Uterine fibroids - clinical presentation and complications

Fibroids are the most common benign tumors of the genital organs in women of childbearing age. In some women, fibroids can be present for years without any symptoms and then are discovered accidentally during a gynecological examination. In others, they can cause significant morbidity and necessitate the need for multiple surgical procedures. The scope of this clinical review is to provide information about the clinical data as well as the complications of uterine fibroids and their clinical presentation. The most common symptoms that may occur in women with uterine fibroids include: bleeding (menometrorrhagia, metrorrhagia or intermenstrual bleeding), pain, symptoms of compression of adjacent structures, changed appearance of the abdomen and infertility. Complications of uterine fibroids include: venous thromboembolism, torsion of pedunculated fibroids, acute urinary retention and renal insufficiency, vaginal and intraabdominal bleeding, mesenteric vein thrombosis and gangrene of the intestine. Complications of uterine fibroids fibroids are rare and though they may cause significant morbidity, and rarely, mortality, which indicates the need for further research in this area. Accurate diagnosis is an essential prerequisite for the evaluation of therapeutic options, especially recently, when medical and numerous non-invasive treatment options have become available

Cesarean myomectomy technique: a critical review

Background: Cesarean myomectomy (CM) is, for many gynecologists, a discussed surgical procedure characterized by fibroid's removal during cesarean section (CS) followed by possible complications. For a long time, it has been common and shared thinking that myoma should not be surgically treated in pregnant women at the time of birth through CS in order to avoid complications for the patient. Nowadays, many studies reconsidered the feasibility of CM. The aim of this investigation is to summarize the scientific evidences on this procedure, highlighting when and how it can be performed safely. Methods: This review has realized basing on evidences reported in scientific database, as PubMed, Scopus, Cochrane Library, Medline and EMBASE databases, found using key words of reference to the main topic, the cesarean myomectomy. All the observational studies and meta-analysis published in the current century has been considered and results were critically evaluated by the authors, experts on CM. Results: According to the findings reported, the CM could be a valid and feasible treatment option for patients, especially when there are specific conditions which are associated with a lower risk of complications, as perioperative blood loss and risk of hysterectomy. Authors' experience and judgment agree with the evidences about the importance of the surgeons' skill and experience, both to make safer the surgical procedure and to have intraoperative and post-surgical outcomes. Conclusion: The applied surgical technique and the informative counselling and/or informed consent, still need standardization for a safer CM, both for the patients and for the operator, at the same time

Long-term obstetric, perinatal, and surgical complications in singleton pregnancies following previous cesarean myomectomy: a retrospective multicentric study

ObjectivesThe safety of cesarean myomectomy has been proven by previous studies. Our study aimed to reveal the long-term perinatal, obstetric, and surgical outcomes of cesarean myomectomy (CM) by comparing different CM techniques.Material and methodsThis retrospective multicentric case–control study involved 7 hospitals and included 226 singleton pregnancies that underwent repeated cesarean section (CS) between 2015 and 2020. Among these pregnancies, 113 of 226 cases had CM (Group A), and 113 had only CS (Group B). Of the 113 cases in which CM was performed, 58 underwent endometrial myomectomy (EM) (Subgroup A1) and 55 underwent serosal myomectomy (SM) (Subgroup A2). The groups were compared in terms of obstetric, perinatal, and surgical outcomes, and fibroid recurrence, myomectomy scar healing rate, and adhesion formation were noted.ResultsThere was no significant difference between the groups in terms of maternal age, body mass index, gravidity, parity, and fibroid diameter in previous CS (p > 0.05). In the perinatal and obstetric evaluation of the groups, there was no significant difference between the groups in terms of neonatal weight, Apgar score, fetal growth restriction, preterm premature rupture of membranes, preterm delivery, hypertension in pregnancy, and diabetes mellitus (p > 0.05). The fibroid recurrence rate was 28.3%, and the myomectomy scar good healing rate was 99.1%. There was no difference between the groups in terms of CS duration, preoperative and postoperative hemoglobin levels, perioperative blood transfusion rates, febrile morbidity, and prolonged hospitalization (p > 0.05). In terms of adhesion formation, although the adhesion rate of the SM group was higher than that of the EM group, no statistically significant difference was detected between the groups.ConclusionThis study showed that in pregnancies following CM, obstetrical, perinatal, and surgical outcomes were unaffected. Obstetricians can safely use CM, either the trans-endometrial or serosal technique, as it is a safe and effective method with long-term results

Predictors of IVF/ICSI success following treatment of endometriosis as the cause of primary infertility

Objectives: Treatment of endometriosis prior to IVF/ICSI could be followed by the significant reduction of ovarian reserve. The aim is to identify potential markers of the IVF/ICSI outcome in patients with endometriosis associated infertility and to evaluate their clinical significance. Material and methods: The prospective cohort study included 73 patients with primary infertility caused by endometriosis that were subjected to 77 IVF/ICSI cycles. Patients were classified into two groups. In the first group some type of treatment had previously been applied, and in the second group patients were immediately subjected to the IVF/ICSI procedures. Results: When pregnancy was achieved, there were significantly more patients under 35 years of age, more patients with primary infertility duration up to 3 years, and more patients with endometriosis that was previously treated (77.4%) (p < 0.039). In the cases of the successful outcome Endometriosis Fertility Index > 7, lower basal FSH and FSH/LH ratio were found, as well as significantly higher basal E2, basal P4 and AMH. Significantly lower doses of gonadotropins were needed in cases of the successful outcome, and long protocol with agonists was more frequently used. Multivariate logistic regres­sion analysis showed that previous therapy of endometriosis, P4 ≥ 0.7 ng/mL, AMH ≥ 0.9 ng/mL, A class of embryos, and the use of long protocol with agonists were predictors of the successful IVF/ICSI outcome. Conclusions: Therapy for endometriosis, AMH and P4 levels appeared to be predictors for the successful IVF/ICSI outcome and the use of long protocol with agonists could be advised in these cycles

Uterine myomas in pregnancy, childbirth and puerperium

Fibroids are the most common benign tumors of the genital organs of women in reproductive age. Achieving reproductive function later in life, with more frequent use of assisted reproductive technologies, leads to an increased number of pregnancies complicated with fibroids. Their size may change during pregnancy, but the changes are mostly individual. Most fibroids stop growing or decline during the puerperium. The effect of fibroids on pregnancy depends on their number, size and location. The mechanisms bringing about perinatal complications are not fully understood. Fibroids during pregnancy can cause many perinatal complications, such as bleeding in pregnancy, miscarriage, pain due to red degeneration, malpresentation, preterm labor, premature rupture of membranes, placental abruption and obstruction of delivery and are associated with higher incidence of cesarean section, operative vaginal delivery, uterine atony and postpartum hemorrhage. Postpartum hysterectomy in these women is also more likely than in general population. Postpartum infections are more common in patients with fibroids, and myomas may also cause retained placenta. The most common cause of neonatal morbidity is prematurity, due to pregnancy ending in an earlier gestational age. Monitoring of pregnancies complicated with fibroids is essentially indistinguishable from monitoring normal pregnancies. Therapy includes only bed rest and observation, symptomatic therapy in case of pain and intensive fetal surveillance, and surgery in the acute situations

Diagnosis and treatment of deep infiltrating endometriosis with bowel involvement: A case report

Introduction. Deep infiltrating endometriosis is a form of endometriosis penetrating deeply under the peritoneal surface causing pain and infertility. Assessment of the pelvis by laparoscopy and histological confirmation of the disease is considered the golden standard of diagnosis. Case Outline. We are presenting a patient diagnosed with deep infiltrating endometriosis by transvaginal ultrasound and treated with minimally invasive radical surgery including segmental resection of the bowel. Conclusion. Transvaginal sonography has an important role in detecting deep endometriosis of the pelvis. Fertility sparing surgery is the treatment of choice in symptomatic women wishing to retain fertility, since drugs used for endometriosis interfere with ovulation. The success of the surgery depends on the accuracy of the preoperative diagnosis. A multidisciplinary approach in managing deep endometriosis is mandatory in order to offer patients the best possible treatment using the combined skills of the colorectal and gynaecologic surgical teams. The presented case exhibits the feasibility of laparoscopic approach to severe pelvic endometriosis with bowel involvement