Following abdominal myomectomy, uterine rupture during pregnancy appears to be a rare event. Two studies comprising 236,454 deliveries reported 209 instances of uterine rupture, with only 4 cases attributable to prior myomectomy (78,79). Because the number of women who had a previous myomectomy was not known, the incidence of rupture in these studies could not be determined. However, a retrospective study of 412 women who had abdominal myomectomies reported only one woman with uterine rupture (0.2%) (80).
Operative techniques, instruments, and energy sources used during laparoscopic myomectomy may differ from those employed during laparotomy. A study of 19 published and unpublished cases of uterine rupture during pregnancy following laparoscopic myomectomy found that almost all cases involved deviations from standard surgical technique as described for abdominal myomectomy (81). In seven cases, the uterine defect was not repaired; in three cases it was repaired with a single suture; in four cases it was repaired with only one layer of suture; and in one case only the serosa was closed. In only three cases was a multilayered closure employed. In 16 of the cases, monopolar or bipolar energy was used for hemostasis.
Although definite conclusions and recommendations regarding appropriate technique for laparoscopic myomectomy must await proper study of myometrial wound healing, it appears prudent for surgeons to adhere to time-tested techniques developed for abdominal myomectomy, including multilayered closure of myometrium (for other than superficial uterine defects) and limited use of electro-surgery for hemostasis. Yet, even with ideal surgical technique, individual wound healing characteristics may predispose to uterine rupture.
The development of new treatments for fibroids is slow, perhaps because many women with fibroids are asymptomatic, fibroids are benign, and mortality is very low (82). If offered hysterectomy as a first, and sometimes only, treatment option, some women choose to accommodate to symptoms and stop seeking treatment. This may lead physicians to underestimate the true impact of the condition, despite the fact that women who have hysterectomies as a result of fibroid-related symptoms have significantly worse scores on SF-36 quality-of-life questionnaires than women diagnosed with hypertension, heart disease, chronic lung disease, or arthritis (44).
After an exhaustive review of the medical literature published between 1975 and 2000, with evaluation of 637 relevant articles and careful study of 200 articles, the authors found no satisfactory answers to fundamental question about fibroid treatments (83). Women and their physicians need information on which to base decisions regarding possible treatments.
This section summarizes the literature regarding the management of fibroids. Treatment options include observation, medical therapy, hysteroscopic myomectomy, laparoscopic myomectomy, hysterectomy, uterine artery embolization, and focused ultrasound.
Watchful Waiting Not having treatment for fibroids rarely results in harm, except for women with severe anemia from fibroid-related menorrhagia or hydronephrosis from ureteric obstruction from an massively enlarged fibroid uterus. Predicting future fibroid growth or onset of new symptoms is not possible (84). During observation, the average fibroid volume increases 9% per year with a range of −25% to +138% (84). A nonrandomized study of women with uterine size 8 weeks or greater who chose watchful waiting found that 77% of women had no significant changes in the self-reported amount of bleeding, pain, or degree of bothersome symptoms at the end of 1 year (85). Furthermore, mental health, general health, and activity indexes were also unchanged. Of the 106 women who initially chose watchful waiting, 23% opted for hysterectomy during the course of the year.