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Yuldashev Sanjar Keldiyarovich, Republican specialized scientific-practice medical center of obstetrics and gynecology, Tashkent, Uzbekistan, scientific explorer,
E-mail: yuldashev_s@inbox.ru
Surgical and obstetrical approach at accompanying of uterine myoma at pregnancy
Abstract: Research objective was working out ofthe new technology ofconservative myomectomy at 79 women with uterine myoma. It was established, that tying of3 ofpairs the main vessels ofuterine at pregnant women with uterus myoma during cesarean section and conservative myomectomia, and also at women at the reproductive age has allowed to reducing of intra — and postoperative haemorrage in 2-3 times. The results of dopplerometry investigations have shown, that from the 2nd days at the postoperative period it is marked gradual blood-groove restoration in the main uterine arterias, and for 6th days the blood-groove in uterus vessels is restored completely.
Keywords: uterine myoma, cesarean section, conservative myomectomy.
Protection of motherhood and childhood, including pregnant women with uterine fibroid were examined, they
preservation of reproductive health of women, remains one of the priority directions of health care of the Republic of Uzbekistan. This problem has the special importance in connection with the steady growth of birth rate, high maternal mortality and decrease in health index of population [1, 3].
Accompanying of uterine fibroid at pregnancy causes serious danger to reproductive health of women [2, 5, 7]. Uterine fibroid is the most often found benign tumour of reproductive system of women. Its frequency in structure of gynaecologic diseases varies from 20 to 44% [7, 9]. In 13,3-27% of cases uterine fibroid is observed at reproductive age [4, 11]. According to data of literature, at 12-20% of the women having infertility, uterine fibroid is the only reason of reproductive failures [8, 10, 13].
Because of the fact that the number of young women with uterine fibroid increases every year, obstetricians even more often should resolve the issue of preservation of pregnancy and reproductive function, and also of the need and expediency of surgical intervention at accompanying of uterine fibroid at pregnancy, considering high risk of the operation [2, 6, 9].
At the present day most of authors consider myomectomy during cesarean section as additional risk factor of bleeding during operation and development of pyoinflammatory diseases in the postoperative period. The problem of conservative conducting patients with uterine fibroid is not fully solved, the issues of myomectomy at cesarean section are considered only in individual works, and tactics of pregnancy and childbirth care at presence of benign tumours of uterus is complex [1, 3, 4, 7, 11, 12].
Research objective is the development of new technology of conservative myomectomy at pregnant women during operation of cesarean section with preservation of reproductive function.
Material and methods. Work is performed on clinical base of the Republican specialized scientific and practical medical center of obstetrics and gynaecology of the Ministry of Healthcare of the Republic of Uzbekistan. Forty five
were divided into two groups, depending on the used method of operational approach. The first (main) group: 21 women, during cesarean section the conservative myomectomy with preliminary deligation of three couples major vessels of uterus by Olliari method was carried out. The second group: 24 women, during cesarean section the conservative myomectomy without preliminary deligation of three couples major vessels of uterus by Olliari method was carried out. Blood loss during the operation was estimated in gravimetric way. Patients of two groups were comparable on age — on average, respectively, 25,5±0,3 and 26,1±0,2 years old, on parity of childbirth and on the anamnesis.
Besides clinical examination and standard laboratory researches, at all women before and after the surgery careful ultrasound scan of pelvic organs with estimation of blood flow in the arterial blood stream of uterus according to dopplerometry was conducted. In the postoperative period examination of uterus vessels was carried out on the 1st, 2nd and 6th day by means of the ultrasonic scanner "Siemens Sonoline Versa Pro" with use of the trans-abdominal convex sensor of 3,5 MHz, at frequency filter of 50 Hz. Angle-independent indicators of the speed curve of blood flow (SCBF) were analysed: resistance index (RI), pulsation index (PI), systolic and diastolic relation (SDO).
Results and discussion. At 13 of 45 pregnant women with uterine fibroid the myomatous nodules were of small sizes and mainly interstitial localization, at the others multiple nodules (from 2 to 7) of various sizes (from 5 to 15 cm in diameter) with various localization in myometrium, generally subserosal-interstitial localization were revealed.
At all women pregnancy ended with planned operative delivery (cesarean section). Indications to it at 6 pregnant women was isthmus localization of myomatous nodule of small size but interfering advance of fetal head in the parturient canal, 2 women had a rapid growth of tumour at the end of pregnancy. At 24 pregnant women indications to operation was the uterine fibroid in combination with pelvic presentation, elderly age of primipara, infertility in anamnesis,
high myopia. At 13 women cesarean section was carried out in the course of childbirth in connection with anomalies of patrimonial activity and fetal hypoxia.
Myomectomy at pregnancy differs from that at not pregnant women. It is connected with the need of observance of the following conditions: 1) minimum injury for the fetus and extent of blood loss; 2) choice of a rational section on uterus taking into account the subsequent abdominal birth; 3) choice of the sutural material possessing durability, minimum allergenicity, ability to form a full scar on the uterus.
Features of surgical interventions in the 1st group were the following.
1. Operation was made under epidural or spinal
anaesthesia, which, from our point of view, is more preferable as it allows creating the maximum relaxation, and thus makes the minimum medicated impact on the fruit.
2. We applied Joel-Cohen laparotomy to provide the most sparing conditions for the pregnant uterus and the fruit, and also for the optimum access to atypically located nodules of fibroid. Thus after carrying out of Misgav Ladach cesarean section and extraction of the fruit and afterbirth the body of uterus was brought out of the abdominal cavity in the wound. Considering the apparent vasculature with well-developed collaterals, in order to avoid large blood loss the preliminary deligation with catgut suture of three couples of major vessels of the uterus (a. uterine, a. ovarica and a. ligamentum teres uteri), and then suture of the wound on uterus with a single-row catgut continuous suture was carried out.
3. The lumps of myoma were taken with the gauze wads moistened with warm isotonic solution of sodium chloride without the use of such forcepses, as Museux's and "corkscrew". Then we dissected by cross-section over the lump the lump capsule, allocated the myomatous nodule by mainly blunt and/or sharp dissection.
4. At subserosal-interstitial location of lump the section was made, bypassing the vessels expanded during pregnancy,
reducing traumatization and solution of continuity of vessels of uterus.
5. The important role in the result of operation and pregnancy is played by sutural material and a technique of suture on uterus. Generally we used Vicryl No. 0 and/or No. 1. Stiches were put, starting from the bottom of the lump bed and fixation of a Z-shaped stich. The second end of the thread remained long for setting of knot with the first thread before the subsequent putting of a circular suture. Circular sutures were put with the first thread in several rows. The last knot on the wound remained under serousa of the uterus. In this case we considered closing of the wound more reliable, the tissues were kept in reposition condition, there was no ischemia of the stitched and adjacent sites, and the absence on the external surface of uterus of stiches reduced the risk of development of adhesive process.
In the 2nd group the conservative myomectomy on the above-described technique was carried out without preliminary deligation of three couples of major vessels of the uterus. The extent of blood loss during the operation in the 1st group made, on average, 360,3+28,1 ml, in the 2nd group — 752,1+18,2 ml.
Postoperative management of the maternity patients after myomectomy has the features caused by the need of creating favourable conditions for reparation of tissues, prevention of purulent-septic complications, adequate functioning of intestinal tract. For the purpose of prevention of purulent-septic complications we administered intraoperative antibiotic (preferably synthetic penicillin or cephalosporin of the III-IV generation taking into account sensitivity of microflora of vagina to antibiotics), continuing administration during a day.
In the postoperative period the dopplerometry of uterus vessels allowed to estimate changes of blood flow in the blood stream of uterus as after intraoperative deligation of three couples of major vessels, and without it (see the table).
Table 1. - Indicators of dopplerometry of vessels of the uterus in the postoperative period depending on deligation of the major vessels
Group Postoperative period, Day PI RI SDO
2 0,36±0,01* 0,82±0,001* 5,66±0,03*
1-group 4 1.28±0,16* 0.68±0.11* 3,10±0,59*
6 1.08±0.13* 0.62±0.06* 2.61±0,35*
2 1.21±0.20 0.60±0.05 2.52±0.37
2-group 4 1.25±0.07 0.62±0.09 2.62±0.71
6 1.18±0.12 0.64±0.07 2.88±0.23
Note: where* — P<0.05 in comparison with women of the I
The received results attest that in the 1st group the course of the first days was defined by the unstable blood flow with a negative diastolic component that was indicative of incremental recovery of blood flow in uterus vessels, however carrying out measurements of indicators of SCBF was complicated. In the 2nd group the positive diastolic component of blood flow was defined, and RI made 0,60±0,05.
From the second day of the postoperative period at women of the 1st groups the full-fledged blood flow in vessels was visualized, it authentically decreased that was indicative of incremental recovery of blood flow in uterus vessels (respectively 0,33+0,01; 0,12+0,001 and 0,66+0,03).
On the 4th day the difference in indicators of speed curve of blood flow at patients of both groups was registered, but thus at women of the 1st group the positive dynamics and
normalization of blood flow remained. Nevertheless, these patients after operation of cesarean section had RI and PI authentically below, than in the 2nd group (p<0,05).
The analysis of condition of blood flow on the 6th day of the postoperative period according to a dopplerometry also revealed almost complete recovery and its improvement in arteries of uterus at patients of the 1st group: the studied parameters came nearer to that of the patients of the 2nd groups.
Changes on the part of haemostasis at these patients, as well as increase in quantity of pyoinflammatory diseases, were not registered.
According to the questioning which was carried out in 3 months after operation, there were no neurologic violations at the operated women of 1 groups observed. Menstrual function at them was restored from the second month.
Main objective of the method of conservative myomectomy is preservation of reproductive organ, and also recovery of reproductive function. For decades of use of this method the cases of successful carrying out operation in the presence of several tens myomatous nodules are recorded.
Thus, technical capability of performance of conservative myomectomy exists at most of patients with uterus fibroid, but much also depend on readiness of the surgeon and expediency of carrying out such an operation in modern conditions. When the issue of need of carrying out conservative myomectomy at the women planning pregnancy is resolved it is very important to define accurately the ratio of advantage and risk of surgical intervention. Removal of myomatous nodules, though recovers integrity and functionality of body, is at the same time interfaced to known complications and consequences for reproductive system. The main complication in modern conditions of surgery is adhesive process, which can become the reason for infertility [5, 7]. Attempt of removal of a
large number of lumps can also be inexpedient as a set of stiches on uterus can render on the subsequent realization of reproductive function more negative effect than the removed lumps. Besides, when putting a stich on the bed after removal of myomatous nodule, owing to damage of trophism of tissues, the local site of damage is formed, therefore in the area of the stich fibrin deposits, that further leads to formation of adhesion of parts [3, 5, 6, 8].
Thus, selective deligation of uterine arteries with use of dissolving material during surgery creates optimum conditions for the surgeon, promotes reduction of the extend of intraoperative blood loss, shortening of time of operation and, above all, eliminates some reasons complicating operational technique during operation. At the same time early recovery of blood circulation in the area of the scar on uterus provides its fast healing, and the minimum sealing of the bed prevents formation of rough scars on uterus, therefore, prevents formation of adhesion of parts in the field of the scar.
Conclusions
1. Timely intraoperative deligation of three couples of maj or vessels ofuterus with use of catgut suture to conservative myomectomy promotes decrease in the extend of intra- and postoperative blood loss, temporary stop of blood flow in this course of blood circulation and is an effective prevention of postoperative complications.
2. The offered new technic of sealing the bed of myomatous nodule allows to hold muscular tissue in reposition condition, without ishemization of the stitched and adjacent areas, and the absence of stiches on external surface of uterus reduces the risk of development of adhesive process. The blood flow in uterus vessels after intraoperative deligation of three couples of major vessels gradually recovers from the second day of the postoperative period, the complete recovery of blood flow comes by the 6th days.
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