Pregnancy Rate and Delivery Characteristics after Isobaric Gasless Laparoscopic Myomectomy under General or Combined Spinal-Epidural Anaesthesia

S154

Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S132–S155

Intervention: Pregnancy complications (first trimester loss, second trimester loss, pre-term labor(PTL), preterm premature rupture of membranes (PPROM), intrauterine growth restriction (IUGR)) and comorbidities including diabetes (DM), asthma, chronic hypertension (CHTN), gestational diabetes (GDM) were compared in the two groups using Fisher’s exact, Pearson’s Chi-square, Mann-Whitney U test for analysis. Measurements and Main Results: A total of 152 patients with fibroids were identified during this study period. The matching control group included 165 patients. Demographics were comparable in the two groups other then the higher prevalence of the African American race in the fibroid group (90.8 vs.68.5%, p\.001). Tables 1 and 2 compare comorbidities and pregnancy complications. Although co-morbidities and histories were comparable between the two groups, with the exception of CHTN and PPROM fibroids were associated with higher incidence of adverse pregnancy outcomes. Fibroid degeneration occurred in 23% of the patients with fibroids. A comparison of co-morbidities and prior history Co-morbidity/history

Fibroid (%)

Control (%)

p value

Asthma CHTN DM History of History of History of History of History of

7.9 6.7 1.8 12.7 13.3 0 0 0.6

10.5 13.8 5.9 26.3 12.5 0.7 3.9 2.6

.441 .040 .076 .003 .868 .479 .012 .198

* D&C cesarean IUGR PPROM PTL

*Dilation and Curettage

Patients: Thirty-two infertile women, aged % 43 years, with one or more intramural or subserosal leiomyomas measuring R 4 cm, symptomatic or progressively enlarging. Intervention: Isobaric gasless laparoscopic myomectomy using a subcutaneous lifting system and conventional laparotomic instruments to remove medium size or large intramural and subserosal leiomyomas under general or combined spinal-epidural anaesthesia. Measurements and Main Results: The number of myomas removed per patient was 2.4  1.5. The biggest fibroid was intramural in 78% and subserosal in 22% of the cases. The mean diameter of the biggest fibroid was 6.4  1.9 cm. The endometrial cavity was never incidentally opened. The median operating time and blood loss were respectively 95 [73-118] minutes and 200 [100-300] mL. Seventeen interventions were performed under spinal-epidural anaesthesia and 15 under general anaesthesia. No conversions to laparotomy and no blood transfusions were required. Of 32 women wishing to conceive after surgery 24 became pregnant spontaneously (75%). There were no significant differences in number, type, position and size of the fibroids and in demographic characteristics between the women who conceived and the other patients. Early miscarriage occurred in 3 cases. Ten patients delivered by elective Caesarean Section. Ten women underwent a trial of labour: eight births took place by vaginal delivery and two by Caesarean Section for cervical dystocia and fetal-pelvic disproportion; the average time between myomectomy and delivery was 26 months. The fetal weight after vaginal and abdominal surgical birth was 3509  186 gr and 3199  424 gr respectively. No uterine rupture during pregnancy or delivery occurred. One patient is currently pregnant. Eight women are still searching for children. Conclusion: Isobaric myomectomy for multiple or large intramural and subserosal leiomyomas has good reproductive and obstetric outcome. No complications occurred in vaginal births after intervention.

Pregnancy Complications Complication

Fibroid (%)

Control (%)

p Value

1st Trimester Loss 2nd Trimester Loss IUGR PTL PPROM * GDM Pre-eclampsia

7.9 5.9 15.1 16.4 15.8 7.2 11.8

3.6 1.2 8.5 2.4 3.6 4.2 3.1

.143 .029 .08 \.001 \.001 .332 .003

*Gestational diabetes

Conclusion: Fibroids are the most common benign tumors in women. They complicate up to 4% of pregnancies. They are more common in African American women. Not only are fibroids correlated with infertility but have shown to have a significant correlation with adverse pregnancy outcomes.

511 Pregnancy Rate and Delivery Characteristics after Isobaric Gasless Laparoscopic Myomectomy under General or Combined SpinalEpidural Anaesthesia Cammareri G, Macalli EA, Lanzani C, Francesco S Di, Turri A, Rehman S, Ferrazzi EM. Obstetrics and Gynaecology University Department, Vittore Buzzi Children’s Hospital, Milano, Italy Study Objective: To investigate reproductive outcome after isobaric gasless laparoscopic myomectomy. Design: Retrospective analysis of 32 isobaric myomectomies, between October 2005 and September 2010. Setting: Obstetrics and Gynaecology University Department.

512 Surgical Dilemma of Managing Concurrent Uterine Factors in a Patient with Recurrent Miscarriages Javaid H,1 Ashraf M,2 Abuzeid M.2 1Gynecology and Obstetrics, Hurley Medical Center, Flint, Michigan; 2Reproductive Endocrinology and Infertility, Hurley Medical Center, Flint, Michigan Study Objective: The aim of this presentation is to bring to attention the unique diagnostic and surgical dilemma of dealing with coexisting uterine leiomyoma and septum; and to propose a possible surgical management. Measurements and Main Results: CASE REPORT: We report a 31-yearold patient who presented with the chief complaint of recurrent miscarriages (two) at 10 weeks gestation. After extensive diagnostic workup including transvaginal ultrasound scan and saline infusion sonohysterogram (SIS) (2-D and 3-D) the patient was found to have a 3 x 2 cm intramural/ submucousal fundal leiomyoma (type 2). The leiomyoma was removed via laparoscopic myomectomy and the myometrial defect was sutured in two layers. Diagnostic hysteroscopy was performed at the conclusion of the procedure which showed no entry into the uterine cavity. However, there was evidence of a possible concurrent incomplete uterine septum. Surgical correction of the septum had to be delayed for fear of interruption of the myometrial sutures as a result of division of the septum. The patient was advised to return after two months for further evaluation and management of the uterine septum. The patient failed to follow up which lead her to have three more miscarriages and one chemical pregnancy. This happened over a period of 18 months after the myomectomy. The patient underwent a hysterosalpingogram which confirmed the diagnosis of incomplete uterine septum and she was scheduled for hysteroscopic division of the uterine septum. (Videos from the actual surgeries will be shown during the presentation) Conclusion: Surgical management of fundal intramural/submucosal leiomyoma and uterine septum cannot be performed concurrently in one session. Attention to the leiomyoma alone does not prevent recurrent pregnancy loss. Hopefully surgical correction of the uterine septum will allow the patient to have a full term pregnancy.