Uterine Rupture after Laparoscopic Myomectomy

doi:10.1016/S1074-3804(05)60020-5

The Journal of the American Association of Gynecologic Laparoscopists

Volume 11, Issue 1, February 2004, Pages 92-93

The Journal of the A...

https://doi.org/10.1016/S1074-3804(05)60020-5 Get rights and content

Abstract

Myomectomy is performed frequently to preserve or increase fertility, although the risk of future uterine rupture is a major concern of any surgery of the uterus. A 36-year-old woman underwent laparoscopic removal of a pendunculated myoma, and 6 weeks later she conceived after IVF. At 35.5 weeks' gestation she was admitted to the hospital because of abdominal pain. Cesarean section revealed rupture of the uterine wall at the site of the myoma. This and similar case reports indicate that inadequate laparoscopic suturing is not the only factor involved in rupture of the uterine wall during pregnancy after laparoscopic myomectomy.

Section snippets

Case Report

A 36-year-old woman had a 5-year history of infertility and one early miscarriage. Transvaginal ultrasound revealed a 4-cm pedunculated myoma on the posterior wall of the uterus; hysteroscopy showed normal anatomy. Laparoscopy confirmed the findings of transvaginal ultrasound. The lesion was only 1 to 2 cm from tubal junctions, pedunculated, with a 2- to 3-cm pedicle. Numerous implants of endometriosis were present in the pouch of Douglas and on both ovaries. Myomectomy was performed, with

Discussion

Several issues might be discussed with regard to this report, such as complications of uterine rupture during subsequent pregnancies, differences between laparoscopy and laparotomy, and whether the time between myomectomy and infertility treatment is important. We can only raise the issues, not provide answers.

The risk of uterine rupture after traditional abdominal and laparoscopic myomectomies is low. The only random ized study to our knowledge comparing fertility and obstetric outcome between

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Cited by (58)

Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review
2021, Reproductive BioMedicine Online
Citation Excerpt :
The 43 studies were from 15 different countries; 29 (67.4%) were retrospective studies (Bernardi et al., 2014; Borja de Mozota et al., 2014; Connolly et al., 2000; Dessolle et al., 2001; Fauconnier et al., 2000; Fukuda et al., 2013; Huberlant et al., 2020a; Kang et al., 2020; Kelly et al., 2008; Koo et al., 2015; Kumakiri et al., 2005, 2008; Lebovitz et al., 2019; Malzoni et al., 2010; Morita and Asakawa, 2006; Paul et al., 2006; Pepin et al., 2020; Pitter et al., 2015, 2013; Pundir et al., 2015; Rovio and Heinonen, 2012; Seinera et al., 2000; Seracchioli et al., 2006; Soriano et al., 2003; Tian et al., 2015; Tsuji et al., 2016; Tusheva et al., 2013; Yoshino et al., 2012; Zhang and Hua, 2014), nine (20.9%) were prospective or cohort studies (Cela et al., 2013; Chang et al., 2009; Chen et al., 2017; Lönnerfors and Persson, 2009, 2011; Nishida et al., 2014; Plotti et al., 2008; Tinelli et al., 2012; Wu et al., 2020), and five (11.6%) were prospective randomized studies (Kameda et al., 2018; Kim et al., 2016; Kubinova et al., 2012; Mara et al., 2008; Samejima et al., 2015). In addition, 37 articles presented summaries or case reports of uterine rupture during pregnancy after myomectomy (n = 37) (Abbas et al., 2018; Asakura et al., 2004; Banas et al., 2005; Cho, 2018; Foucher et al., 2000; Fukutani et al., 2017; Goynumer et al., 2009; Grande et al., 2005; Hagneré et al., 2011; Hasbargen et al., 2002; Hawkins et al., 2018; Hortu et al., 2015; Iemura et al., 2015; Jakiel et al., 2002; Kacperczyk et al., 2016; Kim et al., 2016; Kiseli et al., 2013; Kuwata et al., 2011; Lieng et al., 2004; Mahajan et al., 2019; Matsunaga et al., 2004; Nkemayim et al., 2000; Okada et al., 2016; Oktem et al., 2001; Pakniat et al., 2016; Parker et al., 2007; Pistofidis et al., 2012; Skrablin et al., 2005; Song et al., 2015; Sutton et al., 2016; Tauchi et al., 2016; Tomczyk et al., 2018; Torbé et al., 2012; Vimercati et al., 2017; Wachira et al., 2019; Wu et al., 2018; Yazawa et al., 2018). Altogether, the selected articles represented 7335 myomectomies performed for various conditions: infertility, heavy menstrual bleeding, pelvic discomfort.
The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.
Mesenchymal stem cells and their conditioned medium can enhance the repair of uterine defects in a rat model
2018, Journal of the Chinese Medical Association
Citation Excerpt :
Extensive uterine surgery, such as removal of huge uterine myomas or adenomyomas, can occasionally result in uterine rupture during subsequent pregnancy, particularly when the surgery is performed laparoscopically.1–8
Our aim was to examine the roles of mesenchymal stem cell (MSC) transplantation in the repair of large uterine defects.
Uterine defects were created in both uterine horns of female rats by a punch instrument, and bone marrow-derived MSCs, MSC-conditioned medium (MSC-CM) or vehicle were injected into the myometrium around the defect. The rate of uterine defect repair was monitored on day 2 and 4 after operation. Cytokine array of MSC-CM was performed, followed by neutralizing antibody experiments to clarify the exact cytokine participating in the MSC-CM-enhanced wound repair.
Transplantation of MSCs, but not myometrial cells, significantly enhanced uterine defect repair. The transplanted MSCs were detected in the uterine horn with no signs of rejection on day 4 after transplantation, when the MSC-transplanted uterine wound was nearly healed. Moreover, uterine defect repair was also accelerated by injection of MSC-CM, indicating the paracrine effects of MSCs on uterine wound healing. Cytokine array analysis further revealed that MSC-CM contained abundant cytokines and chemokines, among which high levels of interleukin-6 (IL-6) were found. Additionally, antibodies against IL-6 were shown to block MSC-CM-enhanced uterine defect repair.
This study demonstrated that transplantation of MSCs could enhance uterine defect repair by paracrine effects involving IL-6, which are findings that may be applied to facilitate uterine wound healing in the removal of huge intramural masses.
Pregnancy Outcomes and Risk Factors for Uterine Rupture After Laparoscopic Myomectomy: A Single-Center Experience and Literature Review
2015, Journal of Minimally Invasive Gynecology
Citation Excerpt :
Because of massive hemorrhage, a total hysterectomy was performed, which resulted in fetal death. The 21 articles [10–30] published on uterine rupture after LSM describe a total of 34 events. The results of reviewing cases of uterine rupture from the published reports in the present study are shown in Table 4.
To evaluate pregnancy outcomes after laparoscopic myomectomy (LSM), focusing on the risk of uterine rupture.
Retrospective cohort study (Canadian Task Force classification III).
University hospital.
Of 676 women who visited the obstetrics department for a pregnancy after undergoing LSM performed at the same center between 1994 and 2012, we included the 523 women who had follow-up through the end of pregnancy.
All patients underwent LSM, and their medical charts were retrospectively reviewed.
Multiple myomas were removed in 35.2% of cases, intramural-type lesions occurred in 46.5% of cases, and the mean myoma diameter was 4.9 cm. Pregnancy outcomes after LSM included 400 (76.5%) full-term deliveries and 100 (19.1%) vaginal deliveries, with other adverse outcomes being no different than the general population. The mean interval between LSM and pregnancy was 14 months, and only 3 (0.6%) cases of uterine rupture occurred during pregnancy. In analysis, by reviewing the published cases of uterine rupture, we found that the mean diameter, myoma number and type, and the rate of uterine suture were similar between the ruptured cases and all of our cases of LSM.
LSM can be safely used in women of reproductive age who want to become pregnant. Uterine rupture occurs in rare cases, regardless of myoma features, but further large-scale studies are required to ascertain the detailed effects of various surgical techniques.
Perspectives of Obstetricians on Labour and Delivery After Abdominal or Laparoscopic Myomectomy
2014, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
Despite the dogma that uterine rupture is more likely after a myomectomy with entry into the uterine cavity, there has been no definitive study proving this.3,15 Evidence of uterine rupture after myomectomy is scarce and consists mostly of case reports, with uterine rupture occurring mostly before labour between the gestational ages of 28 weeks and 36 weeks.13,16–20 Uterine rupture can also occur after uterine surgery such as dilatation and curettage and laparoscopy for endometriosis, and these are not otherwise an indication for CS.21
Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy.
We conducted a survey of 49 practising obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy.
Overall, the inter-respondent agreement was fair (kappa 0.3; P< 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour. There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins.
Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach.
En raison de préoccupations au sujet de la rupture utérine, de nombreux obstétriciens recommandent la tenue d’une césarienne planifiée pour ce qui est des femmes ayant déjà subi une myomectomie. Cette pratique a mené à la hausse du taux de césarienne planifiée et, subséquemment, à celle du taux de césarienne itérative. Cette étude avait pour objectif d’évaluer les points de vue des obstétriciens en ce qui concerne le travail et l’accouchement à la suite d’une myomectomie abdominale ou laparoscopique.
Nous avons mené un sondage auprès de 49 obstétriciens praticiens, entre juillet 2012 et janvier 2013, au moyen d’un questionnaire standard. Ce dernier comptait des questions sur le travail et l’accouchement à la suite d’une myomectomie menée par laparotomie ou par laparoscopie.
De façon globale, le consensus inter-répondants était assez bon (kappa 0,3; P < 0,001). Aucune différence significative n’a été constatée en ce qui concerne la probabilité que les répondants permettent la tenue d’un accouchement vaginal à la suite d’une myomectomie menée par laparotomie ou par laparoscopie (27 % et 14 %, si la cavité utérine avait été pénétrée, et 76 % et 71 %, si la cavité utérine n’avait pas été pénétrée, respectivement). Cependant, la probabilité que les répondants permettent la tenue d’un accouchement vaginal était considérablement atténuée lorsque la cavité utérine avait été pénétrée, peu importe l’approche chirurgicale utilisée (P < 0,001). La probabilité que les obstétriciens recommandent la tenue d’une césarienne planifiée, plutôt que celle d’un déclenchement du travail, connaissait également une hausse significative lorsque la cavité utérine avait été pénétrée au cours de la myomectomie. Aucune différence significative n’a été constatée au niveau de la pratique en ce qui concerne l’utilisation d’oxytocine conjointement avec une amniotomie, d’oxytocine en perfusion ou de prostaglandines.
Malgré le manque de données sur le sujet, les obstétriciens considèrent que la pénétration de la cavité utérine pendant la myomectomie (et ce, peu importe l’approche chirurgicale utilisée dans le cadre de cette dernière) constitue un facteur important au moment de prendre des décisions quant au mode d’accouchement, à l’utilisation d’oxytocine et au recours à une césarienne planifiée.
Current role of conservative surgery
2013, Medicina Clinica
No es sencillo establecer el verdadero impacto de los miomas sobre la fertilidad. La miomectomía en pacientes estériles con miomas subserosos no ofrece mejores resultados respecto a pacientes con miomas in situ. Las mujeres con miomas intramurales parecen presentar un descenso en su fertilidad y un aumento de la tasa de aborto, comparadas con mujeres sin miomas. Sin embargo, la miomectomía no siempre revierte este efecto (no aumenta la tasa de embarazo clínica ni de niño vivo en casa), pero la calidad de los estudios aún es pobre. Los miomas con componente submucoso disminuyen significativamente la tasa de implantación y embarazo respecto de controles estériles. Su exéresis claramente mejora los resultados de fertilidad. Son necesarios estudios de mayor calidad, dirigidos a valorar el peso del mioma intramural, con especial atención a factores como el tamaño, el número y la proximidad al endometrio.
La mayor parte de los casos se va a poder abordar por vía endoscópica. Para ello son necesarios equipos debidamente entrenados, que monitoricen sus resultados y sean capaces de ofrecer las mismas garantías que la vía laparotómica, tanto en la técnica quirúrgica como en el porvenir obstétrico de las pacientes. La miomectomía laparoscópica ofrece resultados comparables a la laparotómica. Además minimiza la formación de adherencias, la pérdida sanguínea, la estancia hospitalaria y el tiempo de reincorporación laboral. En pacientes estériles, la miomectomía laparoscópica puede ser la primera elección terapéutica.
It is not easy to establish the true impact of fibroids on fertility. Fibroidectomy in sterile patients with subserosal fibroids does not offer the best results for patients with in situ fibroids. Women with intramural fibroids appear to present reduced fertility and increased miscarriage rates, compared with women without fibroids. However, fibroidectomy does not always reverse this effect (does not increase the clinical pregnancy or “take-home baby” rates), but the quality of the studies is still poor. Fibroids with a submucosal component significantly decrease implantation and pregnancy rates with regard to sterile controls. Fibroid exeresis clearly improves fertility results. There is a need for better quality studies aimed at assessing the impact of intramural fibroids, with a special focus on factors such as size, number and proximity to the endometrium.
The majority of cases can be treated endoscopically. This procedure needs properly trained teams who monitor their results and who are able to offer the same guarantees that laparotomy affords, both in terms of the surgical technique and the patients’ obstetric future. Laparoscopic fibroidectomy offers results comparable to laparotomy and minimizes the formation of adhesions, blood loss, hospital stay and the time to return to work.
For sterile patients, laparoscopic fibroidectomy may be the first choice therapy.
Spontaneous uterine rupture after myomectomy. Case report and review of the literature
2011, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
La rupture utérine après myomectomie est rare mais grave. Elle peut survenir avant tout travail et met en jeu le pronostic vital maternel et fœtal. À partir d’un cas personnel de rupture utérine survenant à 25 SA chez une primipare de 38 ans aux antécédents de myomectomie, nous présentons une revue de la littérature du devenir obstétrical après myomectomie.
Uterine rupture after myomectomy is rare but serious. It can occur before onset of labor and compromise vital maternofoetal outcome. We report the case of a uterine rupture at 25-week gestation in a 38-year-old primiparous woman after myomectomy and we will present a review of the literature concerning obstetric outcome after myomectomy.

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Case ReportsUterine Rupture after Laparoscopic Myomectomy

Abstract

Section snippets

Case Report

Discussion

Eur J Obstet Gynecol

Myomectomy for fertility enhancement and preservation

Fertil Steril

Effect of uterine leiomyomata on the results of in-vitro fertilization treatment

Hum Reprod

Case Reports
Uterine Rupture after Laparoscopic Myomectomy