CLINICAL & BASIC RESEARCH SQU Med J, May 2012, Vol. 12, Iss. 2, pp. 190-196, Epub. 9th Apr 2012 Submitted 21st Sep 11 Revision Req. 11th Dec 11, Revision recd. 25th Jan 12 Accepted 29th Feb 1Department of Obstetrics & Gynaecology, Sultan Qaboos University Hospital, Muscat, Oman; 2Department of Obstetrics & Gynaecology , College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman. *Corresponding Author e-mail: lovina1857@gmail.com عملية استئصال ورم الرحم العضلي أثناء إجراء العملية القيصرية: إمكانية إجراء العملية والسالمة لوفينا مات�سادو، فيدياناثان غوري، نهال الريامي، ملياء اخلرو�سي، حدوث من املخاوف ب�سبب القي�رضية العملية اإجراء اأثناء الع�سلي الرحم ورم ا�ستئ�سال تقبل عدم على العادة جرت الهدف: امللخ�ص: نزيف قد ي�سعب ال�سيطرة عليه اأثناء العملية اجلراحية وب�سبب امل�ساعفات املتوقعة بعد العملية. ومع ذلك، فقد ظهر موؤخرا يف العديد من االأبحاث اأن ا�ستئ�سال ورم الرحم الع�سلي اأثناء العملية القي�رضية اليزيد من خطر النزف اأو امل�ساعفات بعد العملية اجلراحية. الطريقة: نقدم هنا و�سفا لثمان حاالت من م�ست�سفى جامعة ال�سلطان قابو�س، ُعمان، حيث مت اإجراء ا�ستئ�سال اأورام ليفية يف اأ�سفل الرحم اأثناء مت والتي للرحم اخللفي اجلدار يف ليفي وورم االأمامي، الرحم جدار يف امل�ستاأ�سلة الليفية االأورام من �سبعة كانت القي�رضية. العملية ا�ستئ�ساله للتمكن من اإغالق �سق الرحم. النتائج: كان متو�سط عمر الن�ساء الالتي مت اإجراء العملية لهن 28.7 �سنة ومتو�سط عمر احلمل عند الوالدة 36.75 اأ�سبوعا. و فيما يتعلق بفقدان الدم اأثناء العملية، فقدت مري�سة واحدة 900 مل، وخم�س ن�ساء فقدن بني 1 – 1.5 لرتا، واثنتان فقدن بني 1.5 - 2 لرتا، وفقدت امراأة 3.2 لرتا من الدم حيث كان قيا�س الورم الليفي عندها 10×12 �سم. وعلى الرغم من كون اأغلبية االأورام الليفية كبرية )7 من االأورام الليفية كانت اأكرب من 5 �سم يف احلجم( و ٪50 منها �سنفت من �سمن التليفات الداخلة يف اجلدار الع�سلي للرحم، مل تكن هناك حاجة ال�ستئ�سال الرحم. وقد ا�ستدعت حالة واحدة لقطع التغذية الدموية، بينما ا�ستدعت حالة اأخرى للق�سطرة ببالون �رضيان الرحم قبل اإجراء العملية. مت التاأكد من حجم االأورام الليفية عن طريق فح�س الن�سيج املر�سي بعد عملية اال�ستئ�سال. عملية ا�سئ�سال الورم الليفي اأ�سافت 15 دقيقة اإىل الوقت الكلي املعتاد الإجراء العملية القي�رضية ويوما واحدا اآخرا للبقاء يف امل�ست�سفى ومل ت�سجل اأية م�ساعفات لالأمهات اأو اأطفالهن خالل املكوث يف امل�ست�سفى. اخلال�صة: ا�ستئ�سال اأورام الرحم الع�سلية اأثناء العملية القي�رضية يف ن�ساء خمتارات هو اإجراء اآمن وفّعال يف م�ست�سفيات الرعاية الثالثية بوجود جراحني ذوي خربة. مفتاح الكلمات: والدة قي�رضية، عملية ا�ستئ�سال ورم الرحم الع�سلي، اأورام ليفية، حمل، نزيف، ُعمان. abstract: Objectives: Caesarean myomectomy has traditionally been discouraged due to fears of intractable haemorrhage and increased postoperative morbidity. However, a number of authors have recently shown that myomectomy during Caesarean section does not increase the risk of haemorrhage or postoperative morbidity. Methods: We present a series of 8 cases from Sultan Qaboos University Hospital, Oman, where myomectomy was performed during Caesarean section for large lower segment fibroids. Seven were anterior lower segment fibroids, while one was a posterior lower uterine fibroid which interfered with closure of the uterine incision. The antenatal course, perioperative management, and postoperative morbidity are discussed. Results: The average age of the women was 28.7 years and mean gestational age at delivery was 36.75 weeks. Regarding intra-operative blood loss, 1 patient lost 900 ml, 5 patients lost 1–1.5 litres, 2 lost 1.5–2 L, and 1 patient with a 10 x 12 cm fibroid lost 3.2 L. Despite the majority being large myomas (7 of the 8 patients had myomas >5 cm in size) and 50% being intramural, no hysterectomy was required. Stepwise devascularisation was necessary in one case and preoperative placement of uterine balloon catheters was necessary in another. The size of the fibroids was confirmed by histopathology. Myomectomy added 15 minutes to the operating time and 1 day to the hospital stay, but there was no significant postoperative morbidity. Neonatal outcome was good in all patients. Conclusion: In selected patients, myomectomy during Caesarean section is a safe and effective procedure at tertiary centres with experienced surgeons. Keywords: Caesarean section; Myomectomy; Fibroids; Pregnancy; Haemorrhage; Oman. Caesarean Myomectomy Feasibility and safety *Lovina SM Machado,1 Vaidyanathan Gowri,2 Nihal Al-Riyami,1 Lamya Al-Kharusi,1 Advances in knowledge - This is the first study in Oman addressing the controversial and important issue of performing myomectomy during Caesarean section. This procedure is reported to be associated with intractable haemorrhage and postoperative morbidity by some authors while other authors advocate its safety. - Caesarean myomectomy is safe to perform in selected patients and results in no significant post-operative morbidity. The procedure can help younger patients avoid hysterectomy. Lovina S M Machado, Vaidyanathan Gowri, Nihal Al-Riyami and Lamya Al-Kharusi Clinical and Basic Research | 191 The incidence of myoma associated with pregnancy is reported at 0.3–5%, with a majority of myomas not requiring surgical intervention during pregnancy or delivery.1–4 Myomectomy at the time of a Caesarean section has traditionally been discouraged due to fears of intractable haemorrhage and increased postoperative morbidity. However, a number of authors have recently shown that myomectomy at Caesarean does not increase the risk of haemorrhage.2,10–21 We present a series of 8 cases where myomectomy was performed during Caesarean section for large lower segment fibroids ranging in size from 4 to 12 cms. The antenatal course, perioperative management, and postoperative morbidity are discussed. Methods We performed a retrospective cohort study of 8 patients with myomas which resulted in pregnancy complications. All 8 patients underwent myomectomy at the time of Caesarean section at Sultan Qaboos University Hospital (SQUH) between January 1999 and December 2010. Ethical approval for the study was obtained from the University Medical Research and Ethics Committee (MREC #399). Patients’ medical records were perused for demographic data, parity, and antenatal course, type of Caesarean section, size and location of the fibroids, blood loss, postoperative morbidity, and neonatal outcome. All of the women in the study fulfilled the following five criteria: 1) documented fibroid during the index pregnancy by antenatal ultrasound or at surgery; 2) delivery by Caesarean; 3) no evidence of antenatal bleeding; 4) no other procedure at Caesarean apart from myomectomy, and 5) no pre-existing coagulopathy. Informed consent was obtained from all patients preoperatively. Of the 8 patients studied, 7 had anterior lower segment fibroids and one had a posterior lower uterine fibroid which interfered with closure of the uterine incision. Adequate blood and blood products were arranged preoperatively. Myomectomy was performed in the conventional fashion using an incision over the myoma, enucleating it, and obliterating the dead space in two to three layers using interrupted 1-0 Vicryl sutures (Ethicon Inc., New Jersey, USA). Anterior lower segment myomas encroaching on the proposed incision line were excised prior to delivery of the baby while the others were removed after the baby had been delivered. The Caesarean incision was closed in 2 layers with 1-0 Vicryl sutures. High dose oxytocin was used intraoperatively and postoperatively, and some patients required additional uterotonic agents. Blood loss was estimated from suction aspiration, and from weighing mops, swabs and drapes used during surgery. Prophylactic antibiotics were administered to all the patients. A review of literature was performed using PubMed, Medline, and Google. Results The average age of the women was 28.7 years. The age, parity, and associated risk factors of the patients; factors, size and location of the myomas; the operative findings and incisions used during surgery, and the complications and neonatal outcomes are summarised in Table 1. Of those in the study, 7 of the 8 patients had lower segment anterior wall fibroids at or close to the incision site, and one patient had a large posterior wall fibroid which projected through the uterine incision after delivery of the baby and needed removal to facilitate - The article highlights various new techniques that effectively control haemorrhage during Caesarean myomectomy, and has educational value for less experienced obstetricians. Application to patient care - Caesarean myomectomy allows women to have a better obstetric outcome in future pregnancies, and to avoid hysterectomy. - It relieves symptoms associated with fibroids and negates the need for later surgery or sonographic follow-ups for the fibroid after delivery. - It is a safe procedure in selected patients when performed in tertiary care hospitals by experienced obstetricians with newer measures available to curtail haemorrhage. Caesarean Myomectomy Feasibility and safety 192 | SQU Medical Journal, May 2012, Volume 12, Issue 2 closure. In total, 4 were intramural fibroids (50%) and 4 were subserous. The size varied from 4–12 cm with 7 of them being larger than 5 cm in diameter. Regarding intra-operative blood loss, 1 patient lost 900 ml, 5 patients lost 1–1.5 litres, 2 lost 1.5–2 L, and 1 patient with a 10 x 12 cm subserous fibroid lost 3.2 L. Stepwise devascularisation was needed to control atonic postpartum haemorrhage (PPH) in 1 patient. Preoperative placement of uterine balloon catheters was used in another patient with a large posterior wall fibroid. The balloon was inflated intra-operatively after delivery of the baby, effectively controlling the haemorrhage. None of the patients required hysterectomy. Neonatal outcome was good in all the patients. The mean gestational age at delivery was 36.75 weeks (range 33–38 weeks). The 5 minute Apgar score was 9–10 in all the newborns with birth weights ranging from 2160 grams (preterm 33 weeks) to 3,000 grams. Table 1: Demographic and clinical profile, operative findings and outcome of the patients who underwent Caesarean myomectomy at our institution Age/Parity G/P/A Risk factors/ co-morbidities No. & location of fibroids Size at start of pregnancy Size at CS GA at CS in wks Est. blood loss in ml Baby details Incision Postoper- ative morbidity 26 yrs G6/P1/A4 Prev 1 CS Intramural LUS anterior wall + multiple small fibroids 6.2 x 4.3 cms 7 x 6 cms 38 1,100 Female 2,660 gms Apg 9/10 Pfannenstiel UT- Lower seg transverse None 19 yrs G1 Essential HT PPROM 32 w Betamethasone x 2 doses Lower segment left side. Subserous 8.6 x9.1 cms 9 x 9 cms Infarction 33 1,100 Female 2,160 gms Apg 8/9 Vertical SUMLI UT-Low vertical ROP, deflexed head None 35 yrs G4/P3 None Lower segment ant. Wall Intramural 9x10 cms 8 x 8 cms 38 1,500 2 u PRBC Uterine @ balloon catheter in situ Male 2,830 gms Apg 9/10 Pfannenstiel UT-Lower seg transverse Blood transfusion 24 yrs G2/P1 Breech, poly- hydramnios. Prev. multiple myomectomy (4). Cavity not entered Lower segment anterior wall Intramural 6 x 7 cms 8 x 7 cms 38 1,100 Atonic PPH Stepwise devasculari- sation Female 2,790 gms Apg 8/9 Pfannenstiel UT-Lower segment transverse None 28 yrs G2/P1 Previous LSCS PIH Lower segment posterior wall Subserous 6.5 x 5.5 cms 6.5 x 6 cms 38 1,100 2 u PRBC Female 3,000 gms Apg 9/10 Pfannenstiel UT- Lower segment transverse Blood transfusion 38 yrs G5/P4 None Lower segment rt side anterior Subserous 9.8 x 7 cms 10 x 12 cms Degen. 37 3,200 6 u PRBC 4 FFP, uterotonics Male 2,880 gms Apg 5/9 Vertical SUMLI UT- High lower segment transverse Anaemia Blood transfusion 28 yrs G1 PIH Lower segment anterior Subserous 6 x 5 cms 7 x 5 cms Haem. 37 900 Female 2,690 gms Apg 9/10 Pfannenstiel UT- Lower segment transverse None 32 yrs G9/P2/A6 Previous 2 LSCS Upper part of lower segment anterior Intramural 4 x 4 cms 4 x 4 cms Calcified 35 2,000 2 u PRBC Female 2,530 gms Apg 9/10 Pfannenstiel UT- Lower segment transverse Blood transfusion Legend: G/P/A = gravida/para/abortion; CS = Caesarean section; GA =gestational age; LUS = lower uterine segment; HT = hypertension; PPROM = preterm premature rupture of membranes; SUMLI = subumbilical midline longitudinal incision; ROP = right occipito-posterior position; UT = uterus; LSCS = lower segment Caesarean section; PIH = pregnancy induced hypertension; PPH = postpartum haemorrhage; PRBC = packed red blood cells, FFP = fresh frozen plasma; Apg = Apgar score at 1 and 5 minutes Lovina S M Machado, Vaidyanathan Gowri, Nihal Al-Riyami and Lamya Al-Kharusi Clinical and Basic Research | 193 Discussion Uterine myomas are found in approximately 0.3–5% of pregnant women, with the increasing incidence attributable to the fact that more and more women are delaying childbearing.1–4 One in ten of these women will have complications during pregnancy that are related to the myoma. A great majority of myomas associated with pregnancy remain asymptomatic and do not require treatment, with about 22–32% showing increased growth.5 Larger fibroids (>5cm) are more likely to grow during pregnancy and can cause miscarriages, obstructed labour, malpresentations, pressure symptoms, pain due to red degeneration, preterm labour, preterm premature rupture of membranes, Table 2: A comparison of various studies on Cesarean myomectomy Authors Roman11 Kwon15 Kaymak2 Ehigiegba16 Ortac10 Ahikari17 Omar19 Machado LSM Year 2004 2003 2004 2001 1999 2006 1999 2011 No. and type of cases 368 88 120 25 22 14 2 8 111 CM 257 CS NA 40 CM 80 CS NA NA NA NA NA Maternal Age 37 35 32.5±4.4 31.9±4.5 30.8±3.1 30.8±3.8 NA 25–35 yrs NA 28.75 Parity Para 0 NA NA 84.1% 0.8±1.2 1.1±1.1 13 NA 11 2 2 Para 1-4 NA NA 16.9% NA NA 12 NA 3 0 6 Mean GA at CS 38 (27.3– 41.6) 39 (24– 42.6) 38±1.19 37.7±2.5 37.6±1.4 36.9 (29–42) NA NA NA 36.75 (33–38) No. of Fibroids Single 91 67% 75% 10 NA 12 2 7 Multiple 20 33% 25% 15 NA 2 0 1 Location Lower US NA 50% 11 (27.5%) NA NA 6 2 7 Upper US NA 50% 22 (55%) NA NA 5 - 1 Both NA - 7 (17.5%) NA NA 2 - - Pedunculated NA - 0 NA NA 1 - - Size <5 cms Mean 3.5 (0.9–30) Mean 3 (1 –20) NA ≤3cm, 2 (5%) Most 2–4 cms Mean 22 (9.5±4.6) range 5–19 cm 5 NA 1 5-10 cms 4–5cm, 14 (35%) 2 7 - 6 >10 cms ≥6cm, 24 (60%) - 2 2 1 Average Operating time LSCS - 51 (20–07) NA - 44.4±6.7 - - 35±3.28 NA 1,500 ml CM 55 (25– 161) - NA 53.3±18.6 - NA 41.6±8 Range 25–60 54.1±3.84 P >0.05 900– 3200ml Blood loss Blood loss 12.6% 12.8% 731.5 ml 12.5% 11.3% 876 ±312 ml 324.2 ml 472 ml NA 1,500 ml Range Significant haem. Significant haem. 400– 2500ml - - 400–1700ml - 359–600ml 900– 3200ml Postoperative Morbidity Blood transfusion 0.9% 1.2% 1 relap. for bleeding 4 (10%) 5 (6.3%) 5 NA 1 NA 4 Fever 4.5% 4.7% 12 (13.6%) 3 (7.5%) 8 (10%) 2 (8%) NA NA NA 0 Anaemia NA NA NA NA NA 60% NA NA NA 2 Hysterectomy - - - - - - - - - - Postop Hospital stay in days (range) 3.6 (2–7) 3.4 (2–12) NA 3.3±0.8 2.7±0.6 7.4±2.2 (3–12) 3.7±0.9 (2–6) 6 NA 5.0±0.8 (4-7) Legend: GA = gestational age; US =uterine segment; CM = Caesarean myomectomy; CS = Caesarean section; LSCS = lower segment Caesarean section; NA = not available or not specified; relap = relaparotomy Caesarean Myomectomy Feasibility and safety 194 | SQU Medical Journal, May 2012, Volume 12, Issue 2 retained placenta, postpartum haemorrhage and uterine torsion.5–7 Katz et al. found that 10–30% of women with myomas associated with pregnancy had complications as listed above.7 Caesarean section rates in women with myomas are higher, up to 73%, mainly due to obstructed labour and malpresentations.3 Preservation of the uterus without loss of its function and compromising the mother’s ability to bear more children is definitely a greater surgical achievement than a hysterectomy; hence, Caesarean myomectomy must be considered by experienced obstetricians wherever feasible. The orthodox view of one of the pioneers of myomectomy in non-pregnant women, Bonney, is reflected in his writings: “It is tempting for the adventurous and sympathetic surgeon to condense the operation of lower segment Caesarean section and myomectomy into one undertaking and save his patient the ordeal of a second admission to hospital. This kindly but misguided policy we heartily deprecate.” However, his pupils, Hawkins and Stallworthy, did advocate Caesarean myomectomy in selected cases, as in the incidence of anterior lower segment myomas on the proposed incision line.8 Exacoustos and Rosetti reported that in their series of 9 cases of Caesarean myomectomy, three were complicated by severe haemorrhage necessitating hysterectomy; hence, they recommended caution while making the decision to perform this procedure.9 Some authors report a higher incidence of postpartum haemorrhage and puerperal sepsis if the fibroid is not removed at Caesarean section.3,4 In addition, the uterus in the immediate postpartum phase is better adapted physiologically to control haemorrhage than at any other stage in a woman’s life; hence, it seems logical to perform Caesarean myomectomy. The management of fibroids encountered at Caesarean section remains a therapeutic dilemma. Myomectomy during Caesarean section has traditionally been discouraged due to the risk of uncontrollable haemorrhage, unless the myoma is pedunculated.11 Recent studies have described techniques to minimise blood loss at Caesarean myomectomy including uterine tourniquet, bilateral uterine artery ligation, and electrocautery.10,12,13 In our series, stepwise devascularisation was required to control atonic PPH in one patient; in another patient uterine artery balloon catheters were placed preoperatively. Several authors have now shown that in selected patients and in experienced hands, myomectomy at the time of caesarean section is a safe and effective procedure.2,10–21 The experience of different authors who have performed Caesarean myomectomies is presented in Table 2, including the present series. Roman et al. compared the outcomes of 111 patients who had had myomectomy at Caesarean with 257 patients who had undergone Caesarean alone. No significant difference was found in the incidence of intra- or postoperative complications between the 2 groups;11 however, accurate conclusions cannot be drawn from that study as only 22.7% of the patients had fibroids greater than 6 cm in diameter (median 3.5 cm). Kaymak et al. compared 40 patients who underwent myomectomy at Caesarean section with 80 patients with myomas who underwent Caesarean section alone. The mean size of the fibroids removed was 8.1 cms compared to 5.7 cms in the controls. The authors found no significant difference in the incidence of haemorrhage (12.5% in the Caesarean myomectomy group versus 11.3% in the controls), postoperative fever, or frequency of blood transfusions between the 2 groups, and concluded that myomectomy during Caesarean section is not always a hazardous procedure and can be performed by experienced obstetricians without any complications.2 Ortac et al. reported 22 myomectomies during Caesarean for large fibroids (>5 cm) and advocate it to minimise postoperative sepsis.10 In another study by Burton et al., of the reported 13 cases of myomectomy at Caesarean section, only 1 case had intra-operative haemorrhage and they concluded it to be safe in selected patients.14 A large retrospective case-control study by Li Hui et al. assessed the effectiveness, safety, complications, and outcomes of myomectomy during Caesarean section in Chinese women with fibroids antedating pregnancy.20 The study group of 1,242 pregnant women with fibroids who underwent myomectomy during Caesarean section was compared with 3 control groups: 200 pregnant women without fibroids (Group A), 145 pregnant women with fibroids who underwent caesarean alone (Group B), and 51 pregnant women who underwent Caesarean hysterectomy (Group C). No significant differences were noted between Lovina S M Machado, Vaidyanathan Gowri, Nihal Al-Riyami and Lamya Al-Kharusi Clinical and Basic Research | 195 the groups in the mean haemoglobin change, the frequency of haemorrhage, postoperative fever, or the length of hospital stay. These findings corroborate the fact that myomectomy during Caesarean section is a safe, effective procedure not associated with significant complications. Further strengthening the increasing trend towards Caesarean myomectomy is yet another case series by Hassiakos et al.21 They compared 47 pregnant women with fibroids who underwent Caesarean myomectomy with 94 pregnant women with fibroids who had Caesarean section alone. Myomectomy added a mean operating time of 15 minutes to the Caesarean section. No patient had a hysterectomy, postpartum complications, or blood transfusion. The length of hospital stay was comparable in both groups; hence, these authors also generally recommended performing the procedure. Yuddandi reported removal of a 33.3 × 28.8 × 15.6 cm fibroid at Caesarean with an intra- operative blood loss of 1,860 ml, necessitating blood transfusion.22 Leanza et al. and Igwegbe et al. have also reported large myomas removed at Caesarean section.23–24 In our series of 8 patients, 5 lost less than 1.5 L of blood and there was no significant postoperative morbidity. The patient with a blood loss of 3,200 ml had the largest myoma in this series (10 x 12 cm) which showed evidence of degeneration and also had atonicity of the uterus necessitating a higher dose of oxytocin, carboprost, and a blood transfusion. Since the fibroid was on the right anterior lower segment, a low vertical incision was used. The large size of the fibroid and atonic uterus led to the increased haemorrhage. There were no postoperative complications. Despite the majority of the patients having large myomas and 50% being intramurally located, no hysterectomy was required in any patient. Stepwise devascularisation was necessary in one case. The size of the fibroids was confirmed by the pathology reports, and changes like haemorrhage, infarction, calcification, and hyaline degeneration were seen in 4 fibroids. Myomectomy added 15 minutes to the operating time and 1 day to the hospital stay but there was no significant postoperative complication. None of the patients had postoperative sepsis. The limitations of this study are the small sample size and the retrospective nature of the study. Conclusion In conclusion, patient selection is crucial in Caesarean myomectomy. Large fundal intramural fibroids should be intuitively avoided. Intramural myomectomy should be performed with caution. Fibroids obstructing the lower uterine segment or accessible subserosal or pedunculated fibroids in symptomatic patients can be safely removed by experienced surgeons. The message is that what was once considered taboo should now be reconsidered. Measures to minimise blood loss, like preoperative placement of uterine artery, balloon catheters, uterotonic drugs, uterine artery ligation, uterine tourniquets, stepwise devascularisation, and post-Caesarean uterine artery embolisation would optimise outcomes and significantly decrease the chance of hysterectomy. The time is right to recommend Caesarean myomectomy in selected patients in well-equipped tertiary settings, which could also have a positive bearing on future reproductive outcomes. c o n f l i c t o f i n t e r e s t No funding was received for this study and the authors declared no conflict of interest. References 1. Muram D, Gillieson MS, Walters JH. Myomas of the uterus in pregnancy: Ultrasonographic follow-up. Am J Obstet Gynecol 1980; 138:16–9. 2. Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu. Myomectomy during Cesarean section. Int J Gynecol Obstet 2005; 89:90–3. 3. Hasan F, Armugam K, Sivanesaratnam V. Uterine leiomyomata in pregnancy. Int J Gynecol Obstet 1990; 34:45–8. 4. Davis JL, Ray-Mazumder S, Hobel CJ, Baley K, Sassoon D. Uterine leiomyomas in pregnancy: A prospective study. Obstet Gynecol 1990; 75:41–4. 5. Rosati P, Exacoustas C, Mancuso S. Longitudinal evaluation of uterine myoma growth during pregnancy. J Ultrasound Med 1992; 11:511–5. 6. Myerscough PR. Pelvic tumors. Other surgical complications in pregnancy, labor and the puerperium. In: Munro Kerr’s Operative Obstetrics. 10th ed. London: Baillière Tindall Publications, 1982. Pp. 203–411. 7. Katz VL, Dotters DJ, Droegemueller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynaecol 1989; 73:593–6. Caesarean Myomectomy Feasibility and safety 196 | SQU Medical Journal, May 2012, Volume 12, Issue 2 8. Howkins J, Stallworthy J. In: Bonney’s Gynaecological Surgery. 8th ed. London: Baillière Tindall Publications, 1974. P. 421. 9. Exacoustos C, Rosati P. Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obstet Gynecol 1993; 82:97–101. 10. Ortac F, Gungor M, Sonmezer M. Myomectomy during Cesarean section. Int J Gynecol Obstet 1999; 67:189–90. 11. Roman AS, Tabsh KMA. Myomectomy at the time of Cesarean delivery: retrospective cohort study. BMC pregnancy and childbirth 2004; 4:14. Doi: 10.1186/1471-2393-4-14 12. Sapmaz E, Celik H, Altungul A. Bilateral ascending uterine artery ligation vs. tourniquet use for haemostasis in Cesarean myomectomy: a comparison. J Reprod Med 2003; 48:950–4. 13. Cobellis L, Florio P, Stradella L, Lucia ED, Messalli EM, Petraglia F, et al. Electro-cautery of myomas during Cesarean section: two case reports. Eur J Obstet Gynecol Reprod Biol 2002; 102:98–9. 14. Burton CA, Grimes DA, March CM. Surgical management of leiomyoma during pregnancy. Obstet Gynecol 1989; 74:70. 15. Kwon SY, Kim TH, Jeong JH, Lee CN. Is myomectomy safe during Cesarean section? Korean J Perinatol 2003; 14:154–9. 16. Ehigiegba AE, Ande AB, Ojobo SI. Myomectomy during Cesarean section. Int J Gynecol Obstet 2001; 75:21–5. 17. Ahikari S, Goswami S. Cesarean myomectomy: A study of 14 cases. J Obstet Gynecol India 2006; 56:486–8. 18. Umezurike C, Feyi-Waboso P. Successful myomectomy during pregnancy: A case report. Reprod Health 2005; 2:6. 19. Omar SZ, Sivanesaratnam V, Damodaran P. Large lower segment myoma-myomectomy at lower segment Cesarean section: A report of 2 cases. Singapore Med J 1999; 40:109–10. 20. Li H, Du J, Jin L, Shi Z, Liu M. Myomectomy during Cesarean section. Acta Obstet Gynecol Scand 2009; 88:183–6. 21. Hassiakos D, Christopoulos R, Vitoratos N, Xarchoulakou E, Vaggos G, Papadrias K. Myomectomy during Cesarean section: a safe procedure? Ann N Y Acad Sci 2006; 1092:408-13. Doi:10.1196/annals.1365.038 22. Yuddandi N. Management of a massive caseous fibroid at Cesarean section. J Obstet Gynaecol 2004; 24:455–6. 23. Leanza V, Fichera S, Leanza G, Cannizzaro MA. Huge fibroid (g. 3,000) removed during Cesarean section with uterus preservation. A case report. Ann Ital Chir 2011; 82:75–7. 24. Igwegbe AO, Nwosu BO, Ugboaja JO, Monago EN. Inevitable Cesarean myomectomy. Niger J Med 2010; 19:233–5.