What surgical techniques can decrease hemorrhage in a patient undergoing repeat cesarean section with a 6 cm intramural myoma located anteriorly?

Surgical Techniques to Decrease Hemorrhage During Repeat Cesarean Section with Anterior 6 cm Intramural Myoma

For a repeat cesarean section with a 6 cm anterior intramural myoma, avoid concurrent myomectomy and plan for enhanced hemorrhage control measures including preoperative anemia correction, intraoperative vasoconstrictors, and immediate access to blood products, as the combination of anterior location and size creates substantial bleeding risk. 1

Risk Assessment and Decision-Making

The specific characteristics of this case—a 6 cm intramural myoma in the anterior location—place this patient at moderate-to-high risk for intraoperative hemorrhage if myomectomy is attempted:

• Myoma diameter ≥6 cm is an independent risk factor for hemorrhage during cesarean myomectomy (OR 1.167 per cm increase, 95% CI 1.044-1.305, P=0.006) 1
• Lower segmental location increases hemorrhage risk (OR 2.827,95% CI 1.033-7.734, P=0.043), though anterior fundal/body location carries less risk 1
• Intramural myomas specifically carry a 21.2% hemorrhage rate during cesarean myomectomy compared to 12.8% in controls, though this did not reach statistical significance 2
• Myomas >10 cm with intramural type are associated with significant complications including transfusion requirements and postoperative ileus 3

Primary Recommendation: Avoid Concurrent Myomectomy

The safest approach is to perform cesarean delivery alone without myomectomy, deferring fibroid removal to an interval procedure 2-3 months postpartum. 4

Rationale:

• The anterior location places the myoma directly in the surgical field, increasing manipulation and bleeding risk 4
• Repeat cesarean delivery already carries increased baseline risks including wound hematoma (4-6%), transfusion (1-4%), and hysterectomy (0.5-4%) 4, 5
• Myomectomy during pregnancy is particularly hazardous due to increased myometrial vascularity 4
• The 6 cm size approaches the threshold where complications become more likely 1

If Myomectomy Must Be Performed

Preoperative Optimization

Correct anemia preoperatively and arrange autologous blood storage:

• Treat any existing anemia with iron supplementation or erythropoietin 4
• Consider preoperative GnRH agonist therapy to reduce myoma size and improve hemogram, though this may soften small intramural myomas making them harder to identify intraoperatively 4
• Arrange for autologous blood donation if time permits 4
• Ensure availability of blood products and activate massive transfusion protocol readiness 6

Intraoperative Hemorrhage Control Techniques

Apply mechanical and pharmacologic measures to reduce blood flow:

• Vasopressin injection into myometrium surrounding the myoma reduces intraoperative blood loss, though monitor for delayed bleeding after vasopressin clearance 4
• Tourniquet application to vascular pedicles temporarily reduces blood flow during dissection 4
• Confine incisions to the anterior uterine surface to protect bowel and adnexal structures and minimize adhesion formation 4
• Use intraoperative blood scavenger systems (cell saver) to reduce need for homologous transfusion 4

Surgical Technique Considerations

Minimize surgical trauma and optimize hemostasis:

• Make a single vertical incision over the myoma when possible to reduce the number of uterine entry sites 4
• Achieve meticulous hemostasis with careful suturing of the myometrial defect in multiple layers 4
• Consider adhesion barriers (oxidized regenerated cellulose, hyaluronic acid/carboxymethylcellulose combination) to reduce postoperative adhesions 4
• Maintain normothermia using forced-air warming, warmed IV fluids, and increased operating room temperature to optimize coagulation 7

Enhanced Recovery and Monitoring

Implement ERAS protocols and close postoperative surveillance:

• Use regional anesthesia (epidural or spinal) as preferred method 7
• Initiate multimodal analgesia including paracetamol and NSAIDs intraoperatively 7
• Monitor hemodynamics closely for 24-48 hours postoperatively with serial hemoglobin checks 6
• Watch for delayed complications including postoperative atonic bleeding and ileus 3
• Consider thromboprophylaxis given additional VTE risk factors 7

Critical Pitfalls to Avoid

Do not proceed with myomectomy if:

• The myoma is in the lower uterine segment (significantly higher hemorrhage risk) 1
• Multiple large intramural myomas are present 3
• Patient has not been counseled about hysterectomy as potential rescue procedure 4, 5
• Blood products are not immediately available 6
• Surgical team lacks experience with complex myomectomy and hemorrhage management 4

The combination of ≥8 cm diameter OR lower segmental position yields 79.3% specificity for operative hemorrhage, making these absolute contraindications to concurrent myomectomy 1. At 6 cm in an anterior (fundal/body) location, this case falls into a gray zone where individual surgical judgment and patient counseling are essential, but the safer default is interval myomectomy after delivery.