CESAREAN MYOMECTOMY AND POSSIBLE RISK FACTORS FOR INTENSIVE CARE UNIT ADMISSION-A RETROSPECTIVE STUDY

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(1)Ginekol Pol. 2015, 86, 731-736. DOI: 10.17772/gp/57828. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Cesarean myomectomy and possible risk factors for admission to intensive care unit – a retrospective study Miomektomia podczas cięcia cesarskiego i możliwe czynniki ryzyka przyjęcia do oddziału intensywnej terapii – badanie retrospektywne

(2) 1 1. Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia. Laboratory of Hygiene, Department of Biological and Environmental Sciences and Technologies, Faculty of Sciences, University of Salento, Lecce, Italy 3 Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy Department of Obstetrics and Gynecology Vito Fazzi Hospital, Lecce, Italy 4 International Translational Medicine and Biomodeling Research Group Department of Applied Mathematics, Moscow Institute of Physics and Technology, Moscow State University Russia 2. Abstract Objectives: Cesarean myomectomy (CM) allows to remove fibroids and to restore uterine anatomy during delivery, combining two operations in one. It was opposed in the past due to surgical risks, although many reports showed that CM was not associated with increased morbidity. The risk for admission to an intensive care unit (ICU) following CM - as an objective indicator of maternal morbidity, potentially resulting in greater morbidity for patients, increased length of hospital stay, and higher hospital costs – has been poorly evaluated in the literature. The aim of our investigation is to estimate risk factors for ICU admission after CM. Material and methods: The patients were subdivided into two groups: 57 women who were postoperatively admitted to the ICU (study group), and 45 women not treated in the ICU (control group). The p-value of <0.05 was considered as statistically significant. Results: Data showed no statistically significant differences with regard to demographic factors, comorbidity and indications for cesarean section, as well as experience of the surgeon, number of hysterotomies, and incidence of emergency CS between the two groups. The most common reason for admission to the ICU was intraoperative hemorrhage (61.40%). As for the surgical characteristics, the study group showed significant increase in the rates of intraoperative transfusion (p=0.000) and intraoperative hemorrhage (p=0.000), as well as prolongation of surgical time (p=0.002). Myoma type and size were also significantly different between the groups (p=0.003 and p=0.000, respectively). Conclusions: The most important factor contributing to ICU admission after CM is intraoperative hemorrhage in case of bigger myomas and prolonged surgeries.. Key words: myomectomy / cesarean section / cesarean myomectomy / / intensive care admission / myoma / / Corresponding author: Radmila Sparić, MD, MSc Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Višegradska 26, 11000 Belgrade, Serbia Tel.: +381 (0) 66 8301 332 Fax: +381 (0)11 361 5603 Email: radmila@rcub.bg.ac.rs. Nr 10/2015. © Polskie Towarzystwo Ginekologiczne. Otrzymano: 03.03.2015 Zaakceptowano do druku: 01.04.2015. 731.

(3) P R A C E O R Y G I N A L N E poł ożn i ct wo. DOI: 10.17772/gp/57828. Ginekol Pol. 2015, 86, 731-736. Radmila Sparić et al. Cesarean myomectomy and possible risk factors for admission to intensive care unit – a retrospective study.. Streszczenie Cel pracy: Miomektomia podczas cięcia cesarskiego (CM) pozwala na usunięcie mięśniaków i zachowanie anatomii macicy podczas porodu, łączy dwie operacje w jedną. W przeszłości nie zalecana z uwagi na ryzyko okołooperacyjne, jednak doniesienia nie potwierdzają zwiększonej chorobowości związanej z CM. Ryzyko przyjęcia do oddziału intensywnej opieki medycznej (ICU) w związku z CM – jako obiektywny wskaźnik chorobowości matek, przedłużony pobyt w szpitalu i wyższe koszty leczenia szpitalnego – są słabo przeanalizowane w piśmiennictwie. Celem naszego badania było oszacowanie czynników ryzyka przyjęcia do ICU po CM. Materiał i metoda: Pacjentki podzielono na dwie podgrupy: 57 kobiet przyjętych do ICU po operacji (grupa badana) i 45 kobiet nieleczonych w ICU (grupa kontrolna). Jako istotne statystycznie przyjęto p <0.05. Wyniki: Dane dotyczące czynników demograficznych, chorób współistniejących i wskazań do cięcia cesarskiego, jak również doświadczenie chirurga, liczba histerotomii i obecność pilnych wskazań do cięcia cesarskiego nie wykazały istotnych statystycznie różnic między dwiema grupami. Najczęstszą przyczyną przyjęcia do oddziału intensywnej opieki medycznej był krwotok śródoperacyjny (61.40%). Grupa badana cechowała się zwiększoną ilością śródoperacyjnych transfuzji krwi (p=0.000) i śródoperacyjnych krwotoków (p=0.000), jak również wydłużeniem czasu operowania (p=0.002). Typ i rozmiar mięśniaka były także istotnie różne w obu grupach (p=0.003 i p=0.000, odpowiednio). Wnioski: Najważniejszym czynnikim ryzyka przyjęcia do ICU po CM jest krwotok śródoperacyjny w przypadkach większych mięśniaków i przedłużonego czasu operacji.. . Słowa kluczowe:

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(8) Ginekol Pol. 2015, 86, 731-736. DOI: 10.17772/gp/57828. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Radmila Sparić et al. Cesarean myomectomy and possible risk factors for admission to intensive care unit – a retrospective study.. % $ D $ .!' *8,BE" 50 2 #," ' &$ / '! @# $ ' &$ / && , " &$ $ $ % %' $ &%$- Ft-, '% &$ $ & % % ' $ &% : t-, &$ >' ' & $ D F -> , -' GB,B3 $ %(,. Results *B $ %,% $ & '& ' % , " $ ' % $. *B* $ * %% ' ' %,C *B*$ 02 $( H $ 9 %% $ 02 , " 38 !33,99I# $ $ 5"2 ! 5# $ 3 !,*I# $ $ $ , 5"2 $*,HJ*,% ! *-8#,A $ -5"2, 5"2$ ' 3 !4*,BI#= '% . K" 3 $ $ $ , 5"2$ ' ' % & ' ; *4 !9,B8I# , D ' $ 5"2!8,BI# , 5 $ ' $ . &% &% ' '% . $ $ & % , $ $ . ' ' % = ' .K" $*&; ' , L& &% & " $. * $ '% %%, 5&- % $ $$ & % " . ' , & $ $ / & , $ $ $ '; ' % . % % ? % ,5% &' % ' * $ $ $ ' % ' " $&%' , $ % ' % %% & . 5"2 , $ (% $ & ' % 8 9 $$ '%%$ '%. Nr 10/2015. 5"2 $ ! MB,B4*#, (% $ " , " % $ -& " *8,89I $ $ % ' $ > !*8,3I# % , " " '. / & % % " &$ , " $ &% / & & % $ *4,89 J 4,3H % , & % / %% $ "$ % %9 !8,9I# 89$!84,9I#$ $ *4 $ !*3,4HI# % , % ( &$ $ $= > % ' & ' , % ' *, !8,49',4*,# $ > ' & !34,*I ', 9,9HI# >% ' !H,* I ', 4,48I#,& '% K"$(% % !*', MB,BBB#=3 ' $ '," & % (%&$ $ 5"2 (% %6% !6 %=8& 3H,43I$ %#, &$ &5,. Discussion " $ $ 5"2 33,99I , C ( & 5"2 )8 9+ & ",: & %% % 5"2 )3 H+, 5 > 5"2 $ ' ,5 ' ' 49,I5"2, N , )H+ ' . . & ", % HBI $ $ & &6 %&6!# '& $ , % $ % > 5"2 , A' " % % $ % $ % , " $ % % ) 3+, C& > % % & 5"2 . )9+, % )+ % % $ > H $ $ $ " '&, )*B+ - . © Polskie Towarzystwo Ginekologiczne. 733.

(9) P R A C E O R Y G I N A L N E poł ożn i ct wo. Ginekol Pol. 2015, 86, 731-736. DOI: 10.17772/gp/57828. Radmila Sparić et al. Cesarean myomectomy and possible risk factors for admission to intensive care unit – a retrospective study.. Table I. Characteristics and differences between the investigated groups: 57 patients who were postoperatively admitted and treated in the ICU, as group I, and 45 controls, not transferred to ICU, postoperatively treated at the ward, as group II. Indication for admission to the ICU in the study group Indication. No. of patients. Intraoperative hemorrhage. 35. Intensive monitoring. 16. Postoperative hemorrhage. 4. Febrile morbidity with bacteremia. 1. Intestinal sub-occlusion. 1 Patient characteristics. Characteristics. Group I. Group II. p. Age (years). 34.68±4.72. 34.30±4.37. 0.665a. Number of abortions. 1.61±0.88. 1.51±0.87. 0.557a. Parity. 1.16±0.41. 1.18±0.44. 0.815a. Gestational age (weeks of gestation). 38.75±2.11. 39.29±1.50. 0.154b. Cephalic. 42. 37. Breech. 9. 6. Oblique. 2. 1. 4. 1. Fetal presentation. 0.646 Transverse. Presence of comorbidity Characteristic Previous myomectomy Previous laparotomy. Group I. Group II. p. 7. 1. 0.061. 11. 6. 0.723 P. Indications for cesarean section Indication for CS. Group I. Group II. Disproportion. 7. 7. Previous cesarean. 2. 3. Previous myomectomy. 6. 1. Hypertension. 7. 2. Fetal malpresentation. 7. 7.

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(11) . 1. 3. Myoma previa. 10. 7. Fetal indications. 8. 7. Other (non-obstetric) indications. 9. 8. 0.549. Surgery characteristics Characteristic. Group I. Group II. P. Duration of surgery (min.). 73.68±21.22. 61.33±15.93. 0.002b. Surgeon’s years of practice (year). 16.58±6.55. 17.04±6.71. 0.725a. Number of incisions. 2.09±0.66. 2.44±0.80. 0.282a. Incidence of emergency CS. 25. 14. 0.188. Incidence of intraoperative transfusion. 28. 3. 0.000. 35. 4. 0.000. Incidence of intraoperative hemorrhage. Myoma characteristics Characteristics Number of myoma (n) Myoma size (mm). Myoma type. Myoma localization. a b. 734. Group I. Group II. P. 1.95±1.44. 1.64±1.09. 0.246b 0.000b. 67.33±36.54. 40.76±22.92. Pedunculated. 8. 1. Subserous. 15. 26. Intramural. 9. 2. Multiple. 25. 16. Fundal. 5. 3. Anterior wall. 32. 29. Posterior wall. 13. 10. Isthmicocervical. 4. 1. Cornual. 3. 2. 0.003. 0.800. Unpaired Student t test Welch t test. © Polskie Towarzystwo Ginekologiczne. Nr 10/2015.

(12) Ginekol Pol. 2015, 86, 731-736. DOI: 10.17772/gp/57828. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Radmila Sparić et al. Cesarean myomectomy and possible risk factors for admission to intensive care unit – a retrospective study.. " *8% $ ' ",& .$ % % ' " % ", 5 ' > 5"2 % > 'K" $ , ' - & $- )** *+,D %/ & & ' $ '')*+, '% 5"2 % $ ' F ? F > $ & , D $ 5"2 , 5 $ ' , 0. % ( &/ &% '( '% $ , & $ % ' %% % & & $ & &% , D ' %% .$ . ' & %% )*+, A' % ' %% O 5"2 , %% " )*3+ ( %%)*4+, & ( " &/ &%( 6 . &/O, ' " % / . O " % 5"2, % % , 6&%% % % ' /' & $ ( ' %-'' % )*8+, / >. '%,> $& & ' $ > . &% / , A' " > & O%&% (& % &% 6=& % $ ( & . 5"2 , ' $ 5"2 % / $% / (% 5"2 , 6 % . 5"2 ' (& , ( & 6%O " $ )* *9+, $ >(& , %/ .O& (& 5"2 %,. Nr 10/2015. & (& &% ") 3+,C % (& >% ' % )3+ &% 5"2,5 % ,94I $ > 5"2 % $ 38,89I $ > 5"2 & %, (& ," '% $ $ (& $ $/ & O 6 (& 5"2 )+, & ( &$ 6 %5"2 &/ &% ( 6 &/ $& %, % '% & $ %6 '%, 65"2 & $3-& % /%@' %: " C $ &% $" $>& %,. Conclusions "$ % ' $ % - ' &% / , ' %6 $ . 5"2 % " $ . & 5"2, & '& % & % , ' $ &( $ ; % $ . 5"2 ",. Conflict of interests % O % '( >&$ . ' 6 ,. Authors’ contribution: 1. Radmila Sparić – conception and design, acquisition, analysis and interpretation of data, drafting the article, revising the article critically for important intellectual content. 2. Marcello Guido – conception and design, acquisition, analysis and interpretation of data, drafting the article, revising the article critically for important intellectual content. 3. Andrea Tinelli – conception and design, acquisition, analysis and interpretation of data, drafting the article, revising the article critically for important intellectual content.. © Polskie Towarzystwo Ginekologiczne. 735.

(13) P R A C E O R Y G I N A L N E poł ożn i ct wo. DOI: 10.17772/gp/57828. Ginekol Pol. 2015, 86, 731-736. Radmila Sparić et al. Cesarean myomectomy and possible risk factors for admission to intensive care unit – a retrospective study.. Authors’ statement ³ >RS] S] ^Y MO\^SPc ^RK^ ^RO Z_LVSMK^SYX aSVV XY^ `SYVKÔ ^RO MYZc\SQR^] YP K. third party, as understood according to the Act in the matter of copyright and related rights of 14 February 1994, Official Journal 2006, No. 90, Clause 63, with respect to the text, data, tables and illustrations (graphs, figures, photographs); ³ ^RO\O S] XY mMYX»SM^ YP SXÔ\O]^]p aRSMR YMM_\] aROX ^RO K_^RY\ \OWKSX] SX. a financial or personal relationship which unjustly affects his/her actions associated with the publication of the manuscript; ³ KXc ZY]]SLVO \OVK^SYX]RSZ] YP ^RO K_^RY\] aS^R ^RO ZK\^cZK\^SO]. interested in the publication of the manuscript are revealed in the text of the article; ³ ^RO WKX_]M\SZ^ RK] XY^ LOOX Z_LVS]RON SX Y\ ]_LWS^ÔN ^Y KXc Y^RO\. journal. ³ =Y_\MO YP ºXKXMSXQ$ 8YXO. Re fe re nc e s 1. Sparic R. Uterine myomas in pregnancy, childbirth and the puerperium. Srp Arh Celok Lek. 2014, 142, 118-124. 2. Exacoustos C, Rosati P. Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obstet Gynecol. 1993, 82, 97-101. 3. Olamijulo JA. Unplanned lower segment caesarean myomectomy. J Obstet Gynaecol. 2009, 29, 553. 4. Tinelli A, Malvasi A. Mynbaev OA, [et al.]. The surgical outcome of intracapsular cesarean myomectomy. A match control study. J Matern Fetal Neonatal Med. 2014, 27, 66-71. 5. Song D, Zhang W, Chames MC, Guo J. Myomectomy during cesarean delivery. Int J Gynecol Obstet. 2013, 121, 208-213. 6. Brown D, Fletcher HM, Myrie MO, Reid M. Caesarean myomectomy-a safe procedure. A retrospective case controlled study. J Obstet Gynaecol. 1999, 19, 139-141. 7. Loverro G, Pansini V, Greco P, [et al.]. Indications and outcome for intensive care unit admission during puerperium. Arch Gynecol Obstet. 2001, 265, 195-198. 8. Pollock W, Rose L, Dennis CL. Pregnant and postpartum admissions to the intensive care unit. Int Care Med. 2010, 36,1465-1474. 9. Kim YS, Choi SD, Bae DH. Risk factors for complications in patients undergoing myomectomy at the time of cesarean section. J Obstet Gynaecol Res. 2010, 36, 550-554. 10. Seffah JD. Re-laparotomy after cesarean section. Int J Gynecol Obstet. 2005, 88, 253-257. 11. Fong J, Gurewitsch ED, Kang HJ, [et al.]. An analysis of transfusion practice and the role of intraoperative red blood cell salvage during cesarean delivery. Anesth Analg. 2007, 104, 666672. 12. Silverman JA, Barett J, Callum JL. The appropriateness of red blood cell transfusions in the peripartum patient. Obstet Gynecol. 2004, 104, 1000-1004. 13. Sparic R, Lazovic B, Sulovic N, Buzadzic S. Our experience with intraoperative cell salvage during cesarean delivery in women with uterine myomas-four case reports and review of the literature. Med Pregl. 2014, 67, 111-117. 14. Pundir J, Krishnan N, Siozos A, [et al.]. Peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri. Eur J Obstet Gynecol Reprod Biol. 2013, 167, 219-224. 15. Ande AB, Ehigiegba AE, Umeora OU. Repeat myomectomy at caesarean section. Arch Gynecol Obstet. 2004, 270, 296-298. 16. Sparić R, Berisavac M, Buzadžić S, Mirkovic L. Complications during cesarean delivery in a patient with two previous myomectomies. Acta Chir Iugosl. 2013, 60, 99-100. 17. Schuring AN, Garcia-Rocha GJ, Schlosser HW, [et al.]. Perioperative complications in conventional and microsurgical abdominal myomectomy. Arch Gynecol Obstet. 2011, 284, 137-144. 18. Roman AS, Tabsh KM. Myomectomy at time of cesarean delivery: a retrospective cohort study. BMC Pregnancy Childbirth. 2004, 4, 14.. 736. © Polskie Towarzystwo Ginekologiczne. Nr 10/2015.

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