CASE Resolved
The estimated blood loss during surgery was 50 mL. Final pathology reported a 1,660-g intact myoma. The patient’s postoperative course was uncomplicated and she was discharged home on postoperative day 1.
Her postoperative evaluation was 1 month later. Her abdominal incision was well healed. Her fibroid-related symptoms had resolved, and she planned to attempt pregnancy. Cesarean delivery for future pregnancies was recommended.
Increase the chances of a good outcome
Advanced planning for attempted myomectomy of a large cervical fibroid can increase the probability of a successful outcome. We suggest the following:
Counsel the patient on risks. Our preoperative strategy includes extensive counseling on the significantly increased surgical risks and the possibility of unavoidable hysterectomy. Given the anatomic distortion with respect to the ureters, bladder, and major blood vessels, involving gynecologic oncology is beneficial to the surgery planning process.
Prepare for possible transfusion. Ensure blood products are made available in the operating room in case transfusion is needed.
Control bleeding. Randomized studies have shown that intrauterine injection of vasopressin, through its action as a vasoconstrictor, decreases surgical bleeding.3,4 While little data are available on vasopressin’s most effective dosage and dilution, 5 U at a very dilute concentration (0.1–0.2 U/mL) has been recommended.5 A midline cervical incision away from lateral structures and gentle shelling out of the cervical fibroid help to avoid intraoperative damage to the bladder, ureters, and vascular supply.
Close in multiple layers. This approach can prevent a potential space for hematoma accumulation.6 Further, a multiple-layer closure of a myometrial incision may decrease the risk for uterine rupture in subsequent pregnancies.7
Advise abstinence postsurgery. There are no consistent data to guide patient counseling regarding recommendations for the timing of conception following myomectomy. We counseled our patient to abstain from vaginal intercourse for 4 weeks, after which time she soon should attempt to conceive. Although there are no published data regarding when it is best to resume sexual relations following such a surgery, we advise a 1-month period primarily to allow healing of the skin incision. Any further delay in attempting to become pregnant may allow for the growth of additional fibroids.
Plan for future deliveries. When the myomais extensively involved, such as in this case, we recommend cesarean delivery for future pregnancies to avoid the known risk of uterine rupture.8 In general, we recommend cesarean delivery in future pregnancies if an incision larger than 50% of the myometrial thickness is made in the contractile portion of the uterus.
Final takeaway. Despite increased surgical risks, myomectomy of a large cervical fibroid is possible and can alleviate symptoms and improve future fertility.
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