Is it safe to perform a myomectomy at the time of cesarean section?

Cesarean Myomectomy: Safety and Recommendations

The American College of Obstetricians and Gynecologists recommends avoiding concurrent myomectomy during cesarean section and instead deferring fibroid removal to an interval procedure 2-3 months postpartum, due to increased risk of hemorrhage. 1

Primary Recommendation

• Perform cesarean delivery alone without myomectomy, as repeat cesarean delivery already carries increased baseline risks including wound hematoma, transfusion, and hysterectomy. 1
• The safest approach is to complete the cesarean section and schedule interval myomectomy 2-3 months postpartum when the uterus is no longer hypervascular and the patient has recovered from delivery. 1, 2

When Cesarean Myomectomy May Be Considered

While routine cesarean myomectomy is not recommended, it may be performed in highly selected cases by experienced surgeons when specific criteria are met:

Favorable Fibroid Characteristics

• Pedunculated or subserosal fibroids are associated with lower hemorrhage risk and may be safely removed. 3, 4
• Fibroids that are directly interfering with uterine incision closure may necessitate removal. 5, 6
• Anterior lower segment fibroids that are easily accessible may be considered. 5

Unfavorable Characteristics (Avoid Myomectomy)

• Intramural fibroids ≥5 cm significantly increase the risk of postpartum hemorrhage ≥1,000 mL (OR 2.2). 4
• Multiple fibroids are associated with higher complication rates and should generally be left in place. 3
• Posterior uterine fibroids carry substantially higher hemorrhage risk and should be avoided. 7

Critical Prerequisites if Myomectomy is Attempted

Surgical Team Requirements

• Experienced obstetrician with advanced surgical skills in myomectomy and hemorrhage management must perform the procedure. 5, 6, 8
• The surgical team must have expertise in complex myomectomy techniques. 1

Patient Counseling and Preparation

• Patient must be counseled preoperatively about the possibility of hysterectomy as a rescue procedure if hemorrhage cannot be controlled. 1
• Correct preoperative anemia with iron supplementation or erythropoietin. 1
• Arrange for immediate availability of blood products before proceeding. 1

Hemostatic Measures

• Apply vasopressin injection into myometrium surrounding the myoma to reduce blood flow. 1, 7
• Consider tourniquet application to vascular pedicles or bilateral uterine artery ligation prophylactically. 1, 6
• Confine incisions to the anterior uterine surface to protect bowel and adnexal structures. 1, 7
• Achieve meticulous hemostasis with multilayer closure of the myometrial defect. 1

Evidence on Outcomes

Blood Loss Data

• In case series, blood loss ranged from 900 mL to 3.2 L, with most patients losing 1-1.5 L. 5
• The incidence of hemorrhage with cesarean myomectomy (12.5%) was not significantly different from cesarean section alone (11.3%) in one study, though this involved selected cases. 8
• Birth weight ≥4,000 g is an independent risk factor for postpartum hemorrhage ≥1,000 mL (OR 3.1). 4

Operative Considerations

• Myomectomy adds approximately 15 minutes to operative time and 1 day to hospital stay. 5
• No significant differences in postoperative fever or transfusion rates were found in selected case series, but these represent highly selected patients. 8

Critical Pitfalls to Avoid

• Do not proceed if blood products are not immediately available in the operating room. 1
• Do not attempt removal of large intramural fibroids (≥5 cm) or multiple fibroids during cesarean section. 4, 3
• Do not perform cesarean myomectomy if the patient has not been counseled about potential hysterectomy. 1
• Avoid posterior uterine incisions as they are associated with severe bleeding risk. 7
• Remember that the pregnant uterus is markedly hypervascular, making myomectomy especially hazardous compared to interval surgery. 7

Postoperative Management

• Monitor hemodynamics closely for 24-48 hours postoperatively with serial hemoglobin checks. 1
• Watch for delayed complications including postoperative atonic bleeding and ileus. 1
• Patients should wait 2-3 months before attempting pregnancy after any myomectomy to allow uterine incision healing and minimize risk of uterine rupture. 2, 7

Nuance in the Evidence

There is a significant divergence between guideline recommendations and some published case series. While ACOG guidelines clearly recommend against routine cesarean myomectomy 1, multiple retrospective studies from tertiary centers report acceptable outcomes in selected cases 5, 6, 8, 4. However, these case series represent highly selected patients with favorable fibroid characteristics, performed by experienced surgeons with appropriate hemostatic techniques. The guideline recommendation prioritizes maternal safety across all practice settings, not just tertiary centers with subspecialty expertise.