Maternal-Fetal Medicine

Pregnancy Following Myomectomy

Clinical management of high-risk pregnancies with prior uterine surgery

Expert Consultation Framework Evidence-Based Guidelines

Overview

Learning Objectives

▶ Identify key risk factors influencing pregnancy outcomes post-myomectomy
▶ Recognize warning signs of uterine dehiscence and rupture
▶ Apply evidence-based delivery planning strategies

Epidemiology

Fibroids in Pregnancy

2–10% of pregnant women have uterine fibroids

0.7–1% uterine rupture risk post-myomectomy

Most pregnancies following myomectomy result in favorable outcomes with appropriate surveillance.

Risk Assessment

Key Prognostic Factors

Surgical Factors

▶ Approach: laparotomy vs. laparoscopic vs. robotic
▶ Uterine cavity entry status
▶ Multi-layer suture closure

Myoma Characteristics

▶ Size and number removed
▶ Location: intramural vs. subserosal
▶ Conception interval (~18 months mean)

Complications

Associated Obstetric Risks

Complication	Clinical Implication	Evidence
Placenta previa / PAS	Increased risk due to uterine scarring	High
Preterm birth	Spontaneous or medically indicated early delivery	Moderate
Malpresentation	Altered uterine contour may affect fetal position	Moderate
Uterine rupture	0.7–1.0%; typically third trimester, prelabor	High

Critical

Uterine Rupture

<1% incidence — most occur in third trimester before labor onset

⚠

Warning Signs — Educate All Patients

Sudden, localized abdominal pain or abnormal vaginal bleeding

Monitoring

Recommended Surveillance

EARLY Obtain prior operative reports

18–22 WKS Detailed scan: placental site + scar assessment

3RD TRIMESTER Growth, presentation, scar monitoring

DELIVERY PPH preparedness

Management

Fibroids During Current Pregnancy

▶ Residual or new fibroids: conservative management preferred
▶ Red degeneration: supportive care, analgesia, hydration

Antepartum myomectomy may be considered in second trimester only for intractable cases unresponsive to medical therapy — remains exceptional.

Delivery

Mode of Delivery Decision

Prior Myomectomy

Was uterine cavity entered?

No / Superficial

TOLAM may be considered
(selected cases)

Yes / Extensive Intramural

Scheduled Cesarean
(standard of care)

Documentation

Clinical Record Checklist

✓ Operative report: incision depth, cavity entry, suture layers
✓ Ultrasonography at 18–22 weeks and third trimester
✓ Documented patient education on warning signs
✓ PPH preparedness plan (scar + fibroid = atony risk)

Summary

Key Takeaways

1 Uterine rupture risk is low (<1%) but highest in third trimester prelabor

2 Operative report review is essential for delivery planning

3 Cavity entry during prior surgery typically indicates cesarean delivery

4 Early placental localization helps identify PAS risk

Discussion

Questions?

?

Thank you for your attention.
Open for discussion and case review.