurally or with centripetal growth, measuring more than 10 cm (no more than one).
Myoma nodes of different locations with good access to them, excluding intramural nodes less than 5 cm in size.
Myomectomy is not advisable
In the presence of one or several nodes with a diameter of up to 2 cm, especially with concomitant extragenital pathology.
Premature placental abruption, leading to acute blood loss.
Acute intraoperative blood loss.
Severe anemia of any etiology on the eve of surgery.

Ttechnique and tactics for myomectomy during cesarean section

For planned surgical intervention, which involves cesarean section and myomectomy, both regional anesthesia (epidural or spinal anesthesia) and endotracheal anesthesia are used if there are contraindications or the anesthesiology service is unprepared for regional anesthesia.

It is preferable to enter the abdominal cavity using the Joel-Cohen method. The transverse fascial incision in the Joel-Cohen modification, in contrast to the Pfannenstiel incision, is made slightly higher in the “avascular zone”. A straight-line skin incision is made 2–2.5 cm below the line connecting the anterosuperior iliac spines, then fatty tissue, and after incising the aponeurosis, it is dissected to the sides. The surgeon and assistant simultaneously separate the subcutaneous fat and rectus abdominis muscles by gentle bilateral traction along the skin incision line. After this, the peritoneum is opened index finger in the transverse direction so as not to injure the bladder. A partially blunt entry into the abdominal cavity avoids vascular damage and bleeding. This incision can be used in thin women; it is not acceptable in obese patients.

In the presence of a scar after a previous operation, Pfannenstiel transection is preferably used, and in case of giant myomatous nodes, it is necessary to use lower median laparotomy. An incision into the uterine wall during a caesarean section is made taking into account the upcoming conservative myomectomy. The main condition was to create the maximum favorable conditions both for careful delivery and for subsequent manipulations. Myomectomy is performed after suturing the uterine incision and its good contraction.

The incision on the uterus is repaired with a single-row continuous polyglycoline suture with Riverden overlap; peritonization may not be performed.

The choice of the direction of incisions on the uterus is made taking into account the localization of myomatous nodes, their number, depth, the architectonics of the myometrium and blood vessels. Considering the transverse direction muscle fibers in all layers of the myometrium and relatively large arterial vessels of the second order, covering the most powerful vascular layer of the myometrium, when enucleating myomatous nodes, transverse incisions on the uterus are preferable. As they approach the fundus of the uterus, the incisions take on an arched shape with a convexity towards the fundus of the uterus. Enucleation of nodes is carried out in a blunt and sharp way. After dissection along the top of the node, the uterine wall is sharp

m, by separating the adjacent areas of the myometrium from the node, the fibrous bridges are intersected. Considering that the elements of the “capsule” of the node are nothing more than hypertrophied muscular structures of the uterine wall, the latter are not excised. The separated sections of the “capsule” quickly contract,their thickness increases 2–3 times, which indicates their functional usefulness. AsEnucleation of the myomatous node increases the bleeding surface. Bleeding occurs mainly from the corners of the wound and the loose bed of the node, where the second-order arterial vessels pass.

In order to reduce blood loss, a step-by-step method of suturing the wound on the uterus is recommended. First, the knot is separated from one side and ∞-shaped sutures are applied to the edge of the wound, then the second corner of the wound is similarly isolated and sutures are also applied. Thus, the main arterial branches that bring blood to the wound are hemostasis. Then, as the node is enucleated, the first row of submersible muscular-muscular and the second (third) row of muscular-serous ∞-shaped sutures are gradually applied to the node bed.

When removing myomatous nodes without step-by-step suturing of a wound on the uterus, the bed of the node usually goes deep, bleeds diffusely, which makes it difficult to apply sutures to the bottom of the bed and can lead to the formation of hematomas and an increase in total blood loss.

For suturing a wound on the uterus, ∞-shaped sutures are used as modified by Yu.D. Landekhovsky. In this case, the seams are placed in such a way that the crossing of the threads passes not outside, but inside the fabrics. Such sutures provide not only good hemostasis, but also correct tissue connection without displacement of muscle bundles. Depending on the depth of the wound on the uterus, such sutures were placed in two or three layers. The use of ∞-shaped sutures ensures the juxtaposition of a significant area of ​​the wound, which reduces the amount of suture material left in the wound and has a beneficial effect on wound healing. The use of modified ∞-shaped sutures when applying the last row (muscular-serous sutures) in most cases does not require additional peritonization and additional hemostasis.

When large intermuscular myomatous nodes (more than 10 cm) are removed, a deep bed is formed, and when sutured, increased tension is created in the last row of muscular-serous sutures, which can lead to their eruption and bleeding in the postoperative period. To ensure the reliability of hemostasis and prevent the cutting of sutures, it is necessary to apply a supporting U-shaped suture along the sutured incision on the uterus.

Catgut, vicryl, dexon or domestic nylon thread with antibacterial fillers “Kaproag” are used as suture material. Clinical and experimental studies have shown that catgut has significant disadvantages: allergenic effect, especially when used repeatedly; swelling in the first hours after surgery and a tendency to untie knots; unpredictable resorption of catgut often leads to a decrease in the strength of the sutures even before the wound heals.

Catgut in the early postoperative period causes a sharp inflammatory reaction of tissues, which is pronounced and ends in a later period with extensive fibrosis, 3-4 times the diameter of the suture canal. All this causes inadequate tissue regeneration and the formation of a dense fibrous scar. In this regard, today the use of catgut for reconstructive surgical interventions on the genital organs is considered unacceptable.

Synthetic absorbable suture materials (SRSM) have distinct advantages over natural absorbable materials. They are 6–7 times more tensile strength compared to catgut, have a lower Young’s modulus (due to which the thread is softer, more elastic and less traumatic soft fabrics), high strength in the knot, which practically does not depend on the wet state of the thread, since SRSM has very weak hydrophilicity and does not increase its diameter when implanted into tissue.

Synthetic threads are used with atraumatic needles, while thinner threads (3/0, 2/0) are used for deeper layers, and thicker threads are used for muscular-serous sutures (1/0, 0), since thinner threads can erupt in the postoperative period.

One of the main advantages of SRSM is their high biological inertness - they are practically in tissues.practically do not cause a response. Unlike catgut, the disintegration and resorption of vicryl and dexondoes not come from enzymatic reactions, but due to hydrolysis and phagocytosis. In this case, the exudative reaction and tissue swelling are practically absent.

The technique of myomectomy has its own characteristics depending on the location of the myomatous node.

As a rule, myomectomy is performed after the fetus and placenta are removed. Although sometimes, if there is a large node that prevents the extraction of the child, the capsule of the node is initially opened, then the node is removed, after which an incision is made in the uterus along the bed of the node and the child is removed, with further restoration of the integrity of the uterus.

If there are interstitial or interstitial-subserosal nodes located on the anterior wall of the uterus in the lower segment, which do not interfere with the extraction of the child, after the uterus has emptied, an incision is made along the upper or lower pole of the node and is peeled into a wound on the uterus. Next, sutures are placed on the incision on the uterus and the bed of the node.

For interstitial nodes that deform the uterine cavity, and nodes of submucosal-interstitial localization, myomectomy is performed from the side of the uterine cavity before suturing the incision on it. The node bed is restored with a continuous suture.

It is necessary to note some features of the technique for removing interstitial nodes.

A midline incision is most often used when a large myomatous node is localized in the fundus of the uterus, when the node is located cervico-isthmus along the posterior wall of the uterus, and when multiple uterine fibroids are present.

When large nodes are localized in the fundus of the uterus, a transverse incision poses a threat of damage to the interstitial part of the fallopian tubes, therefore, in these cases, midline (linear or oval) incisions are preferred.

Nodes of this localization, as they enlarge, in most cases deform the uterine cavity, that is, they have centripetal growth. In most patients, enucleation of the nodes can be performed without opening the uterine cavity, however, with a pronounced thinning of the muscle layer that makes up the bed of the myomatous node, spontaneous opening of the uterine cavity often occurs. In this case, it is better to apply a mucomuscular suture to the wall defect with inside uterus from an incision in the lower segment.

When enucleating subserous nodes on a thin base, in order to avoid creating excessive tension during subsequent peritonization and suturing of the node bed, the incision line does not pass at the very base of the tumor stalk, but 1–1.5 cm higher and has a circular direction in the form of an oval. Considering that a large arterial vessel feeding the tumor necessarily passes through the base of the node's pedicle, after separating the serous membrane from the lower pole of the node, a clamp is applied to the arterial vessel, and the node is cut off, followed by the application of submersible muscle-muscular sutures, and then ∞-shaped muscular-serous sutures are made final closure of the wound.

For subserous nodes on a wide base most of it protrudes from the walls of the uterus and becomes covered on the outside serosa and a thin muscle layer, which usually does not exceed 2–3 mm. To prevent the formation of a deep pocket after enucleation of nodes that are difficult to compare and excess tissue, oval rather than linear incisions are made.

Myomectomy of intraligamentary nodes and with their low localization is an operation of increased complexity. Such operations should be performed only by highly qualified surgeons, as serious complications are possible during the operation: damage to the bladder, intersection or ligation of the ureters, damage to the large vessels and the development of bleeding.

With intraligamentary localization of the node, depending on the direction of its growth anteriorly or posteriorly, the uterus is almost always displaced in the opposite direction, upward and partially posteriorly or anteriorly.

For intraligamentary nodes with predominant growth of the node anteriorly, a transverse incision is made the anterior layer of the broad uterine ligament at the top of the node below the round uterine ligament. In the presence of large intraligamentary myomatous nodes exceeding 10 cm in diameter, to ensure good access to the node, a transverse incision is made with the intersection of the round uterine ligament and its subsequent restoration, and in most cases, the vesicouterine fold is additionally partially opened, and the bladder is separated downwards. The node is fixed with bullet forceps and carefully isolated from the surrounding tissues, remembering that with this localization of the node, especially if it is low, an abnormal location of the ureter and vascular bundles is possible. As the node is enucleated, it is very important to adhere to the rule of step-by-step suturing of the node bed, since after removal of the node the bed immediately goes deeper and with constant diffuse bleeding and limited space, it can be difficult to suture thoroughly, and most importantly, the danger of suturing the ureter increases. After suturing the node bed, peritonization is performed using leaves of the broad uterine ligament to restore the integrity of the vesicouterine fold.

When the node grows more posteriorly, an incision is made in the posterior leaf of the broad uterine ligament below the proper ovarian ligament. In the case of a high location of the intraligamentary node, the incision is made between the round ligament of the uterus and the fallopian tube.

When myomatous nodes are located low on the posterior wall, the use of transverse incisions increases the risk of damage to the vascular bundles of the uterus and the development of bleeding.

With cervical-isthmus nodes located along the anterior wall, the uterus is usually displaced upward and posteriorly, the vesicouterine fold is spread out on the node, and the bladder is displaced upward. The myomatous node is located deep in the pelvis behind the womb.

After opening the vesicouterine fold, the bladder is separated downwards, the knot is fixed with bullet forceps and pulled up. Through an oval or linear incision (depending on the size of the node) in the transverse dimension, the node is enucleated with step-by-step suturing of the node bed. Given the rather thin muscle layer in this part of the uterus, the node bed is usually sutured with single-row ∞-shaped Vicryl or Dexon sutures. Peritonization is carried out through the peritoneal vesicouterine fold. With the cervical-isthmus location of the node along the posterior wall of the uterus, displacement of the uterosacral ligaments to the sides and upwards is observed. When enucleating a node, a midline incision is often made, since a transverse one increases the risk of injury to vascular bundles. The incision is made along the top of the node between the uterosacral ligaments. The knot is fixed with bullet forceps, pulled up and partially bluntly, partially sharply isolated from the surrounding tissues. After removal of the myomatous node, there is usually a deep bed left, which is difficult to stitch due to limited spatial relationships, so in some cases the bed is stitched from the peritoneum of the uterorectal cavity through all layers, which allows for reliable hemostasis.

With multiple uterine fibroids, in some cases, midline incisions are dictated by the need to select the most rational approach to myomatous nodes during their enucleation and reducing the number of incisions on the uterus, while transverse and median incisions are often made simultaneously. In case of multiple fibroids, it is necessary to remove large nodes, and it is better not to touch intramural nodes with a diameter of 4–5 cm, since in the postoperative period they decrease in size and in the future respond well to drug treatment.

According to the authors, the need to remove large fibroids increases the duration of the operation - from 45 to 160 minutes. However, in most patients it does not exceed 65–70 minutes, and only in some cases the operation lasts more than 125 minutes due to the gigantic size of the nodes located in the lower segment of the uterus during the removal of multiple uterine fibroids and placenta previa. The main concerns of surgeons when removing large fibroid nodes during cesarean section issignificant blood loss due to expansion of the scope of intervention. Reaction to blood loss due to fibroidsthe uterus may be more pronounced than without it. As is known, in the presence of uterine fibroids in a woman’s body, changes are observed that aggravate blood loss: a decrease in the albumin fraction, a decrease in the volume of circulating plasma, anemia, impaired liver function and decreased immunity. Therefore, the amount of blood loss during a cesarean section in patients with uterine fibroids, even without expanding the scope of the operation, can be significant. If blood loss during a cesarean section is from 500 to 1000 ml, then when the volume of the operation increases due to myomectomy, extirpation or amputation of the uterus, the blood loss on average increases to 1300 ml.

When individually analyzing the relationship between the volume of blood loss, topography, localization, size of the nodes and the presence of concomitant complications of pregnancy, it was found that blood loss of 400–700 ml occurred with nodes located mainly in the body and fundus of the uterus, and blood loss of 1000–1200 ml - with nodes in the lower segment of the uterus and with a combination of uterine fibroids.

Despite the many factors influencing the volume of intraoperative blood loss, it should be noted that the reasons greatest blood loss are following conditions: location of the node in the lower segment of the uterus, large (giant) size of the nodes, multiple fibroids and placenta previa.

To reduce blood loss during cesarean section and myomectomy, it is necessary to use an electric knife and an electrocoagulator. Prevention of bleeding is carried out immediately after extraction of the fetus. 1 ml of 0.02% methylergometrine solution is injected into the uterine muscle and intravenous administration of 1 ml (5 units) of oxytocin diluted in 500 ml of isotonic sodium chloride solution is started. Considering that disruption of the integrity of the uterus after myomectomy can cause postoperative bleeding, intravenous administration of oxytocin is continued for 2 hours in the early postoperative period.

In case of significant blood loss, it is necessary to use a device for intraoperative reinfusion of autologous blood “Cell saver 5+ Haemonetics”, which simultaneously facilitates accurate calculation of blood loss. Other options for preventing intraoperative blood loss are also possible, depending on the scale of the surgical intervention: temporary ligation of internal iliac arteries, temporary clamping of the uterine arteries.

After surgery, patients were observed in the department intensive care within 24 hours, then they were transferred to the postpartum wards.

Maintaining postoperative period does not differ from that in patients after standard cesarean section. Adequate pain relief and administration of uterotonic drugs are carried out within 2–3 days. It is advisable to carry out preventive antibacterial therapy Due to the high volume of the transaction completed within 5-7 days. The postpartum period generally proceeds without complications; sometimes there is subinvolution of the uterus, requiring additional contraction therapy. In some parturient women, postoperative anemia requires intravenous administration iron preparations.

Thus, correctly selected indications, tactics and technique of surgical intervention, anesthesia, use effective methods prevention of intraoperative blood loss and modern suture material, antibiotic prophylaxis and antibiotic therapy allow us to expand the indications for myomectomy during cesarean section.

WITHpijuice of used literature

1. Vikhlyaeva E.M., Vasilevskaya L.I. Uterine fibroids. M.: Medicine, 1981.
2. Kulakov V.I., Adamyan L.V., Askolskaya S.I. Hysterectomy and women's health. M.: Medicine, 1999.
3. Vikhlyaeva E.M. Guide to the diagnosis and treatment of uterine fibroids. M.: MEDpress-inform, 2004.
4. Botvin M.A. Modern aspects reconstructive plastic surgery in patients with uterine fibroids productive age: issues of pathogenesis, surgical techniques, rehabilitation system, immediate andlasting results. Author's abstract. dis. ...Dr. med. Sci. M., 1999.
5. Kulakov V.I., Shmakov G.S. Myomectomy and pregnancy. M.: MEDpress-inform, 2001.
6. Cooper NP, Okolo S. Fibroids in pregnancy – common but poorly understood. Obstet Gynecol Surv 2005; 60: 132–8.
7. Kozinszky Z, Orvos H, Zoboki T et al. Risk factors for cesarean section of primiparous women aged over 35 years. Acta Obstet Gynecol Scand 2002; 81:313–6.
8. Sleptsova N.I. The influence of the volume of surgical intervention for uterine fibroids on the hemodynamic parameters of the internal genitalia and the quality of life of a woman. Author's abstract. dis. ...cand. honey. Sci. M., 1999.
9. Shmakov G.S. Myomectomy during pregnancy. Author's abstract. dis. ...Dr. med. Sci. M., 1997.
10. Kurtser M.A., Lukashina M.V., Tishchenko E.P. Conservative myomectomy during cesarean section. Issues of gynecology, obstetrics and perinatology: scientific and practical journal of the Russian Association of Perinatal Medicine Specialists. 2008; 3:82–7.
11. Landekhovsky Yu.D. Clinicopathological rationale for the management of patients with uterine fibroids. Auto-ref. dis. ...Dr. med. Sci. M., 1988.
12. Chernukha E.A. Caesarean section - present and future. Obstetrics and gynecol. 1997; 5:22–8.
13. Jabiry-Zieniewicz Z Gajewska M. The pregnancy and delivery course with pregnant women with uterine myomas. Ginecol Pol 2002; 7:271–5.
14. Kaymak O, Ustunyurt E, Okyay RE et al. Myomectomy during cesarean section. Int J Gynaecol Obstet 2005; 89:
90–3.
15. Sidorova I.S. Uterine fibroids and pregnancy. M.: Medicine, 1985; With. 116–8.
16. Sidorova I.S. Uterine fibroids. M.: MIA, 2003.
17. Cobellis L, Pecori E, Cobellis G. Hemostatic technique for myomectomy during cesarean section. Int J Gynaecol
Obstet 2002; 79:261–2.
18. Ehigiegba AE, Ande AB, Ojobo SI. Myomectomy during cesarean section. Int J Gynaecol Obstet 2001; 75:21–5.
19. Lethaby A, Vollenhoven B. Fibroids (uterine myomatosis, leiomyomas). Clin Evid 2004; 2406–26.
20. Sheiner E, Bashiri A, Levy A et al. Obstetric characteristics and perinatal outcome of pregnancies with uterine leiomyomas. J Reprod Med 2004; 49: 182–6.

Childbirth with uterine fibroids poses a threat to the life of the expectant mother and her unborn child. Therefore, doctors carefully study everything possible indications. The decision that a cesarean section will be performed for uterine fibroids is made collectively or individually by a gynecologist, depending on the current circumstances. In most cases, fibroids and cesarean sections are inextricably linked, since a woman with a tumor gives birth naturally can not. Natural childbirth with fibroids is allowed only if complete absence any contraindications. You can read about how decisions are made and what parameters of the health of the mother and unborn child doctors pay attention to on this page. It describes all the indications for the use of cesarean section for fibroids as the main or only way to prevent a woman from becoming pregnant.

Is natural childbirth possible with large fibroids?

Pregnant women with uterine fibroids should be hospitalized at 37-38 weeks for examination, preparation for childbirth and choice rational method delivery. But is it possible to have safe natural childbirth with fibroids, we will consider further in the article.

Due to the fact that the presence of myomatous nodes on the posterior wall of the uterus and their centripetal growth may not be recognized in a timely manner, surgical delivery is not excluded in every patient with this pathology.

Features of the management of childbirth with large fibroids through the natural birth canal in patients with uterine fibroids who are at low risk are the following:

1. The use of antispasmodic drugs during active phase first stage of labor (opening of the uterine pharynx by 5-8 cm).
2. Limit the use of labor stimulation with oxytocin. If necessary, reinforcement labor activity It is advisable to prescribe prostaglandin preparations that have optimal action on the myomatous uterus, do not disrupt the microcirculation of the myometrium and the hemostatic system.
3. Prophylaxis of fetal hypoxia during childbirth.
4. Prevention of bleeding during labor and the early postpartum period with the help of a strongly contracting agent for the uterus. It is administered simultaneously intravenously immediately after the birth of the fetal head.

Indications for caesarean section for uterine fibroids

Caesarean section for uterine fibroids to prevent pregnancy is used in most cases with a preliminary diagnosis of the tumor. Indications for cesarean section for fibroids in a planned manner are:

• Low-lying myomatous nodes (cervix, isthmus, lower segment of the uterus), which can be an obstacle to the dilation of the cervix and the advancement of the fetal head.
• The presence of multiple intermuscular nodes or large fibroids (diameter 10 cm or more).
• A scar on the uterus after myomectomy, the consistency of which is difficult to assess. This is due to the fact that, firstly, a whole conglomerate of nodes is often removed, and secondly, diathermocoagulation is used for hemostasis. This is especially true for myomectomy using laparoscopic access. All these features are rarely reflected in discharge summary after myomectomy.
• Malnutrition leading to secondary changes in tumor nodes, which after vaginal delivery can undergo necrotic changes. In this case, necrotic inflammatory and dystrophic changes spread to unchanged areas of the uterus (metritis).
• Breech presentation of the fetus, which may be a consequence of a myomatous node with centripetal growth.
• Suspicion of malignancy or necrosis of fibroids (rapid growth, large size, soft consistency, local pain, anemia).
• The combination of uterine fibroids with other diseases and complications of pregnancy that worsen the prognosis for the mother and fetus (ovarian tumor, endometriosis, late age women, data indicating a proliferating variant of the fibroid morphotype, placental insufficiency).
• Multiple uterine fibroids with different locations of myomatous nodes in women of late reproductive age (39-40 years or more).
• Necrosis of the interstitial (intermuscular) node.
• Relapse (further growth of myomatous nodes) after a previously performed myomectomy (most often this is a variant of the active growth of this muscular fibrous tumor).
• The location of myomatous nodes in the area of ​​vascular bundles, the lower segment of the uterus, interligamentous localization, centripetal growth and submucosal nodes.

These are the main indications for cesarean section for fibroids and the need for a planned abortion of a woman from a full-term pregnancy. In case of low location of fibroids emanating from the lower segment, isthmus, cervix, in case of malignancy (established by urgent histological examination), hysterectomy is necessary.

In the postpartum period, patients with uterine fibroids should be prescribed antispasmodic drugs. If there are signs of decreased contractility of the uterus, uterine contracting agents are injected into the muscle.

After myomectomy and complicated cesarean section, broad-spectrum antibiotics are used. Combinations of drugs that have an effect on aerobic and anaerobic microorganisms are used.

This article has been read 4,484 times.

07 February 2018 6549 0

Uterine fibroids are a reaction of the female body to damage. Menstruation is such a damaging factor. Myoma rudiments form in the muscular layer of the uterus, from which myomatous nodes subsequently grow. A woman’s first reaction after being diagnosed with uterine fibroids is confusion and fear.

Please note that this text was prepared without the support of our website.

Don't be discouraged when you find out you have fibroids. Call us

Currently, the issue of tactics for managing pregnancy and childbirth in patients with uterine fibroids remains relevant. Myoma is diagnosed in 20% of women over 30 years of age. The number of primigravidas increases after 30 years, fibroids develop at a young age, and the boundaries of childbearing age expand

Most gynecologists perform supravaginal amputation or hysterectomy after cesarean section in women suffering from fibroids. The only exceptions are nodes located on the stalk and small fibroids along the uterine incision line. In these cases, myomectomy is performed. The young age of many women in labor requires a careful approach to this group of patients and preservation of the uterus. Doctors at the clinics with which we cooperate perform uterine artery embolization at the pregnancy planning stage. After the procedure, the nodes disappear, the structure of the uterus is restored. Patients whose pregnancy occurs after recovery are allowed to give birth naturally.

Preoperative preparation for delivery

Pregnant women with uterine fibroids at 36-37 weeks of gestation are routinely hospitalized for examination, determination of labor management tactics and preparation for cesarean section. Patients undergo an ultrasound examination, during which the size, number, location of myomatous nodes and their relationship to the vascular bundles of the uterus are determined. Doctors determine indications for cesarean section and surgical removal of fibroids.

Myoma nodes that are removed during cesarean section with a size of 10 to 14 cm are considered large, and fibroids with a diameter of 15 cm or more are considered gigantic. In the pregnant uterus during surgery, interstitial, subserous and subserous-interstitial nodes, as well as their localization along the posterior anterior and posterior wall of the uterus, are found with equal frequency. Sometimes myomatous formations are located in the lower segment of the uterus, preventing natural childbirth.

During pregnancy, 47.4% of women do not experience pronounced dynamics in the growth of nodes; in 42.1%, there is a moderate increase in fibroid formations. Only in 10.5% of patients with their first pregnancy, fibroids grow quickly. Necrotic changes are observed in myomatous formations, often accompanied by leukocyte infiltration or hyalinosis and calcification. In other cases, fibroids are combined with hemorrhages, edema and foci of leukocyte infiltration. Necrotic changes are detected in giant nodes.

Functional examinations before surgery include assessment of the intrauterine state of the fetus: cardiotocography, Doppler measurements of the vessels of the uterus, umbilical cord and fetal aorta. A study of the microflora of the vagina and cervical canal is carried out, since when the uterine cavity is opened during a cesarean section, the infection can enter the abdominal cavity, which leads to complications in the postoperative period.

When deciding on the method of delivery for patients with uterine fibroids, doctors take into account:

• woman's age;
• obstetric history;
• the nature and location of the fibroid node;
• the course of this pregnancy;
• condition of the fetus.

The presence of uterine fibroids in pregnant women is rarely the only indication for cesarean section.

Indications for caesarean section for uterine fibroids

For women who become pregnant due to uterine fibroids, a cesarean section is performed if the following indications exist:

• large fibroids, the location of which prevents the passage of the fetus through the birth canal;
• the presence of fibroids of large submucosal fibroids;
• degeneration of myoma nodes detected before birth;
• torsion of the base of a subserous myomatous formation with the development of inflammation of the peritoneum;
• uterine fibroids, accompanied by dysfunction of adjacent organs;
• The patient's age is more than 35 years.
• suspicion of malignant degeneration of the fibroid node;
• myomatous formations in women with a scar on the uterus due to a previous cesarean section, uterine perforation, myomectomy;
• the presence of additional unfavorable factors: severe somatic diseases, gestosis, partial placenta previa, large fetus.

Relative indications for cesarean section for uterine fibroids are:

• multiple fibroids in “elderly” pregnant women;
• uterine fibroids and placental insufficiency (fetal hypotrophy and hypoxia);
• fibroids and long-term reproductive function(induced pregnancy, unfavorable outcomes of previous pregnancies, long-term infertility);

Caesarean section is performed in the presence of anomalies in the development of the female internal reproductive organs.

Indications and contraindications for myomectomy

Myomectomy during cesarean section is performed in the presence of subserous nodes on a thin base in any accessible place of the uterus, subserous nodes on a wide base (with the exception of formations located on vascular bundles and in the lower segment of the uterus). The operation is performed in the presence of no more than 5 large nodes whose size is more than 10 cm. During a cesarean section, 1 myoma node with a diameter of no more than 10 cm, located intramurally or with centripetal growth, can be removed. Myomatous formations of different localization are subject to surgical removal with good access to them, with the exception of intramural nodes less than 5 cm in size.

Myomectomy during cesarean section is not performed in the presence of one or more nodes up to 2 cm in size, especially in the presence of concomitant extragenital pathology. Myoma formations are not removed in case of premature placental abruption, leading to acute blood loss, acute bleeding during cesarean section, severe anemia of any origin on the eve of surgery.

Removal of fibroids during cesarean section

Myomectomy during cesarean section is performed under general anesthesia or epidural anesthesia. The surgeon cuts the abdominal wall and examines the uterus. If the fibroid node is small, the doctor first removes the fetus and placenta, and then restores the integrity of the uterus. If the operating gynecologist is convinced that fibroids big size, first of all removes fibroids.

During the operation, special attention is paid to dressing blood vessels. For speedy recovery The abdominal cavity is drained. The patient is prescribed antibacterial, painkillers and detoxification drugs. During the first 24 hours, the patient is in the postpartum ward under the supervision of medical personnel.

A sterile bandage is applied to the suture area. Medical staff monitors the cleanliness of the wound and the skin around it. During dressing, the skin is treated with antiseptic solutions.

Myomectomy during cesarean section lengthens the rehabilitation period. After the operation, the patient needs dietary nutrition. If she has constipation, she is given a cleansing enema. In order for the uterus to quickly restore its tone, the patient is recommended to breastfeed the baby.

Possible complications of childbirth with fibroids

The presence of a fibroid node can complicate the course of labor. Volume formations are located in the myometrium and cause a decrease in uterine contractility during labor. With fibroids, the structure of the uterus is disrupted, which increases the risk of postpartum hemorrhage. If the node is located in the cervix, it prevents the passage of the fetus through birth canal. If there is a large fetus in the initial stage of labor, premature placental abruption may develop.

In this case, the optimal option for delivery with fibroids is a cesarean section. The combination of two operations increases the risk of complications in the postoperative period. If fibroid nodes do not interfere with labor, gynecologists prefer to treat fibroids after restoring the functions of the mother’s body.

The organ-preserving surgical method for treating fibroids is conservative myomectomy - removal of fibroid nodes. Surgeons prefer to perform surgery at the stage of pregnancy planning. After surgery, scars form on the uterus. They can cause complications during pregnancy and childbirth. In this regard, women after myomectomy are often delivered by cesarean section.

Our experts are of the opinion that treatment of fibroids should be carried out before conception. Endovascular surgeons perform on patients with fibroids safe procedure– embolization of the uterine artery. After it, the fibroid is replaced connective tissue. No scars form on the uterus, pregnancy proceeds without complications. Women after embolization do not need a caesarean section; they can give birth to a child on their own.

Uterine artery embolization

Gynecologists at our clinics use an innovative method of treating fibroids – uterine artery embolization. The procedure has the following advantages:

• Performed under local anesthesia;
• Does not require long-term rehabilitation;
• Minimum amount of blood loss;
• No risk of complications.

After embolization, the structure of the uterus is restored. Myoma formations decrease in size and eventually disappear altogether. The uterine cavity takes on a normal shape. In women it is restored reproductive function. Pregnancy proceeds without complications. Due to the fact that there are no obstacles to the passage of the fetus through the birth canal, the risk of complications during childbirth is minimized. Our gynecologists do not perform cesarean sections after uterine artery embolization, since women give birth without complications.

Bibliography

• Aksenova T. A. Features of the course of pregnancy, childbirth and the postpartum period with uterine fibroids / T. A. Aksenova // Current issues in the pathology of pregnancy. - M., 1978.- S. 96104.
• Babunashvili E. L. Reproductive prognosis for uterine fibroids: dis. Ph.D. honey. Sciences / E. L. Babunashvili. - M., 2004. - 131 p.
• Bogolyubova I. M. Inflammatory complications of the postpartum period in women with uterine fibroids / I. M. Bogolyubova, T. I. Timofeeva // Scientific. tr. Center. Institute for advanced training of doctors. -1983. -T.260. - pp. 34-38.

IN Lately Cases of diagnosis of uterine fibroids during pregnancy have become more frequent. This is often associated with an increase in the average age of women in labor, because fibroids appear just after the age of thirty. In addition, the level of diagnostics has increased significantly these days.

The reasons for the development of fibroids, according to experts, are very diverse. These include disgusting ecology, various inflammatory diseases sexual sphere, problems endocrine system and much more. Myoma itself is relatively safe, but during pregnancy it can cause some trouble.

Difficulties associated with fibroids during pregnancy

First of all, regardless of the period, there is a threat of miscarriage. In addition, the presence of myomatous nodes is dangerous due to difficult and protracted labor. Therefore, from the moment this neoplasm is detected, the pregnant woman should be under the supervision of doctors, and, most likely, she will have to give birth by cesarean section. And here many people ask the question: is it possible to remove uterine fibroids during a cesarean section?

It should be noted that doctors have a very negative attitude towards this possibility, for several reasons:

• It is not without reason that surgeons believe that removal of fibroids by caesarean section is fraught with significant blood loss.
• In addition, fibroids cause a completely different reaction from the body to blood loss than in the absence of it.
• The mere presence of fibroids already provokes heavy bleeding during surgery. Therefore, any increase in its volume is dangerous for both the woman in labor and her baby.
• Removal of fibroids during cesarean section will almost certainly result in the formation of adhesions. In turn, they can provoke obstruction of the tubes, that is, infertility.

In addition, even if the nodes are removed, there is a high probability that a recurrence of the disease will occur in the future, and, therefore, within 1-2 years, the issue of treating fibroids will still have to be resolved again. Of course, if the fibroid nodes are in the path of the cesarean section incision, then the surgeon will certainly remove them. Otherwise, most likely, he will not do this. Doctors instead recommend uterine artery embolization some time after birth. This is a much more gentle procedure that allows you to get rid of fibroids and makes it possible to get pregnant and give birth in the future without problems.