Myomectomy with subsequent pregnancy

MYOMECTOMY

WITH

SUBSEQUENT A.

THOMAS

(From

the Gynecological

Seruice,

St. Johds

Episcopal

PREGNANCY” M.D.,

MCCORMICK,

BROOKLYN,

N. Y.

Hospital)

I

N THE 10 year period from Jan. 1, 1946, to Dec. 31, 1955, 66 myomectomies were performed at St. John’s Episcopal Hospital. This number is to be compared with that of 1,431 hysterectomies for fibromyomas during the same period. The data compiled from the records of the patients treated by myomectomy present some interesting statistics. Of the 66 patients, 59 of whom were married, 32 had been pregnant a total of 65 times prior to myomectomy. Of this number, 41 pregnancies (63 per cent) were carried to term, while 23 (37 per cent) were aborted before viability. This is to b,e compared similarly with a series reported from Mt. Sinai Hospital, New York,l wherein 59 per cent of 742 pregnancies associated with fibromyomas terminated with living infants. That fibromyomas may be a causative factor in sterility or abortion is well known. The tumor may be so located as to prevent migration of the sperm to the ovum; or it may compress or distort the Fallopian tube sufficiently to delay or prevent passage of the ovum down the oviduct. Then, too, fibroids are oftentimes found when a low-grade pelvic inflammatory disease is present. Likewise, the meno- or metrorrhagia frequently associated with fibroids causes a poor site of nidation for a fertilized ovum. Finally, distortion and compression of the endometrial cavity through rapid growth and enlargement of the fibroid tumors during pregnancy contribute to early abortion in many cases. 'PBBLE

I.

AGE AT WHICH

MYOMEOTOMY

WAS

PEBFORYED MO.OFPATIJ!XTS

AGE 15-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60

i ;“6 i 1 0 1

Of the 66 patients in our series treated by myomectomy, 33 complained of lower abdominal or low back pain. Eighteen presented meno- or metrorrhagia. Seven were conscious of an abdominal mass, and 15 complained of pelvic pressure. Twelve patients had had no children despite one or more Twenty patients were subjected to myomectomy for previous pr&gnancies. *Presented

at 8 meeting

of the Brooklyn

Gynecological 1128

Wety,

&y

16. 1967.

Volume 75 Number 5

MYOMECTOMY

WITH

SUBSEQUENT

11.29

PREG:NANCY

reasons of primary sterility. In 3 patients, myomectomy was performed during pregnancy, each time after the fourth month of gestation, and each with a preoperative diagnosis of ovarian cyst. In all 3 cases, the tumor was pedunculated. Each patient continued to carry to term and was delivered vaginally without incident. The age of the patients at which myomeetomy was performed varied, in our series, from 20 to 60 years, with 79 per cent being performed in the 25 to 40 year age group. A complete grouping by ages is shown in Table I. The number and site of fibromyomas are not a contraindication to myomectomy. In our series, the fibroids ranged in number from one to twenty (Table II) and were located in various sites. Counselle? reported an interesting case in which he successfully anastomosed the uterine fundus and cervix after enucleating a cervical fibroid which necessitated section of the cervix. Davitls’ described a case wherein 80 fibromyomas were removed from a single uterus with subsequent reconstruction of the organ. TABLE

II.

NUMBER

NO.OFTUMORS 1 2 i

OF FIBROMYOMAS

EXCISED I

FROM

SINGLE

UTERUS

No.OFCASES 24 15 Gc

-_

There are, of course, instances in which myomectomy would be inadvisable, as in acute pelvic inflammatory disease, uterine carcinoma, or badly diseased adnexa, where reconstruction of the Fallopian tubes would be impossible. The operative technique used in our series was similar in all cases. Upon mobilization of the uterus, a rubber catheter was placed through the broad ligaments, at the level of the lower uterine segment, in order to compress the uterine arteries. This tourniquet was loosened at intervals of 10 to 15 minutes throughout the operative procedure. An attempt was made to keep the in&&ma in the midline of the anterior surface of the fundus; and? where possible, multiple myomas were enucleated through a single incision. Incisions were made posteriorly when necessary ; and in several eases the anterior incision had to be extended over the fundus to the posterior surface. The endometrial cavity was entered 19 times, in 12 inadvertently, and in 7 deliberately, to rule out submucous or pedunculated fibromyomas. A hysterosalpingogram prior to operation is invaluable in such cases, and may obviate the need to open the endometrial cavity. The majority of the patients showed some febrile morbidity postoperatively, but recovery in all cases was prompt and complete. In follow-up, 14 (21 per cent) had one or more pregnancies after myomectomy. Of the 20 patients on whom myomectomy was done for primary sterility, 6 (30 per cent) had one or more pregnancies after operation, an acceptable percentage similar to that reported by other clinies.3 All of the patients who became pregnant after myomectomy were delivered by cesarean section. There were 4 patients treated by myomectomy who subsequently required hysterectomy.

1130

MC

Am. J. Obst. & Synec. May. 1958

CORMICK

Conclusions Although the percentage of pregnancies following myomectomy in the series presented may be small, the fact that 30 per cent of the patients treated for primary sterility who conceived after myomectomy makes the consideration of this operation of prime importance. References 1. Davids, A. M.: AM. J. OBST. & GYNEC. 63: 592, 1952. 2. Counseller, V. 8.: J. A. M. A. 109: 1687, 1937. 3. Miller, Hilliard, and Tyrone, Curtis H.: AM. J. OBST. & GYNEC.

26:

575,

1933.