07 February 2018 6546 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.

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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 first-time mothers 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 the 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 prolonged fertility (induced pregnancy, adverse outcomes of previous pregnancies, prolonged 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 the fibroid is large, he first removes the fibroid formation.

During the operation, special attention is paid to ligation of blood vessels. For a 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 personnel keep the wound and the skin around it clean. 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. Space-occupying 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 the birth canal. If there is a large fetus in the initial stage of labor, premature placental abruption may develop.

In this case, the best 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 a safe procedure for patients with fibroids - uterine artery embolization. After it, the fibroid is replaced by 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. Women's reproductive function is restored. 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.

Pregnant women with uterine fibroids should be hospitalized at 37-38 weeks for examination, preparation for childbirth and selection of a rational method of delivery.

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. Therefore, in the hospital, an additional in-depth examination of the pregnant woman and the fetus is carried out, including an assessment of the hemostatic system, ECG data, the state of the utero-placental-fetal blood flow, the position and presentation of the fetus, the proportionality of the fetal head and the mother’s pelvis, the state of cervical maturity and other indicators.

Uterine fibroids and pregnancy - preparation for childbirth

All risk factors for uterine fibroids (high - low) are also taken into account. As a rule, in patients with uterine fibroids who are at low risk, childbirth is carried out through the vaginal birth canal. In patients with high-risk factors, delivery by cesarean section is preferable, taking into account that there may be a single pregnancy.

As prenatal preparation, antispasmodic drugs are prescribed (in suppositories, tablets, intramuscularly, intravenously), since increased tone, excitability and contractile activity in the preparatory period can disrupt the nutrition of myomatous nodes, cause their swelling and hemorrhage.

It is also necessary to prepare the fetus for the stress of childbirth. For this purpose, 3-4 intravenous infusions of Actovegin are performed (20-50 ml of Actovegin are diluted in 300-500 ml of 5% glucose solution or 0.9% sodium chloride solution). A replacement for Actovegin is a solution of a domestic drug with the same effect - carnitine chloride.

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

The use of antispasmodic drugs during the active phase of the first stage of labor (opening of the uterine pharynx 5-8 cm).

Limit the use of labor stimulation with oxytocin.

If it is necessary to enhance labor, it is advisable to prescribe prostaglandin E2 drugs (Prostin E2), which have an optimal effect on the myomatous uterus and do not disrupt the microcirculation of the myometrium and the hemostasis system.

Prophylaxis of fetal hypoxia during childbirth.

Prevention of bleeding in the afterbirth and early postpartum periods with the help of methylergometrine. To do this, 1.0 ml of methylergometrine is diluted in 20.0 ml of 40% glucose solution and administered simultaneously intravenously immediately after the birth of the placenta.

7. 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 of the woman, data indicating a proliferating variant of the fibroid morphotype, placental insufficiency).

Indications for myomectomy during cesarean section:

1. Subperitoneal nodes on a leg (all must be removed in any accessible place).

2. Dominant intermuscular myomatous node of medium and large size. You can delete no more than one or two nodes. Synthetic threads are used to suture the myomectomy site. Careful hemostasis is necessary, especially at the site where the node is cut off, where the vessels always change.

3. Single nodes.

4. Secondary changes in one of the nodes.

Myomectomy is not advisable in cases of multiple myomatous changes in the uterus, or in cases of late age of the woman in labor (39-40 years or more).

Despite the apparent simplicity of execution, myomectomy can be accompanied by severe complications. Firstly, the intermuscular myomatous node is well vascularized during pregnancy and myomectomy may be accompanied by bleeding and difficulty in hemostasis (the use of diathermocoagulation is undesirable). Secondly, when large fibroids are removed, deep cavities remain. Bleeding vessels can go deep into the myometrium, and after some time, bleeding in the tumor bed can resume. Therefore, it is very important to carefully ligate the vessels before removing the lower pole of the tumor, align the edges of the wound and close it with an 8-shaped or double-row suture. Peritonization should be performed using continuous or U-shaped sutures, covering the incision line with a piece of omentum or biofilm.

After myomectomy, it is advisable to drain the abdominal cavity. In the postoperative period, it is necessary to use broad-spectrum antibiotics. When two or three large nodes are removed, the uterus contracts poorly, and inflammatory complications often occur, requiring the prescription of two antibiotics, detoxifying agents, drugs that contract the uterus, in combination with antispasmodics (oxytocin, no-spa). On the 3-5th day, ultrasound control is required.

Indications for subsequent removal of the uterus during cesarean section:

1. Multiple uterine fibroids with different locations of myomatous nodes in women of late reproductive age (39-40 years or more).

2. Necrosis of the intermuscular node.

3. Relapse (further growth of myomatous nodes) after a previously performed myomectomy (most often this is a proliferating variant of the tumor).

4. Location of myomatous nodes in the area of ​​vascular bundles, the lower segment of the uterus, interligamentous localization, centripetal growth and submucosal nodes.

In case of low location of fibroids emanating from the lower segment, isthmus, cervix, with 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 subinvolution, oxytocin is prescribed 0.5-1.0 ml 2-3 times a day along with 2-4 ml of no-shpa intramuscularly.

After myomectomy and complicated cesarean section, broad-spectrum antibiotics are used. Combinations of drugs with aerobic and anaerobic effects are used (cephalosporins + metronidazole, aminoglycosides + clindamycin, gentamicin + lincomycin).

Uterine fibroids and second pregnancy

Long-term results of monitoring women who have given birth indicate that the majority of those examined for 5-8 years do not experience further growth of uterine fibroids. Maintaining natural breastfeeding for at least 6 months stabilizes the size of the tumor. The growth of nodes is observed in 10-15% in cases of refusal for various reasons to maintain lactation, the use of hormonal drugs for the purpose of contraception, or if there was an artificial termination of pregnancy by curettage of the uterus.

A differentiated approach to recommending continuation of pregnancy, management of pregnancy and childbirth in accordance with the degree of risk, conducting pathogenetically based prevention and treatment help reduce the incidence of complications and improve outcomes for the mother and fetus. Myomectomies should not be performed during pregnancy without strict and justified indications. When fibroids grow even to gigantic sizes, pregnancy can be saved, while surgical removal of large nodes almost always leads to premature termination of pregnancy and death of a non-viable fetus.

During cesarean section in patients with multiple nodes, large fibroids, a history of uterine scar after conservative myomectomy, either a longitudinal or transverse incision of the anterior abdominal wall can be made, but good access to the myomatous nodes is necessary, the possibility of their removal without violating the integrity of the wall ( pseudocapsules), when the contents (necrotic masses) can penetrate into the abdominal cavity. The fetus should also be removed from the uterus freely and without obstacles, which may not be easy due to large fibroids located near the incision. Cosmetic problems in difficult cases should be of secondary importance, since a patient with uterine fibroids may have only one pregnancy. In all cases, the newborn must be born without birth trauma. The optimal outcome of pregnancy is the birth of a healthy child, preservation of the reproductive organ - the uterus - with the possibility of subsequent treatment.

Uterine fibroids and its effect on pregnancy

Pregnancy has a positive effect on fibroids. Firstly, a woman’s body is saturated with hormones for a long time, the ratio of which is most favorable for hormone-dependent organs and tissues, including the vascular system. Secondly, the changes that occur during pregnancy in the uterus (gradual stretching of smooth muscle bundles, natural processes of hypertrophy, hyperplasia, increased blood supply and microcirculation) normalize the structure of the myometrium, its functional activity, and prevent the processes of premature “aging” of myocytes.

Prevention of further growth of fibroids consists in maintaining breastfeeding of the child, re-occurrence of pregnancy and childbirth after 2-3 years, a healthy lifestyle, and the prevention of somatic and gynecological diseases.

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 of the 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 a younger 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, Faculty of Medicine No. 1, First Moscow State Medical University named after. 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 supravaginal amputation or hysterectomy after a cesarean section. The only exceptions were nodes located on the stalk, small nodes of fibroids 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 the large number of postoperative complications: uterine hypotension, peritonitis, septic conditions.

The question of the possibility of myomectomy during pregnancy and childbirth remained controversial for a long time. 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 for the feasibility of active surgical tactics with the 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% in isolated cases wound infections in recent 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 an ultrasound examination, the presence of a surgeon who will perform the operation is necessary. 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 pregnancy, no pronounced dynamics of node growth were found in 47.4% of patients; 42.1% had a moderate increase in nodes (3-4 cm in diameter). Only 10.5% of primigravidas showed rapid growth of 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 the presence of giant fibroid nodes, in all observations there were necrotic changes 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 there were pronounced areas of necrosis, and the structure of the large node was a leiomyoma without secondary changes.

Functional examinations before surgery should include an assessment of the intrauterine state of the fetus (carditocography, Doppler measurements 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 of adjacent organs.
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 cesarean 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 the 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 with the 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 the creation of the most favorable conditions both for gentle 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 of muscle fibers in all layers of the myometrium and the 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 than catgut, have a lower Young’s modulus (due to which the thread is softer, more elastic and less damaging to soft tissues), high knot strength, which is practically independent of the wet state threads, 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 from the inside of the 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.

With subserous nodes on a wide base, most of it protrudes from the walls of the uterus and is covered on the outside with a serous membrane and a thin muscular 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 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.

In case of multiple uterine fibroids, in some cases, midline incisions are dictated by the need to choose the most rational approach to myomatous nodes during their enucleation and to reduce the number of incisions on the uterus; in this case, both transverse and midline 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 causes of the greatest blood loss are the 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 the internal iliac arteries, temporary clamping of the uterine arteries.

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

Management of the postoperative period does not differ from that of patients after a 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 antibiotic therapy due to the large volume of completed surgery within 5–7 days. The postpartum period generally proceeds without complications; sometimes there is subinvolution of the uterus, requiring additional contraction therapy. In some postpartum women, postoperative anemia requires intravenous administration of iron supplements.

Thus, correctly selected indications, surgical tactics and techniques, anesthesia, the use of effective methods for preventing intraoperative blood loss and modern suture material, antibiotic prophylaxis and antibiotic therapy can expand the indications for myomectomy during cesarean section.

WITHpijuice of used literature

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Catad_tema Pathology of pregnancy - articles

Obstetric tactics in the management of pregnant women with uterine fibroids

The article is devoted to obstetric tactics in the management of pregnant women with uterine fibroids. 153 pregnant women with uterine tumors were examined. At 16-18 weeks of gestation, 25 pregnant women underwent myomectomy. After the operation, the pregnancy in 15 women was prolonged to full term and a caesarean section was performed. In 48 pregnant women, abdominal delivery was performed when uterine fibroids were combined with obstetric or extragenital pathology. 80 patients were delivered through the vaginal canal, also in the presence of a uterine tumor. Outcomes of both operative and spontaneous births were favorable for both mothers and their newborns. L.S. Logutova, S.N. Buyanova, I.I. Levashova, T.N. Senchakova, S.V. Novikova, T.N. Gorbunova, K.N. Akhvlediani
Moscow Regional Research Institute of Obstetrics and Gynecology of the Ministry of Health of Russia (director of the institute - corresponding member of the Russian Academy of Medical Sciences, Prof. V.I. Krasnopolsky).

In recent years, obstetricians have increasingly had to decide on the possibility of prolonging pregnancy when it is combined with uterine fibroids. This is due to the fact that the number of women of fertile age suffering from uterine tumors is increasing from year to year. The course of pregnancy, obstetric tactics, as well as methods of delivery have their own characteristics. Features of the course of pregnancy when combined with uterine fibroids include the threat of miscarriage at various stages of gestation, fetoplacental insufficiency (FPI) and fetal growth restriction syndrome (FGR), rapid tumor growth, malnutrition and necrosis of the myomatous node, placental abruption, especially in those cases when it is partially located in the area of ​​the myomatous node, incorrect position and presentation of the fetus. Childbirth in pregnant women with uterine fibroids also occurs with complications (untimely rupture of water, abnormalities of uterine contractility, fetal distress, tight attachment of the placenta, hypotonic bleeding, subinvolution of the uterus in the postpartum period, etc.).

The complicated course of pregnancy and childbirth determines the high frequency of surgical interventions and obstetric care in pregnant women with uterine tumors. Caesarean section in the presence of uterine fibroids, as a rule, ends with an expansion of the scope of surgical intervention (myomectomy, removal of the uterus). The complicated course of pregnancy and childbirth requires a strictly differentiated approach to the management of pregnant women with uterine fibroids and determines individual obstetric tactics in each specific case. First of all, this concerns resolving questions about the need, possibility and conditions of myomectomy during gestation. Indications for this operation may arise in situations where prolongation of pregnancy is practically impossible (cervical-isthmus or intraligamentary location of the myomatous node, centripetal growth of interstitial fibroids, large sizes of subserous-interstitial tumors). Pregnancy in these women, as a rule, proceeds with a pronounced threat of miscarriage, but when a miscarriage begins, curettage of the walls of the uterine cavity is sometimes technically impossible (cervical-isthmus location of the node). Gynecologists have to resort to radical operations (removal of the uterus along with the fertilized egg), which is a great tragedy for women who do not have children. At the same time, in many women, with a small tumor size and no signs of malnutrition of the nodes, pregnancy proceeds favorably and, as a rule, ends in spontaneous birth.

We observed 153 pregnant women with uterine fibroids. In 80 women, pregnancy ended with spontaneous birth, 63 had a cesarean section, 10 women continue to be monitored for pregnancy (they underwent myomectomy at 15-18 weeks of pregnancy). Another 15 patients underwent surgical treatment during gestation; their pregnancies had already ended with surgical birth. Thus, 25 women underwent myomectomy during pregnancy.

All pregnant women at various stages of gestation were observed in the scientific advisory department and the department of pathology of pregnant women of MONIIAG, 143 pregnant women gave birth at the institute. There were 33 (23.1%) women aged from 20 to 29 years, 89 (62.2%) from 30 to 39 years old, and 21 (14.7%) pregnant women were over 40 years old. Thus, the age of 76.9% of women exceeded 30 years, 80 (55.9%) pregnant women were about to give birth for the first time. In 128 patients, uterine fibroids were detected before pregnancy and only in 25 in the early stages of gestation. In addition to uterine fibroids, 15 (10.4%) patients suffered from adenomyosis, 23 (16.0%) had infertility, and 19 (13.3%) had ovarian dysfunction. Of the extragenital diseases, 13 (9.1%) pregnant women had myopia, 17 (11.9%) had hypertension, 11 (7.7%) had an enlarged thyroid gland, and two had mitral valve prolapse.

When examining pregnant women with uterine fibroids, attention was paid to the following features: localization of myomatous nodes, their structure, location of the placenta, tone and excitability of the myometrium. In 6 pregnant women, at the first examination, isthmus uterine fibroids were discovered, but the size of the tumor was small and did not interfere with the development of pregnancy. In 12 women, the nodes were subserous-interstitial (from 8 to 15 cm in diameter), located in the fundus or in the body of the uterus, nutritional disturbances in the nodes were not noted, and the pregnancy was also prolonged to full term. In 106 patients, uterine fibroids were multiple, myomatous nodes were small in size, predominantly subserous-intrastial. In 4 pregnant women, centripetal growth of fibroids was detected, but the fertilized egg was implanted on the opposite wall of the uterus, and the pregnancy was also able to be prolonged until the period at which the fetus became viable.

And finally, in 25 patients at 7-14 weeks of gestation, giant tumors were found, located intraligamentously, preventing the development of pregnancy, with symptoms of compression of the pelvic organs. These pregnant women underwent conservative myomectomy at 16-18 weeks. 3-5 days before the operation, “conservation therapy” was carried out, including tocolytic drugs, which were prescribed to all pregnant women with symptoms of threatened miscarriage and for prophylactic purposes. Tocolytics - partusisten, bricanil, ginipral - were used either per os, 1/2 tablet 4-6 times a day together with verapamil, or intravenously at a dose of 0.5 mg of a tocolytic drug with 40 mg of verapamil in 400 ml of isotonic sodium chloride solution. The most favorable results were obtained by alternating intravenous administration of partusisten with a solution of magnesium sulfate (30.0 g of magnesium sulfate diluted in 200 ml of isotonic sodium chloride solution). At the end of infusion therapy, drugs such as baralgin or spazgan were used in a dose of 5 ml intravenously. They are anti-prostaglandin agents and normalize the tone of the uterus. In addition, the complex of therapy aimed at prolonging pregnancy included drugs such as Magne-B6; vitamin E, spazgan 1 tablet per day.

Considering the adverse effect of uterine fibroids on the state of fetoplacental blood flow, especially when the placenta is localized in the area of ​​the myomatous node, therapy was carried out aimed at its improvement (chirantil 25 mg or trental 300 mg 3 times a day), as well as the prevention of intrauterine fetal hypoxia (sigetin, cocarboxylase , ascorbic acid).

We considered the optimal time for conservative myomectomy to be 16-19 weeks of pregnancy, when the concentration of progesterone produced by the placenta increases approximately 2 times. The latter is considered a “protector” of pregnancy. Under the influence of progesterone, the contractile activity of the uterus decreases, the tone and excitability of the myometrium decreases, the extensibility of muscle structures increases, and the obturator function of the internal pharynx increases. The last date for possible surgery during pregnancy is 22 weeks, since in the event of premature labor, a very premature newborn is born.

The surgical tactics of conservative myomectomy during pregnancy differ significantly from those performed outside of pregnancy. This is due to the need to perform an operation in compliance with the following conditions: 1) minimal trauma to the fetus and blood loss; 2) selection of a rational incision on the uterus, taking into account subsequent abdominal delivery: 3) suture material with sufficient strength, minimal allergenicity, and capable of forming a full-fledged scar on the uterus. Features of surgical interventions during pregnancy were as follows.

1. The operation was performed under endotracheal anesthesia or epidural anesthesia. This type of anesthesia, from our point of view, is the most preferable, as it allows for maximum relaxation and minimal impact on the fetus.

2. To create the most gentle conditions for the pregnant uterus and fetus, as well as optimal access to atypically located fibroid nodes, lower median laparotomy was used. In this case, the body of the uterus with the fetus located in it was not fixed, but was freely located in the abdominal cavity. Given the pronounced vascular network with well-developed collaterals, in order to avoid additional blood loss, fibroid nodes were captured with gauze swabs moistened with warm isotonic sodium chloride solution, without the use of clamps such as Museau and “corkscrew”.

3. If the myomatous node is located cervically on the anterior wall of the uterus, the peritoneum was opened in the transverse direction between the round ligaments, and the bladder was bluntly relegated to the womb. Then, the capsule of the node was dissected with a longitudinal incision along the midline. The myomatous node was isolated by sharp and blunt methods with simultaneous ligation of all vessels located in the myometrium. Careful hemostasis was performed, taking into account the severity of the blood supply to the nodes during pregnancy.

4. If the node is located intraligamentously, the round ligament of the uterus was transected above the node. In some cases, with a large tumor size and its intraligamentary location, it became necessary to intersect the ligament of the ovary and the tube, or the vascular bundle (in those cases when the listed formations are located on top of the node). The node was peeled out using a partially blunt and partially sharp method. The bed of the latter was sutured with interrupted vicryl sutures in two rows. Careful hemostasis and peritonization of the parametrium were performed.

5. If the node is located subserosally-interstitially, the incision was made longitudinally, bypassing the vessels dilated during pregnancy, reducing trauma to the uterus.

6. An important point in surgical tactics during pregnancy, to which we would like to pay special attention, is the advisability of removing only large nodes (from 5 cm in diameter or more) that prevent the bearing of a real pregnancy. Removal of all nodes (smaller ones) creates unfavorable conditions for the blood supply to the myometrium, wound healing on the uterus and fetal development.

7. We assigned an important place in the outcome of the operation and pregnancy to the suture material and the technique of suturing the uterus. The main suture material used for surgical interventions during pregnancy was vicryl N 0 and 1. Sutures were applied to the uterus in one or two rows. Only interrupted sutures were applied, since in this case the closure of the wounds was considered more reliable. The distance of the sutures from each other was 1-1.5 cm. Thus, the tissues were kept in a state of reposition, and ischemia of the sutured and adjacent areas did not occur.

Postoperative management of pregnant women who underwent conservative myomectomy had its own specific features, due to the need to create favorable conditions for tissue repair, prevention of purulent-septic complications, and adequate intestinal functioning. At the same time, a complex of therapeutic measures aimed at developing pregnancy and improving uteroplacental blood flow was continued. After surgery, intensive infusion therapy was carried out for 2-3 days, including protein, crystalloid drugs and agents that improve microcirculation and tissue regeneration (reopolyglucin in combination with trental and chimes, native plasma, 5-20% glucose solutions, actovegin or solcoseryl ). The question of the duration of infusion therapy was decided individually in each specific case and depended on the volume of surgery and blood loss. In order to prevent purulent-septic complications, a course of antibiotic prophylaxis was prescribed (preferably synthetic penicillins or cephalosporins). Bowel stimulants (cerucal, oral magnesium sulfate) were used with caution.

Depending on the severity of clinical signs of threatened miscarriage, therapy aimed at preserving pregnancy (tocolytics, antispasmodics, magnesium sulfate according to generally accepted regimens) was continued from the first hours after surgery. Oral medication was prescribed until 36 weeks of gestation with a gradual dose reduction. Taking into account hyperestrogenism in pregnant women with uterine fibroids, progestin drugs (turinal) were used together with minimal doses of glucocorticoids or duphaston until 24-25 weeks of pregnancy. On days 12-14 after surgery, pregnant women with progressive pregnancy were discharged for outpatient treatment.

At 36-37 weeks of gestation, 15 pregnant women were hospitalized at the institute for delivery. In case of full-term pregnancy, a caesarean section was performed. Newborns with a high score on the Algar scale (8 and 9 points) weighing 2800-3750 g were removed. The incision of the anterior abdominal wall was inferomedian with excision of the skin scar. When opening the abdominal cavity, only three women had a slight adhesive process in the abdominal cavity. Scars on the uterus after myomectomy were practically not visualized. The duration of cesarean section was 65-90 minutes; blood loss during surgery is 650-900 ml. Pregnancies combined with uterine fibroids in another 48 patients were completed by caesarean section. The localization of the tumor was different: in the body of the uterus or the lower segment there were small subserous-interstitial nodes (less than 10 cm in diameter): large subserous-interstitial nodes were located mainly in the fundus of the uterus, as well as in its body, but at a considerable distance from lower segment. In neither case did the presence of a tumor prevent the prolongation of pregnancy and there was no need for surgical treatment before the due date. The gestational age before delivery was 37-39 weeks. In only one case, in an elderly primigravida with a history of long-term infertility, with FPN due to the localization of the placenta in the area of ​​a large interstitial myomatous node (15 cm in diameter), a cesarean section was performed at 34-35 weeks of pregnancy. A newborn weighing 1750 g was extracted with an Algar score of 5 and 7 points at 1 and 5 minutes, respectively.

In 32 (66.7%) pregnant women, cesarean section was planned. Indications for surgery in 6 women were the isthmus location of the myomatous node, which prevented the advancement of the fetal head along the birth canal; in 2 - rapid tumor growth at the end of pregnancy with signs of malnutrition; In 24 pregnant women, the indications for cesarean section were combined: breech presentation of the fetus, advanced age of the primipara, a history of long-term infertility, unpreparedness of the body for childbirth, FPN, high myopia, etc. In 16 (33.3%) women in labor, cesarean section was performed during labor, mainly due to labor anomalies (13 women) and fetal hypoxia (3 women in labor). In 30 women giving birth, the scope of the operation was expanded: 24 women underwent myomectomy, 5 had supravaginal amputation, and one had hysterectomy. 34 (70.8%) children were extracted in satisfactory condition (state assessment on the Algar scale - 8 and 9 points at the 1st and 5th minutes, respectively), 13 (27.1%) - in a state of mild hypoxia and only one child with moderate hypoxia. The weight of the newborns was 2670-4090 g. The course of the postoperative period in 45 women was uncomplicated, in two with myomectomy during cesarean section subinvolution of the uterus was noted and in one there was a wound infection.

Pregnancy in combination with uterine fibroids in 80 women ended in spontaneous birth. Myomatous nodes, as a rule, were small in size and located in the body of the uterus, without interfering with the spontaneous birth of the fetus. In this group, 28 (35%) pregnant women were elderly primiparas: 13 suffered from hypertension, 10 had an enlarged thyroid gland, and 9 had myopia. In all pregnant women, at 37-38 weeks of gestation, preparation for childbirth began with antispasmodic and sedative drugs; 6 women were prepared with intravenous drip administration of enza-prost. Childbirth in 34 (42.5%) women was complicated by premature rupture of water, in 4 (5%) - bleeding in the placenta and early postpartum periods. The average duration of labor was 10,425 minutes +/- 1 hour 7 minutes, the anhydrous interval was 15 hours 12 minutes +/- 1 hour 34 minutes. 56 (70%) children were born in satisfactory condition, 22 (27.5%) in a state of mild hypoxia and two newborns with moderate hypoxia. The weight of newborns ranged from 2050 to 4040 g. In four, the weight exceeded 4000 g. In all postpartum women, the course of the postpartum period was uncomplicated. 78 (97.5%) newborns were discharged home on days 5-7 in satisfactory condition, two children were transferred to staged nursing and then also discharged.

Thus, the increasing incidence of uterine fibroids in women of fertile age increasingly raises the question of obstetricians and gynecologists about the possibility of prolonging pregnancy with this pathology. Conservative myomectomy, especially in women with the last and often only opportunity to have a child, is a method that makes it possible to realize this opportunity.

LITERATURE

1, Ivanova N.V., Bugerenko A.E., Aziev O.V., Shtyrov S.V. // Vestn. Ross. accots, obstetrics-gin. 1996. N 4. P. 58-59.
2. Smitsky GA. // News. Ross. assoc. obstetrics-gin. 1997. N3. pp. 84-86.

Women often find out about the presence of a benign tumor in the uterine cavity during pregnancy. The presence of a tumor in the uterine cavity and the progressive development of the node is an indication for surgical delivery. A caesarean section for fibroids differs from a regular caesarean section in a healthy woman only in the course of the early postpartum period - in the first case, the woman in labor will have more profuse bleeding.

Often, myomatous nodes are removed during a cesarean section.

Preparation for the procedure

Planned hospitalization of a pregnant woman occurs at the 37th week of pregnancy and the expectant mother is thoroughly examined before giving birth.

During an ultrasound, a surgeon must be present - specialists study not only the condition of the fetus, but also determine the size, location, number of myomatous nodes, and also examine the vessels feeding the tumor. Standard diagnostics of the state of health and development of the fetus includes fetometry, cardiotocography and Doppler measurements of the umbilical cord vessels. The results of past ultrasounds and the latest study are necessarily compared - this allows specialists to determine how much the tumor has progressed in growth and how this affected the development of the fetus.

Progress of the operation

The operation is performed using epidural (spinal) anesthesia or endotracheal anesthesia. Through a transverse incision in the abdomen along the “bikini line,” the newborn baby is removed, and then the placenta.

If the myomatous nodes are small, they are resected after delivery.

The following stages of caesarean section are distinguished:

1. Abdominal incision using the Joel-Cohen method in thin girls without bladder trauma. The Pfannenstiel incision is performed in large women.
2. Section of the uterine tissue in accordance with the localization of myomatous nodes, their size and depth of occurrence in the muscle structure. As a rule, an arc-shaped transverse incision is made.
3. Removal of the fetus.
4. Separation of the placenta.
5. Removal of myomatous nodes.
6. Layer-by-layer suturing of the walls of the uterus and abdominal wall.

Removal of myomatous node after childbirth

The indication for removal of myomatous nodes after childbirth is tumor recurrence or detection of a neoplasm in the superficial layers of the uterus. The operation is completely safe for the fetus and the woman’s further recovery, but the contractility of the uterus becomes lower. This means that it takes longer for the organ to return to its normal size than it would for a normal caesarean section in a woman without fibroids.

Indications for fibroid resection

Surgery to remove a benign tumor during childbirth is performed if:

• subserous nodes on a thick or thin stalk, localized under the peritoneum;
• intramural nodes measuring about 5 cm;
• fibroids with progressive growth, the size of which is about 10 cm;
• multiple large formations in the uterine cavity (up to five units);
• impossibility of suturing after delivery;
• intermuscular node in the uterine cavity.

Contraindications to fibroid removal during cesarean section

Removal of a myomatous node during cesarean section is contraindicated if a woman has the following conditions:

• severe manifestations of iron deficiency anemia;
• severe blood loss during fetal extraction;
• divergence of the vascular network feeding the nodes in the lower part of the uterus;
• extragenital pathology;
• premature placental abruption;
• the patient is over forty years old;
• multiple nodes that deform the uterus;
• distant localization of nodes from the incision site.

It is not advisable to carry out the procedure if there is one node up to two centimeters, since after delivery it can resolve on its own.

Indications for hysterectomy after cesarean section

Indications for removal of the uterus affected by fibroids immediately after extraction of the fetus are:

• presence of atypical tumor cells;
• necrosis of the node and development of septic processes in the uterus;
• tumor recurrence after a previous myomectomy with aggressive development and damage to several areas of the uterus;
• concentration of the node in the plexus of large arteries and vessels;
• detection of uterine cancer during diagnosis in preparation for caesarean section.

Stages of tumor removal

Myomectomy is performed in stages as follows:

1. Separation of the myometrium from the node, on the one hand.
2. Figure-of-eight sutures - the crossing of threads occurs inside the tissues.
3. Separation of the myometrium from the node, on the other hand.
4. Re-suturing in a figure-eight pattern uses self-absorbable suture material.
5. Layer-by-layer sutures on the muscular and muscular-serous layer in the area where the node is located.
6. Application of an additional U-shaped suture around the internal sutures when removing large fibroids.
7. Layer-by-layer suturing of the wound.

This type of suturing prevents the formation bed from deepening inward, the development of major blood loss and the formation of hematomas. If a subserous node on a thin stalk is removed, an incision is made above the formation several centimeters. An electric knife is used to reduce blood loss. The duration of the procedure is about one and a half hours.

Recovery after fibroid removal during cesarean section

At the end of the operation, the woman in labor is moved to the intensive care unit. She spends one day there, after which she is transferred to the postpartum ward.

The mother's condition is most often normal, and the condition of the born child is characterized as satisfactory, since signs of mild hypoxia are observed. Oxygen starvation is eliminated quickly without consequences. The course of the postoperative period does not differ from rehabilitation after a regular cesarean section. As a rule, no complications are observed.

The woman in labor must be prescribed a weekly course of antibacterial therapy, as well as painkillers and drugs to contract the myometrium for two to three days. If there are signs of anemia, additional iron supplements are administered through an IV. It is worth noting that the doctor prescribes medications that do not affect lactation and the properties of breast milk.

There is a drainage tube in the abdominal cavity for about two days. A bandage is applied to the wound. It should not be wetted, touched, much less removed. A woman should monitor the hygiene of the skin around the suture every day. On the third day, a control ultrasound is performed.

The diet of a nursing mother should be enriched with nutrients, but at the same time not cause gas formation. Constipation and excessive straining during bowel movements should be avoided.

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