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Husanghodjaeva Malika Tursunkhodzhaevna, Head of the Department of Emergency Gynecology Republican Scientific Center of Emergency medical center, Uzbekistan E-mail: [email protected]
TO THE QUESTION OF ORGAN-SPARING SURGICAL TREATMENT OF UTERINE FIBROIDS ON PREGNANCY
Abstract: As a result of conservative myomectomy, 24 out of 28 women managed to maintain the desired pregnancy. Pregnancy was terminated in 4 patients 12-22 days after the operation in the period of 11-25 weeks. There were no serious complications during the operation and in the postoperative period. All 24 women with retained carried her pregnancy to full-term period, among all, resulting in prompt delivery.
Keyword: uterus, pregnancy, myomectomy.
In choosing the tactics of surgical treatment of MM among pregnant women, perhaps the most important is the introduction of objective arguments on the most discussed issues: what is better, to terminate the pregnancy artificially, to carry out a conservative myomectomy after a while and then allow a woman to become pregnant; the second option may be a conservative myomectomy (CM) against the background of pregnancy with a clinical focus on its preservation; and finally, the third - to use one and the other tactics depending on the model of pathology [5; 6]. However, it requires the creation of comprehensively balanced models of pathology, coordination and consensus on their content among the leading domestic and foreign experts. Otherwise, the whole problem, as before, will be outside the Protocol clinical strategy, which is the basis for the formation of the medical state standard.
Purpose ofresearch. The study of the feasibility, effectiveness, safety of CM in order to maintain the desired pregnancy.
Material and methods of examination. Under our supervision there were 779 patients with uterine myoma in the period from 2001 to 2007, of this number, 86 were women (11.0 per cent) of pregnant women in the period 4-32 weeks. In this group, special attention was drawn to 28(3.6%) pregnant women at gestation from 6 to 26 weeks. All pregnancy was desirable, and this criterion was the main factor in the formation of this sample. In 18 out of 28, pregnancy occurred after long-term treatment of primary infertility. The presence of uterine fibroids before pregnancy was known to 22 women out of 28, the rest she was first identified during this pregnancy. The age of pregnant women ranged from 24 to 32 years, the average-26.7 ± 2.1. All women were registered in the women's consultation, had no severe extragenital pathology. Primipara, including avtomobilnyj, was 21 out of 28 multipa-rous -7, nagaragawa was not. All 28 patients were admitted with the presence of intramural and intramural-submucous myomatous nodes. At the same time, their value ranged from
4.0 cm to 18.0 cm in diameter, and the number - from 1 to 4. Pregnant women with subserous nodes on the leg, small single asymptomatic myomas, as well as with small-nodular diffuse myometrial lesions, as well as those with irreversible forms of abortion, were not included in the development.
Research result. Among all 28 women, there was an increase in fibroids during the present pregnancy. However, in 11 out of 28, we described it as fast growth for the following reasons. Of these 11 women, 8 were aware of the presence of fibroids before pregnancy, and 3 it was detected for the first time during this pregnancy. The growth of fibroids, exceeding its initial (before pregnancy) size in 2 times was observed in 4 of 8 patients, 3-4 times - in 2, 5 times - in 2. In 3 women with newly diagnosed myoma during pregnancy, the tumor growth recorded in the women's consultation was: 2 times-in 2.3 times-in 1. At the same time, only 2 of11 revealed growth of nodes with uterine cavity deformation. On the anterior wall and in the bottom of the body of the uterus, the nodes were located in 7 of 11, on the back wall - in 2, on the back and front wall of the body of the uterus - in 2 of 11.
Eating disorders of myomatous nodes, registered clinically in 6 of 28 patients, were verified by histological studies in all without exception episodes. In 5 of 6 patients myoma was monocular, large size (from 6 to 18 cm.), all lay deep, affecting the vascular layer of the myometrium. In 1 of 6 weeks of pregnancy, the size of the tumor in the uterine day reached 18 cm in diameter, exceeding the size originally established during pregnancy by 5 times. During the operation, the perimeter in the area of the outer pole of the tumor was inflammatory and covered with a thin fibrin coating, soldered to the lower pole of the greater omentum. In 5 others, on the background of pregnancy of 15-26 weeks, there was also a rapid growth of monocular tumor in 3 and 4 times compared to the established size in the early stages of this pregnancy. During the operation, the perimetry above the nodes in 3 of these 5 was
TO THE QUESTION OF ORGAN-SPARING SURGICAL TREATMENT OF UTERINE FIBROIDS ON PREGNANCY
cyanotic, but without fibrin plaque, there were obvious foci of softening, areas of hemorrhage, swelling of the myomatous node. None of the 6 cases had purulent complications of eating disorders of myomatous nodes. In 4 of 6 episodes, myomatous nodes were located in the bottom and body along the anterior wall of the uterus, in 1 in the utero-tubal angle on the right, in 1 in the body of the uterus along the posterior wall. The examination in all cases showed moderate leukocytosis to 11.0 x 109 ml., noticeable irritation in the leukocyte formula, subfibrillitis, unevenness of echo density to echonegative foci in myomatous nodes in ultrasound. In 5 out of 6 cases, myomatous nodes were palpated, demonstrating the deformation of the surface of the pregnant uterus, and the most indicative was a symptom of local pain in the area of the myomatous node location.
As a result of surgical treatment, 24 out of 28 women managed to keep their pregnancy to full term, and 4(14.3%) patients (2 with eating disorders of fibroids and 2 with the symptom of rapid growth) had it spontaneously 12-22 days after CM in terms of 11-25 weeks. It should be noted that among these 4 women, the symptoms of threatened miscarriage gradually disappeared in the first 3-7 days after the operation, and they were discharged from the Department under outpatient control. Later, however, on the above date, for unknown to us reasons, once again developed the signs of threats of termination, which failed to stop. All 4 patients were admitted to our clinic again on the background of spontaneous abortion in the course. The miscarriage had no signs of violation of the integrity of the fresh stitches in the uterus (clinical and ultrasound monitoring). All underwent instrumental revision of the uterine cavity after spontaneous abortion under ultrasound control, in which all patients visualized the suture area on the uterus without doubt in its viability. Post-abortion period in all proceeded without significant complications.
In the remaining 24 patients, the dynamics of lysis of the symptoms of threatened abortion (in the near future after surgery) clinically did not differ from that observed among women with interrupted pregnancy. The level of blood loss, duration of intervention, the nature of anesthetic benefits (all women operated under endotracheal anesthesia), also did not differ significantly. At the same time, such factors as the size and number of myomatous nodes, the depth of tumor occurrence in the uterine wall, as well as its proximity to the placenta, significantly distinguished the group of operated pregnant women with interrupted pregnancy.
In 25 out of 28 women, the operation began with a pfa-nenstiel incision, in 3 - median laparotomy. Conservative myomectomy was done through the cross section of electrocautery of the myometrium in the projection of the greatest convexity of the tumor. In this case, not only the myometrium
was dissected, but also the surface part of the tumor, which was captured by bullet forceps for external traction. Carefully, stupidly and acutely performed intracapsular enucleation of myomatous nodes using bipolar coagulation hemostasis. The void tried to take in in a single layer using only the nodal cooperhouse the seams such as peterbourgskaya, and its own method, depending on the depth of the niche and nature occur in a number of cases of "surplus" tissue of the myometrium. Resection of these "surpluses" never produced. Long-term absorbable suture material (vicryl, dexon) was used on atraumatic needles. Intraoperative protection of gestation was carried out by giving antispasmodics (baralgin, no-shpa), intravenous infusion of 25.0% -20.0 magnesia sulfate against the background of basic therapy with tocolytics (ginipral). At the initial stages of the operation, all intravenously administered 1.0 Gy without exception. Ceftriaxone, the appointment of which continued in the postoperative period. In one case out of 28 cases intraoperative plasma transfusion was performed, in none case blood transfusion was required. The level of intraoperative blood loss was dependent on the mass of removed myomatous nodes and the depth of their occurrence, ranged from 150,0 to 600,0 ml., on average 340.0 ± 25.0 ml.
As our sample clinical material shows, the threat of termination of pregnancy was the main symptom that patients received. The frequency of development of this syndrome among pregnant women with uterine myoma varies significantly from 30 to 75% [3; 4; 5; 6]. Probably, the localization, size and number of myomatous nodes in the pregnant uterus affect the frequency and severity of the threat of interruption. In our study, in a significant proportion of pregnant women (50%), the threat of interruption developed in the early stages of gestation. This is most clearly manifested in large (6-18 cm. in diameter) myomatous nodes with intramural localization.
As it was noted in the results of our studies, among 4 women whose pregnancy was terminated 12-22 days after the operation, the symptoms of the threat of interruption in the early postoperative period gradually disappeared, there were no visible complications, there were no blood secretions, ultrasound showed no signs of detachment of the child's place and expressed the threat of interruption. However, the pregnancy they broke off in the above terms. According to our observations, the unfavorable outcome of pregnancy was affected by the depth of occurrence, the number and size of myomatous nodes, as well as the rapid growth of the tumor with eating disorders. It should be noted that the operation in the above conditions in the early stages of gestation (up to 10 weeks), probably also had a negative impact on the outcome of pregnancy. Most researchers recommend CM closer to 16 weeks, because in this period, the placenta has already been formed and the level of progesterone significantly increases. However, in an urgent situ-
ation (eating disorders of fibroids), we were not always able to prolong the pregnancy to the optimum date.
However, in some cases, when removing large myomatous nodes, excessive flaps of the myometrium may form in the outer part of the uterus. Resect them in any case impossible. This consideration arose in the light of the recent fundamental studies of the morphology of myometrium, where the minimum proliferation of myocytes during pregnancy is established, and the growth of the pregnant uterus occurs in the majority of cases of hypertrophy of myometrial cells. Therefore, resection of the resulting excess myometrium can significantly reduce its total mass, which will adversely affect the further course of pregnancy [1]. This phenomenon was also noted in earlier studies, when, after resection of "excessive myometrium", in long-term terms, the uterus significantly decreased in size, resembling an infantile organ [2]. At the same time, in such conditions, the submerged method of niche restoration can significantly deform the uterine cavity, cause an increase in pressure in the cavity of the amnion, rupture of the membranes, detachment of the child's place. Therefore, we have proposed and implemented in their practice a way to
restore the niche overlap. In this case, one part of the excess flap falls into the niche cavity, and the second on top of it. Both of the flap shall be attached to the underlying tissues independently for better fixation, hemostasis and reparation. Fears that one part of the flap lies on the perimeter of the contralateral flap were in vain, because the subsequent course of pregnancy and cesarean section showed quite normal retraction of the myometrium layers and repair of the organ without significant deformation of the uterine wall.
Conclusion. Thus, as shown by the practice of working with pregnant women against the background of uterine fibroids, there is a group ofwomen, among whom the traditional conservative treatment to prolong the desired pregnancy is ineffective. Studies have shown that CM, in such conditions, quite effectively allows, in most cases, to maintain the desired pregnancy.
However, despite the very traumatic operation, there were no serious uncontrolled complications that could require urgent termination of pregnancy or hysterectomy. This is essential because otherwise the CM would lose all rational meaning during pregnancy.
References:
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3. Botwin M. A., Pobedinsky N. M. Clinical management of pregnancy with centripetally the growth of large fibroids // Obstetrics and gynecology. 2004.- No. 1.- P. 24-27.
4. Bunin G. S. Shmakov. Features of the course and management of pregnancy and childbirth in pregnant women with uterine myoma // Obstetrics and gynecology. 1996.- No. 1.- P. 64-65.
5. Krasnopolsky V I., Logutova L. S., Buyanova S. N. Surgical and obstetric tactics in combination with pregnancy and genital tumors // Obstetrics and gynecology. 2002.- No. 2.- P. 41-45.
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