Cesarean myomectomy in the last ten years; A true shift from contraindication to indication: A systematic review and meta-analysis.

BACKGROUND: A lot of debate is present about Cesarean myomectomy (CM) in women with uterine myoma whether to consider it a feasible and safe procedure or an absolute contraindication. OBJECTIVE: To assess the safety and feasibility of myomectomy during cesarean section in women with uterine myoma. SEARCH STRATEGY: Electronic search was made on MEDLINE, EMBASE, Cochrane Library, ISI web of knowledge and Scopus from January 1, 2008 to December 31, 2019 using terms "Caesarean section", "Myomectomy", "Fibroid", "Caesarean myomectomy". SELECTION CRITERIA: All full length studies either prospective or retrospective that address caesarean myomectomy were included. DATA COLLECTION AND ANALYSIS: The outcomes studied were haemorrhage, mean change in haemoglobin, operative time, need for blood transfusion, febrile morbidity and duration of hospital stay. RESULTS: Total 249 studies were assessed for eligibility and 17 studies included in analysis with 6545 women. There were 4702 (71.85 %) women in caesarean myomectomy (CM) group and 1843 (28.15 %) women in cesarean section (CS) group. There was statistically significant but clinically insignificant decrease in hemoglobin [MD = 0.27, 95 %CI = 0.08-0.45, p = 0.005; very low quality], significant higher need for blood transfusion [RR = 1.45, 95 %CI = 1.05-1.99, p = 0.02; high quality] in CM group versus CS alone. The mean operative time (minutes) [MD = 14.77, 95 %CI = 6.91-22.64, p = 0.0002; moderate quality] and mean hospital stay (days) [MD = 0.36, 95 %CI = 0.19-0.53, p < 0.00001; high quality] was significantly less in CM group, though of not any clinical significance. No difference in incidence of haemorrhage [RR = 1.16, 95 %CI = 0.86-1.56, p = 0.32; moderate quality evidence] and fever [RR = 1.17, 95 %CI = 0.83-1.65), p = 0.36; moderate quality] in two groups. CONCLUSIONS: The meta-analysis suggests CM is associated with clinical insignificant increase in operative time, blood loss and hospital stay, especially with multiple and large size myomas. CM should be preferred over CS alone especially by experienced surgeons with appropriate haemostatic techniques and tertiary care centres.

The impact of mechanical cervical dilatation during elective cesarean section on postpartum scar integrity: a randomized double-blind clinical trial.

OBJECTIVE: The current study aimed to evaluate the impact of mechanical cervical dilatation during elective cesarean section (CS) on postpartum scar integrity at 6 months post operation. METHODS: A randomized double-blind clinical trial (UMIN000027946) was conducted at a tertiary university hospital in the period between July 1, 2017 and April 30, 2018. The study included pregnant women with a singleton fetus at term ≥37 weeks of gestation scheduled for elective CS. Eligible participants were allocated either to the study group (women with intraoperative cervical dilatation) or the control group (women with no intraoperative cervical dilatation). The patients were followed up at 6 months after CS by 3D ultrasonography to check for the scar integrity and quality. The primary outcome was the difference in sonographic parameters of the scar integrity between the two groups. RESULTS: Four hundred twenty two women were approached to participate in the study. There was no statistically significant difference regarding the baseline characteristics of both the groups. Scar width and depth were significantly higher in the cervical dilatation group (P=0.002 and 0.001, respectively). Fewer cases with scar defects (niche) were found in the cervical dilatation group than in the control group (5.03% vs 11.04%, respectively, P=0.048). There was no significant difference regarding the rate of wound infection or endometritis in both the groups (P=0.717 and 0.227, respectively). The incidence of febrile morbidity was higher in the no cervical dilatation group (10.5%) compared to (5.0%) the cervical dilatation group (P=0.045). CONCLUSION: Cervical dilatation during elective CS is associated with thick scars with low incidence of scar defects.