Caesarean myomectomy in pregnant women with uterine fibroids.

rationalePostpartum haemorrhage, defined as a blood loss of 500 mL or more within 24 hours of birth, is the leading global cause of maternal morbidity and mortality. Uterine fibroids are non-cancerous growths that develop in or around the uterus, and affect an increasing number of women. Caesarean myomectomy is the surgical removal of fibroids during a caesarean section. Traditionally, obstetricians have avoided this procedure given the risk of uncontrollable haemorrhage. There is also the risk of longer operating time and more days in the hospital. However, there could be potential benefits in removing uterine fibroids for improved fertility, and caesarean section may provide an effective and efficient opportunity to perform this procedure. Given the link between removal of uterine fibroids and postpartum haemorrhage, it is prudent to evaluate current literature and assess the benefits and harms of caesarean myomectomy in pregnant women with uterine fibroids.

objectivesTo assess the benefits and harms of caesarean myomectomy in pregnant women with uterine fibroids undergoing caesarean section. SEARCH

methodsWe searched CENTRAL, MEDLINE, Embase, Global Index Medicus, ICTRP portal, and ClinicalTrials.gov; performed supplementary searches of references and citations; and contacted study authors on 2 February 2024. ELIGIBILITY CRITERIA: We included published randomised and quasi-randomised controlled trials, and observational controlled studies that assessed the impact of myomectomy on maternal health outcomes in pregnant women with fibroids undergoing caesarean birth. We excluded qualitative studies, case reports or series, conference abstracts, opinion papers, letters, and book chapters. There were no restrictions on ethnicity, race, socioeconomic status, education level, or place of residence. OUTCOMES: Critical outcomes were requirement for blood transfusion, risk of haemorrhage, change in haemoglobin, length of hospitalisation, length of operation, major surgery at time of procedure, fertility outcome, and postpartum fever. RISK OF BIAS: We assessed risk of bias for non-randomised controlled studies using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. SYNTHESIS

methodsWe conducted a meta-analysis for each outcome when more than one study provided data. If it was not possible to analyse data via meta-analysis, we synthesised results narratively using Synthesis Without Meta-analysis (SWiM) guidance. We used GRADE to assess certainty of evidence for each critical and important outcome. INCLUDED STUDIES: We included 23 non-randomised studies with 7504 women. Most studies were conducted in high-income or upper-middle-income countries. Five studies enrolled women with singleton pregnancies and one study was restricted to women with a twin pregnancy. Most studies did not report whether the caesarean section was elective or emergent. Thirteen studies diagnosed fibroids prior to operation. SYNTHESIS OF

resultsBlood transfusion The evidence is very uncertain about whether caesarean myomectomy affects the risk of requiring blood transfusion compared to caesarean section alone (risk ratio (RR) 1.34, 95% confidence interval (CI) 1.01 to 1.79; I AUTHORS'

conclusionsThe available evidence for all critical outcomes is very low certainty. As such, it is not possible to draw conclusions about the effects of caesarean myomectomy on the risk of requiring blood transfusion, risk of haemorrhage, length of hospitalisation, length of operation, risk of major surgery at time of procedure, and risk of postpartum fever. Data retrieved on mean change in haemoglobin were too heterogenous to be pooled. There were no data on fertility outcomes.

fundingThis Cochrane review had no dedicated funding. REGISTRATION: The review was registered with PROSPERO (CRD42024554215) and available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024554215.