Vaginal delivery after laparoscopic myomectomy can be accomplished safely without uterine rupture by using management protocols that are similar to those used for vaginal birth after cesarean section, reported Jun Kumakiri, M.D., and his associates at Juntendo University, Tokyo.
In a study of 108 women who wanted to become pregnant after undergoing laparoscopic myomectomy (LM) and were followed for at least 6 months, 40 spontaneous pregnancies and 7 pregnancies by assisted-reproductive technology occurred in 40 women over a 4-year period.
Using Cox regression analysis, the investigators found that pregnancy after LM was positively associated with the diameter of the largest myoma (odds ratio [OR] 1.06) and negatively associated with the patient's age (OR 0.88) and with the number of enucleated myomas (OR 1.17).
A total of 32 deliveries occurred after LM. Of these, vaginal birth was attempted in 23, resulting in 19 (83%) successful vaginal births, with all but one occurring after 37 weeks' gestation. Attempted vaginal birth after LM was unsuccessful in four patients (J. Minim. Invasive Gynecol. 2005;12:241–6).
Vaginal birth after LM was performed according to recommendations from the American College of Obstetricians and Gynecologists on vaginal birth after cesarean section, Dr. Kumakiri said.
In the 19 pregnancies that resulted in vaginal deliveries after LM, the average diameter of the largest myoma at LM was 68.7 mm, the average number of enucleated myomas was 2.9, and the average number of hysterotomies was 2.5.
In the 68 patients who received LM but didn't get pregnant, the average diameter of the largest myoma was 62.3 mm and the average number of enucleated myomas was 3.7.
No patient suffered uterine rupture during or after delivery, the investigators said, perhaps because all enucleation wounds were sutured, as they would be with laparotomy.
Because some patients had infertility factors other than myoma before LM, the researchers said, “it is necessary to examine a larger population, not including such patients, to evaluate whether the implantation environment alone is responsible for the reduced fertility associated with uterine myomas.”