Do patients need to see a maternal-fetal medicine (MFM) specialist during pregnancy after myomectomy?

Maternal-Fetal Medicine Consultation After Myomectomy During Pregnancy

Patients who have undergone myomectomy should be considered high-risk during pregnancy and should be referred to a maternal-fetal medicine (MFM) specialist for consultation and management. 1

Risk Assessment After Myomectomy

Pregnancy after myomectomy carries specific risks that warrant specialized care:

• Uterine rupture is the most serious potential complication, with reported rates ranging from 0.5-0.7% after myomectomy 2
• Risk factors for uterine rupture include:
  • Entry into the uterine cavity during the original myomectomy procedure 3
  • Multiple myomas removed or multiple hysterotomies performed 4
  • Deep intramural myomas that were removed 4
  • Laparoscopic approach (higher risk compared to abdominal myomectomy) 5

Recommended Monitoring and Management

First Trimester

• Initial MFM consultation to establish baseline assessment 1
• Detailed ultrasound to evaluate the location of the pregnancy in relation to the myomectomy scar 6
• Review of operative records to determine:
  • Surgical approach (laparoscopic, hysteroscopic, or abdominal) 6
  • Number and size of myomas removed 6
  • Whether the uterine cavity was entered 3

Second and Third Trimesters

• Serial growth ultrasounds to monitor for:
  • Fetal growth restriction 5
  • Placental location in relation to myomectomy scar 1
• Increased surveillance for signs of:
  • Preterm labor 5
  • Preterm premature rupture of membranes 5
  • Pregnancy-induced hypertension 5

Delivery Planning

• MFM should be involved in creating a delivery plan 1
• Mode of delivery considerations:
  • Vaginal birth after myomectomy (VBALM) can be successful in 82-90% of attempted cases when properly selected 3, 4
  • Cesarean delivery should be considered when:
    • The uterine cavity was entered during myomectomy 3
    • Multiple large myomas (>7cm) were removed 4
    • Deep intramural myomas were removed 4
    • Multiple hysterotomies were performed 4

Special Considerations

• Timing of delivery: For high-risk cases (extensive myomectomy, entry into endometrial cavity), consider scheduled delivery at 37-38 weeks to prevent spontaneous labor and reduce uterine rupture risk 2
• Intrapartum monitoring: Continuous fetal monitoring is essential during labor to detect early signs of uterine rupture 4
• Postpartum hemorrhage risk is increased, particularly after laparoscopic myomectomy 5

Common Pitfalls to Avoid

• Failing to obtain complete operative records from the myomectomy procedure 1
• Assuming all myomectomy patients require cesarean delivery - vaginal birth can be safe in selected cases 3, 4
• Not recognizing signs of potential uterine rupture during pregnancy (unexplained pain, vaginal bleeding, fetal distress) 2
• Delaying MFM consultation until late in pregnancy 1

Pregnancy after myomectomy should be managed as high-risk, with early MFM involvement to optimize maternal and fetal outcomes 1. The specific management approach should be based on the details of the original myomectomy procedure, with particular attention to surgical technique, location and number of myomas removed, and whether the uterine cavity was entered 3, 4.