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1.  Laparotomic Myomectomy in the 16th Week of Pregnancy: A Case Report 
Myomectomy is rarely performed during an ongoing pregnancy because of fear of miscarriage and the risk of an uncontrolled haemorrhage necessitating a hysterectomy. In cases where myomectomy is undertaken, most are performed at the time of cesarean section or with a laparoscopic approach. We report a case of a successful laparotomic myomectomy in the 16th week of pregnancy. A 35-year-old primigravida was admitted to our department with acute abdominal pain and hydronephrosis (serum creatinine 1.6 mg/dL). Imaging revealed a large implant myoma compressing the bladder, ureters, rectus, and gestational chamber and causing hydronephrosis. Laparotomic myomectomy was successfully performed and pregnancy continued uneventfully until the 38th week when a cesarean section was performed. Surgical management of myomas during pregnancy is worth evaluating in well-selected and highly symptomatic cases.
PMCID: PMC3970342  PMID: 24716028
2.  A Case Report on A Myomectomy which was Done During A Caesarean Section 
Uterine myomas are being observed in pregnancy more frequently now than in the past, because many women are delaying child bearing till their late thirties, which is the time for the greatest risk of the myoma growth. Traditionally, obstetricians are trained to avoid myomectomies during caesarean sections as severe haemorrhages can occur, which may often necessitate hysterectomies. Pedunculated fibroids which can be easily removed are an exception. Here, we are reporting one case of a myomectomy which was done during a caesarean section.
PMCID: PMC3644458  PMID: 23730660
Leiomyoma; Myomectomy; Pregnancy
3.  Caesarean Myomectomy 
Caesarean myomectomy has traditionally been discouraged due to fears of intractable haemorrhage and increased postoperative morbidity. However, a number of authors have recently shown that myomectomy during Caesarean section does not increase the risk of haemorrhage or postoperative morbidity.
We present a series of 8 cases from Sultan Qaboos University Hospital, Oman, where myomectomy was performed during Caesarean section for large lower segment fibroids. Seven were anterior lower segment fibroids, while one was a posterior lower uterine fibroid which interfered with closure of the uterine incision. The antenatal course, perioperative management, and postoperative morbidity are discussed.
The average age of the women was 28.7 years and mean gestational age at delivery was 36.75 weeks. Regarding intra-operative blood loss, 1 patient lost 900 ml, 5 patients lost 1–1.5 litres, 2 lost 1.5–2 L, and 1 patient with a 10 x 12 cm fibroid lost 3.2 L. Despite the majority being large myomas (7 of the 8 patients had myomas >5 cm in size) and 50% being intramural, no hysterectomy was required. Stepwise devascularisation was necessary in one case and preoperative placement of uterine balloon catheters was necessary in another. The size of the fibroids was confirmed by histopathology. Myomectomy added 15 minutes to the operating time and 1 day to the hospital stay, but there was no significant postoperative morbidity. Neonatal outcome was good in all patients.
In selected patients, myomectomy during Caesarean section is a safe and effective procedure at tertiary centres with experienced surgeons.
PMCID: PMC3327566  PMID: 22548138
Caesarean section; Myomectomy; Fibroids; Pregnancy; Haemorrhage; Oman
4.  Successful myomectomy during pregnancy : A case report 
The medical literature has reported an increase in myomectomy during caesarean section in the past decade. However, myomectomy performed during pregnancy remains a rarity. The management of uterine fibroids during pregnancy is usually expectant and surgical removal is generally delayed until after delivery. We present a case of a large, symptomatic uterine fibroid diagnosed during pregnancy which was successfully managed by antepartum myomectomy.
Case presentation
A 30 year old woman presented with a one year history of abdominal swelling, amenorrhea and severe epigastric discomfort of 19 weeks duration. The abdomen was grossly distended and tense. A sonographic diagnosis of ovarian tumor in pregnancy was made. Laparotomy revealed a 32 cm degenerating subserosal uterine fibroid co-existing with an intrauterine pregnancy. Myomectomy was successfully performed. The subsequent antenatal period was uneventful with a spontaneous vaginal delivery of a female baby at 38 weeks.
This report supports other studies and case series that have demonstrated the safety of myomectomy during pregnancy in selected circumstances.
PMCID: PMC1198256  PMID: 16105174
5.  Management of Cervical Fibroid during the Reproductive Period 
This is a case report of a 29-year-old lady who presented with excessive vaginal discharge and sessile cervical fibroid arising from the vaginal portion of the cervix. She was not suitable for uterine artery embolization as she has never previously been pregnant before. She was encouraged to get pregnant and to avoid surgical excision which can lead to hysterectomy. Shortly after, she became pregnant. She had many admissions during pregnancy due to bleeding from the fibroid, and in one occasion she had blood transfusions. The fibroid increased in size to become larger than the head of the baby. An emergency caesarean section was performed at 37 weeks when she attended in labour before the date of her elective caesarean section. She was managed conservatively following delivery in the hope that the fibroid becomes smaller making surgery easier. The fibroid degenerated and reduced in size. Vaginal myomectomy was carried out. The patient is now pregnant for the second time and had a cervical suture at 20 weeks gestation. In this educational case report we discuss the different management options of cervical fibroids and review the literature of other similar cases and their outcome.
PMCID: PMC3787639  PMID: 24109537
6.  Parasitic Myoma After Morcellation 
We report an interesting case of parasitic fibroid which developed from a morcellation remnant following laparoscopic myomectomy. The patient presented with incidental finding of pelvic mass in 2005. She underwent laparoscopic myomectomy for a myoma extending from the Pouch of Douglas to both sides of broad ligament. She subsequently presented with abdominal pain 3 years later in 2008. She underwent total laparoscopic hysterectomy with removal of broad ligament fibroids. During her hysterectomy, a right lumbar mass attached to the omentum was detected, which was excised laparoscopically. Histopathology of the mass confirmed it to be consistent with leiomyoma. This mass could probably be a morcellation remnant that has grown to this size taking blood supply from the omentum. We report this case to emphasize that all tissue pieces that are morcellated should be diligently removed. Even small bits displaced into the upper abdomen can result in parasitic fibroids. Thus, it can be concluded that parasitic myomas can arise from morcellated remnants and grow depending on the blood supply.
PMCID: PMC3304268  PMID: 22442523
Laparoscopic myomectomy; parasitic fibroid; retained fragment after morcellation
7.  Myomectomy at time of cesarean delivery: a retrospective cohort study 
Myomectomy at time of cesarean delivery is traditionally discouraged because of the risk of hemorrhage. A retrospective cohort study was performed to determine whether myomectomy at time of cesarean delivery leads to an increased incidence of intrapartum and short-term postpartum complications.
A computer search of medical records from May 1991 to April 2001 identified a total of 111 women who underwent myomectomy at time of cesarean delivery and 257 women with documented fibroids during the index pregnancy who underwent cesarean delivery alone. Charts were reviewed for the following outcome variables: change in hematocrit from preoperative to postoperative period, length of operation, length of postpartum stay, incidence of postpartum fever, and incidence of hemorrhage. Hemorrhage was defined as a change in hematocrit of 10 points or the need for intraoperative blood transfusion.
The incidence of hemorrhage in the study group was 12.6% as compared with 12.8% in the control group (p = 0.95). There was also no statistically significant increase in the incidence of postpartum fever, operating time, and length of postpartum stay. No patient in either group required hysterectomy or embolization. Size of fibroid did not appear to affect the incidence of hemorrhage. After stratifying the procedures by type of fibroid removed, intramural myomectomy was found to be associated with a 21.2% incidence of hemorrhage compared with 12.8% in the control group, but this difference was not statistically significant (p = 0.08). This study had 80% power to detect a two-fold increase in the overall incidence of hemorrhage.
In selected patients, myomectomy during cesarean delivery does not appear to result in an increased risk of intrapartum or short-term postpartum morbidity.
PMCID: PMC487902  PMID: 15257757
8.  Laparoscopic myomectomy of a subserous pedunculated fibroid at 14 weeks of pregnancy: a case report 
Uterine leiomyomas are seen in 1.6% to 4% of pregnancies. With the increasing age of obstetric patients, more cases are being encountered during pregnancy.
Case presentation
We report the case of a 31-year-old Caucasian woman with acute recurrent abdominal pain due to a subserous fundic myoma, measuring 48 × 52 × 63 mm, with an implantation base of 22 × 18 mm, which was successfully treated by laparoscopy at 14 weeks of pregnancy. At a gestational age of week 40, the patient spontaneously delivered a healthy 3216 g girl baby.
As far as we know, this is the first reported case of laparoscopic myomectomy this early during a pregnancy. Our experience together with an analysis of cases reported in the literature suggests that myomectomy during pregnancy may be considered safe, but only in the hands of experienced laparoscopic surgeons. There are a few reports in the literature about laparoscopic myomectomy during the first half of pregnancy that demonstrate its feasibility in selected cases. Some technical tools could improve the procedure with a minimum of risk for the ongoing pregnancy.
PMCID: PMC3225401  PMID: 22054171
9.  Myomectomy during Caesarean Birth in Fibroid-Endemic, Low-Resource Settings 
If myomectomy during caesarean delivery becomes a widespread practice, it could potentially eliminate multiple surgeries for both indications. However, many surgeons have been reluctant to adopt this policy without conclusive evidence demonstrating its safety. This study reviews the publications on caesarean myomectomy especially from the African Continent with respect to duration of surgery, blood loss, length of hospital stay, and blood transfusions. Judging from the lack of large studies on caesarean myomectomy, the proportion of surgeons who attempt the procedure is largely low because of concerns about its safety. However, most of the authors suggested that the complications and morbidity following caesarean myomectomy do not significantly differ from those occurring during caesarean section alone, while fertility is apparently not compromised by this treatment. With careful patient selection, adequate experience, and efficient haemostatic measures, the procedure does not appear as hazardous as was once thought. This piece of information is relevant for counseling women who request for the simultaneous removal of previously diagnosed fibroids during caesarean section. Staff and facilities for safe management of haemorrhage are a requisite for the procedure. Large randomized trials are needed to guide decisions as to the best clinical practice regarding myomectomy during caesarean delivery.
PMCID: PMC3848339  PMID: 24348568
10.  Laparoscopic Myomectomy with Uterine Artery Ligation: Review Article and Comparative Analysis 
Uterine leiomyomas are one of the most common benign smooth muscle tumors in women, with a prevalence of 20 to 40% in women over the age of 35 years. Although many women are asymptomatic, problems such as bleeding, pelvic pain, and infertility may necessitate treatment. Laparoscopic myomectomy is one of the treatment options for myomas. The major concern of myomectomy either by open method or by laparoscopy is the bleeding encountered during the procedure. Most studies have aimed at ways of reducing blood loss during myomectomy. There are various ways in which bleeding during laparoscopic myomectomy can be reduced, the most reliable of which is ligation of the uterine vessels bilaterally. In this review we propose to discuss the benefits and possible disadvantages of ligating the uterine arteries bilaterally before performing laparoscopic myomectomy.
PMCID: PMC3304288  PMID: 22442527
Laparoscopic myomectomy; fibroids; myomectomy; uterine artery ligation; uterine artery embolisation; uterine devascularisation
11.  Management of uterine fibroids in the patient pursuing assisted reproductive technologies 
Women's health (London, England)  2009;5(4):413-421.
Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated, and how they should be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate approximately 30%. In contrast, studies on subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.
PMCID: PMC3444289  PMID: 19586433
Fibroids; infertility; ART; implantation rate; pregnancy rate; myomectomy
12.  Vaginal Delivery under Caudal Analgesia after Caesarean Section and other Major Uterine Surgery 
British Medical Journal  1972;2(5816):740-742.
In the absence of a recurring indication for caesarean section vaginal delivery in subsequent pregnancy is a “trial of scar,” with potentially serious implications for mother and baby. Labour under caudal analgesia was carefully supervised for 75 women with a surgically scarred uterus—due to lower segment section in 72, abdominal hysterotomy in one, and transcavity myomectomy in two. Every caesarean scar was assessed digitally during labour and every uterus was examined after delivery. Caudal analgesia provided a painless labour and delivery and made scar assessment easy. Controlled intravenous Syntocinon infusion was given to 25 patients. One scar dehiscence occurred early in labour and one in the second stage. Seventy mothers had 71 vaginal deliveries with one pair of twins and one breech. There was one stillbirth and no neonatal death. There were five repeat sections.
PMCID: PMC1788447  PMID: 5036881
13.  Laparoscopic Approach to Fibroid Torsion Presenting as an Acute Abdomen in Pregnancy 
This case report demonstrates the safe application of laparoscopic excisional myomectomy in the first trimester of pregnancy.
Uterine leiomyomas (fibroids) are seen in up to 4% of pregnancies, and most commonly present with pain in pregnancy, which can be due to red degeneration or torsion. Most cases previously have been managed with open resection. We report the case of a 35-y-old primagravida woman, presenting with acute lower abdominal pain at 11 wk gestation. Ultrasound demonstrated an 8-cm fibroid only. She demonstrated features of lower abdominal peritonitis and was scheduled for a diagnostic laparoscopy. At operation, a torsed subserosal fibroid was found. She successfully underwent laparoscopic myomectomy with the endoGIA vascular stapler and subsequent Pfannenstiel delivery. The patient was discharged 48 h postoperatively to continue her pregnancy. This case demonstrates the safe application of laparoscopic excisional myomectomy in the first trimester of pregnancy. Previously reported cases in the literature have focused on open resection or bipolar diathermy enucleation and morcellation. A high degree of suspicion should be maintained for the diagnosis in patients presenting to the surgical service with acute lower abdominal peritoneal signs during pregnancy.
PMCID: PMC3866077  PMID: 24398215
Leiomyoma; Pregnancy; laparoscopy; Acute Abdomen
14.  Surgical Management of Neurovascular Bundle in Uterine Fibroid Pseudocapsule 
The authors propose that intracapsular myomectomy be recommended to maximize the potential for future fertility and to minimize the risk of labor dystocia or uterine rupture during pregnancy or labor.
The uterine fibroid pseudocapsule is a fibro-neurovascular structure surrounding a leiomyoma, separating it from normal peripheral myometrium. The fibroid pseudocapsule is composed of a neurovascular network rich in neurofibers similar to the neurovascular bundle surrounding a prostate. The nerve-sparing radical prostatectomy has several intriguing parallels to myomectomy. It may serve either as a useful model in modern fibroid surgical removal, or it may accelerate our understanding of the role of the fibrovascular bundle and neurotransmitters in the healing and restoration of reproductive potential after intracapsular myomectomy. Surgical innovations, such as laparoscopic or robotic myomectomy applied to the intracapsular technique with magnification of the fibroid pseudocapsule surrounding a leiomyoma, originated from the radical prostatectomy method that highlighted a careful dissection of the neurovascular bundle to preserve sexual functioning after prostatectomy. Gentle uterine leiomyoma detachment from the pseudocapsule neurovascular bundle has allowed a reduction in uterine bleeding and uterine musculature trauma with sparing of the pseudocapsule neuropeptide fibers. This technique has had a favorable impact on functionality in reproduction and has improved fertility outcomes. Further research should determine the role of the myoma pseudocapsule neurovascular bundle in the formation, growth, and pathophysiological consequences of fibroids, including pain, infertility, and reproductive outcomes.
PMCID: PMC3407432  PMID: 22906340
Fibroid pseudocapsule; Uterine leiomyoma; Myoma pseudocapsule; Myomectomy; Prostatectomy; Neurovascular bundle; Laparoscopy; Uterine rupture; Fertility; Sterility; Reproduction; Labor; Neurotransmitters; Neuropeptides; Intraoperative complications; Postoperative compliance; Surgical outcome
15.  Synchronous Uterine Artery Embolization and Laparoscopic Myomectomy for Massive Uterine Leiomyomas  
This report relates that preoperative uterine artery embolization and laparoscopic morcellation may be appropriate treatment for even the largest of leiomyomas. Size need not be a limiting factor for laparoscopic myomectomies.
Uterine leiomyomas remain the commonest cause of menorrhagia and frequently cause pressure symptoms. Management of leiomyomas depends on the presenting symptoms, size, location, number of myomas, and the patient's desire to retain her uterus, fertility, or both. We present the first case of laparoscopic myomectomy for a fibroid measuring 30cm in maximum diameter.
PMCID: PMC3021304  PMID: 20529536
Fibroid size; Laparoscopic myomectomy; Uterine artery embolization
16.  An Unusual Presentation of a Severely Calcified Parasitic Leiomyoma in a Postmenopausal Woman 
Laparoscopic removal of a “parasitic” leiomyoma separate from the uterus was found to constitute effective management of this rare condition.
We report the case of a calcified parasitic leiomyoma in a 51-year-old postmenopausal woman with lower abdominal discomfort. She had no history of surgery. Workup confirmed a calcified leiomyoma. On laparoscopy, the mass was separate from the uterus and adhered to the bowel and bladder. Histopathological examination confirmed a calcified leiomyoma. A calcified parasitic leiomyoma in a postmenopausal woman is rare. Most prior cases were in persons with a history of a laparoscopic myomectomy. The diagnosis can be made by radiological findings. Laparoscopic excision is the treatment of choice in such cases.
PMCID: PMC3043590  PMID: 20932391
Postmenopausal; Parasitic calcified leiomyoma; Laparoscopic excision
17.  Obstetric outcomes after uterine myomectomy: Laparoscopic versus laparotomic approach 
Obstetrics & Gynecology Science  2013;56(6):375-381.
To compare the pregnancy-related complications after laparoscopic and laparotomic uterine myomectomy.
A retrospective study of 415 women who received laparoscopic (n = 340) or laparotomic (n = 75) resection of uterine leiomyomas in one center. The mean follow-up period was 26.5 months in laparoscopic group and 23.9 months in laparotomic group.
Fifty-four and 12 pregnancies occurred in laparoscopic and laparotomic myomectomy group, respectively. The major obstetric outcomes were similar between two groups. There was no ectopic pregnancy or preterm birth. There were two cases of obstetric complication in laparoscopic group only; one experienced neonatal death and postpartum hemorrhage due to placental abruption and the other underwent subtotal hysterectomy due to uterine dehiscence identified during Cesarean section.
Uterine rupture or dehiscence after laparoscopic myomectomy occurred in 3.7% (2/54) which lead to unfavorable outcome. Appropriate selection of patients and secure suture techniques appears to be important for laparotomic myomectomy in reproductive-aged women.
PMCID: PMC3859018  PMID: 24396816
Laparoscopic myomectomy; Laparotomic myomectomy; Myomectomy; Obstetric outcome
18.  The evaluation of myomectomies performed during cesarean section in our clinic 
We evaluated the data of patients who had applied myomectomy during cesarean section operation in our clinic between April, 2008 and December, 2010. Objective: I0 n this period, 3689 cesarean sections were done in our clinic, we analyzed their data retrospectively and determined 27 myomectomy cases during cesarean section operation. The age of the patients, the numbers of pregnancy, parities, the rates of abortus, indications of cesarean, pregnancy weeks, residential areas of myoms detected during the cesarean and their size, were recorded. Furthermore, pre-operative and post-operative hemoglobin (Hb) values, differences between hemoglobin values, whether there was bleeding or not, the need of blood transfusion if it occurred, the duration of operation and hospitaization and the pathological diagnoses of myomectomy materials, were examined.
Materials and Methods:
Retrospective study of myomectomies.
The mean age of patients was 29.6±5.9 (19-42) and mean gestational age was 39.2±1.0(37-42) weeks. The mean size of the fibroids was 5.94±6.29 cm3 (0.96-26.50 cm3). Subserous myoms were the most frequently seen ones (24 of 27 patients=89%) with fundal, corporal localizations in most of the instances. T0 he pre-operative and post-operative values of Hb were 11.8±1.52 (8.6-10.5) and 10.3±2.6 (6.9-13.3) g/dl respectively and the difference was statistically significant (P<0.001). Blood transfusion was not necessary in any patient. The mean duration of the operation was found to be 40.7±13.9 (13-60) minutes.
Myomectomies can be performed safely during cesarean section by experienced obstetricians and gynecologists, and myomectomy performed for fibroids in appropriate localizations does not increase post-operative bleeding or maternal morbidity or mortality.
PMCID: PMC3213751  PMID: 22083246
Cesarean section; myomectomy; pregnancy
19.  Risk of Uterine Rupture and Placenta Accreta With Prior Uterine Surgery Outside of the Lower Segment 
Obstetrics and gynecology  2012;120(6):1332-1337.
Women with a prior myomectomy or prior classical cesarean delivery are often delivered early by cesarean due to concern for uterine rupture. Although theoretically at increased risk for placenta accreta, this risk has not been well quantified. Our objective was to estimate and compare the risks of uterine rupture and placenta accreta in women with prior uterine surgery.
Women with prior myomectomy or prior classical cesarean delivery were compared to women with a prior low transverse cesarean to estimate rates of both uterine rupture and placenta accreta.
One hundred seventy-six women with a prior myomectomy, 455 with a prior classical cesarean delivery, and 13,273 women with a prior low transverse cesarean were evaluated. Mean gestational age at delivery differed by group (p<0.001), prior myomectomy (37.3 weeks), prior classical cesarean delivery (35.8 weeks), and low transverse cesarean (38.6 weeks). The frequency of uterine rupture in the prior myomectomy group was 0% (95% CI 0-1.98%). The frequency of uterine rupture in the low transverse cesarean group (0.41%) was not statistically different from the risk in the prior myomectomy group (p>0.99) or in the prior classical cesarean delivery group (0.88%, p=0.13). Placenta accreta occurred in 0% (95% CI 0-1.98%) of prior myomectomy compared with 0.19% in the low transverse cesarean group (p>0.99) and 0.88% in the prior classical cesarean delivery group (p=0.01 relative to low transverse cesarean). The adjusted OR for the prior classical cesarean delivery group (relative to low transverse cesarean) was 3.23 (1.11-9.39) for uterine rupture and 2.09 (0.69-6.33) for accreta. The frequency of accreta for those with previa was 11.1% for the prior classical cesarean delivery and 13.6% for low transverse cesarean groups (p>0.99=1.0).
A prior myomectomy is not associated with higher risks of either uterine rupture or placenta accreta. The absolute risks of uterine rupture and accreta after prior myomectomy are low.
PMCID: PMC3545277  PMID: 23168757
20.  Pregnancy Complicated with Severe Recurrent Aortic Coarctation: A Case Report 
A 23-year-old primigravida was referred to our clinic for evaluation of high blood pressure (BP) in her 16th week of gestation. She had an operation to repair congenital aortic coarctation and patent ductus arteriosus 8 years ago. On physical examination the blood pressure in upper extremity was 155/95 and in lower extremity was 90/55 mmHg, and heart rate was 93 beats/min. Transthoracic echocardiography showed narrowing of the descending aorta, the diameter of the aortic arch was 10.60 mm and an echocardiographic gradient was 96 mmHg. During the pregnancy (from 16 weeks to 38 weeks) BP was regulated with metoprolol. Cesarean section delivery was applied at 38 weeks of gestation. There was no complication in postpartum period. Spinal anesthesia application was used for caesarean section intervention and healthy female baby was delivered with the APGAR scores of 10/10. Herein the diagnosis of aortic coarctation is reviewed and the management when found during pregnancy is discussed.
PMCID: PMC3485907  PMID: 23133787
21.  Pulmonary embolus arising from sloughed off myoma in late puerperium 
Pulmonary embolus is a rare and serious complication of myoma uteri in the puerperium that resulted in late postpartum hysterectomy A 38-year-old, multiparous woman with a large myoma located on the left lateral wall of the uterus underwent emergency cesarean section due to fetal distres at 28 weeks. During the operation, a 15 cm sized intramural myoma was left without any intervention. On the 40th day postpartum the patient returned to the clinic with sepsis and pulmonary embolus because of obstruction of lochia drainage by the sloughed off myoma. The patient underwent hysterectomy and medical therapy for pulmonary embolus.
We presented an unusual complication of uterine leiomyoma in the late postpartum period after cesarean section. Whatever the mode of sloughing off of the myoma, the results of the obstruction of lochia drainage may be devastating as in our case. To avoid these complications, clinicians must be aware of these symptoms and prompt intervention is essential.
PMCID: PMC3939226  PMID: 24591925
Myoma uteri; pregnancy; puerperium; pulmonary embolus; sepsis
22.  Vaginal Myomectomy for a Thirteen-Centimeter Anterior Myoma 
Vaginal myomectomy is an uncommon but advantageous approach for large interstitial uterine fibroids. Myomectomy is performed via laparotomy and laparoscopy; however, in selected cases, vaginal myomectomy has been proven to be a safe and an effective surgical procedure. We report the case of a 38-year-old para one woman with complaints of chronic lower abdominal pain. Preoperative workup revealed a thirteen-centimeter interstitial uterine myoma in the anterior wall. Successful myomectomy was performed via the vaginal route. We will share the preoperative images, operative technique, and postoperative images.
PMCID: PMC3639674  PMID: 23662225
23.  Timing of planned caesarean section and the morbidities of the newborn 
Elective caesarean section rates have risen over the last decade worldwide. The increase in this rate is not associated with clear benefit for the baby or mother but proportionally associated with increased morbidity for both. Neonatal adverse outcomes in infants born before 39 weeks of gestation are increased and increase progressively as gestational age at birth declines
To compare neonatal outcomes of elective caesarean section performed at or beyond completed 37 weeks of gestation with ≥ 38 weeks of gestation.
Material and Method:
This is a prospective observational study. During the period from July 2010 through April 2011 a total 134 neonates delivered by elective Cesareans at term and were divided into two groups, those who were born (early term) before 38 weeks of gestation (37+0 – 37+6) and those who were born (late term) at or greater than 38 weeks of gestation. We analyzed the following variables sex, number of maternal parities, mode of anesthesia, Apgar score at first and fifth minute, respiratory complications, hypothermia, hypoglycemia, feeding difficulties and admission to neonatal intensive care unit.
During the period of the study 890 live births whether delivered by Cesarean section or normal vaginal delivery. Of these only 134 neonates fulfilling the inclusion criteria were included. About 50% of them were delivered before 38 weeks of gestation. We performed our analysis on those 134 neonates and we found a significant risk in the early Cesareans group in comparison to later group for development of respiratory complications (P=0.0001), hypothermia (P=0.0001) and feeding difficulty (P=0.0001).
Significant reduction in the neonatal morbidities if the time of elective Cesareans is at completed 38 weeks or beyond 38 weeks of gestation. Further larger studies are needed to analyze the factors responsible for our new date regarding the hypothermia and feeding difficulty in neonates born electively by Cesareans before 38 completed weeks of gestation.
PMCID: PMC3271426  PMID: 22363085
Elective caesarean section; neonatal morbidities; neonatal outcome
24.  Fertility outcomes following myomectomy in an urban hospital setting. 
OBJECTIVE: Infertility is rarely a consequence of myomas. However, a causal relationship may be suspected when other causes of infertility have been excluded. Uterine myomas have been reported in 27% of infertile women; 50% of women with unexplained infertility become pregnant after myomectomy. The objective of this study was to establish the impact of the surgical removal of myomas on fertility outcomes in women experiencing recurrent pregnancy loss or unexplained infertility. Fallopian tube, anovulatory disorders and male fertility factors had been appropriately excluded. DESIGN: This was a retrospective study in which we compiled data from the medical records of eight patients from 2003-2004 who underwent abdominal myomectomy for infertility or recurrent pregnancy loss. We calculated rates for subsequent spontaneous abortion, preterm delivery, cesarean delivery, malpresentation and postpartum hemorrhage. RESULTS: There were two patients who were nulliparous premyomectomy, and six had recurrent pregnancy losses. There was a cumulative success rate of 75% (six live births in eight patients) following myomectomy. One had two subsequent pregnancies. There were no spontaneous abortions. Three (37.5%) patients failed to conceive postmyomectomy, one of which was found to have bilateral tubal occlusion. Of the six pregnancies achieved, two (33%, 95% CI 2.06, 3.14) were preterm deliveries, six (100%, 95% CI 1.74, 3.50) were delivered by cesarean section and three (50%, 95% CI 3.50, 1.73) were malpresentations (two breech, one transverse lie). One patient (16%, 95% CI 2.06, 3.30) had abruptio placentae and two patients (33%, 95% CI 2.06, 3.14) experienced postpartum hemorrhage. CONCLUSION: This study suggests that there may be a beneficial effect of surgical removal of myomas on enhancing fertility and successful pregnancy outcome. However, the sample was too small to achieve statistical significance.
PMCID: PMC2594713  PMID: 16353656
25.  Successful pregnancy outcome after laparoscopic-assisted excision of a bizarre leiomyoma: a case report 
Bizarre leiomyoma is a rare leiomyoma variant that requires a precise histopathological evaluation. Especially when diagnosed in a younger woman, this tumor leads to challenging treatment issues involving fertility preservation. Owing to the low incidence of bizarre leiomyoma, there is insufficient evidence to support myomectomy alone as an appropriate management option. Also, the impact of bizarre leiomyoma on fertility is not well known.
Case presentation
A 30-year-old Japanese woman who had never given birth was referred to us because of a uterine tumor with an unusual diagnostic image and was treated by a gasless laparoscopic-assisted excision with a wound retractor. Owing to an unclear margin between her uterine tumor and myometrium, a concomitant excision of adjacent myometrial tissue was required to achieve the maximum resection of her tumor. The histopathological diagnosis was bizarre leiomyoma. Seven months later, she conceived spontaneously and her pregnancy course was uneventful. At 37 weeks of gestation, an elective cesarean section was performed. Although a slight omental adhesion was noted at the postexcisional scar, her uterine wall structure was well preserved and a recurrence of bizarre leiomyoma was not noted.
A laparoscopic-assisted excision of bizarre leiomyoma is a feasible and minimally invasive conservative measure for a woman who wishes to preserve fertility.
PMCID: PMC3199851  PMID: 21812974

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