What are the benefits and risks of using caesarean myomectomy in pregnant women with fibroids in the womb?

Key messages

  • The evidence is very uncertain about the effect of caesarean myomectomy (surgery to remove uterine fibroids, which are non-cancerous growths) on the requirement for blood transfusion, risk of bleeding, length of hospitalisation, length of operation, risk of major surgery, and risk of postpartum fever (high temperature in the days following delivery), so it is not possible to generate any meaningful conclusions.

  • The authors do not know the effect of caesarean myomectomy on change in haemoglobin (a protein in red blood cells that helps carry oxygen around the body) or future fertility.

What is postpartum haemorrhage?

Postpartum bleeding is defined as heavy bleeding and a blood loss of 500 mL or more within 24 hours of birth. It is the leading cause of maternal deaths and illness across the world. Postpartum haemorrhage causes one maternal death every seven minutes.

What did we want to find out?

Uterine fibroids (non-cancerous growths that develop in or around the womb) affect a growing number of women. In the past, doctors have avoided the removal of fibroids (also known as myomectomy) during caesarean birth (a surgical procedure where babies are delivered through a cut in the mother's tummy) due to the risk of excessive or heavy bleeding. The removal of fibroids during birth is thought to be associated with longer operating times and more days in the hospital. However, removal of fibroids has potential benefits for women in preserving future fertility. For women already having a caesarean section, it may provide a unique opportunity to do this procedure. We wanted to find out the benefits and harms of conducting a myomectomy compared to not conducting a myomectomy in pregnant women with fibroids undergoing a caesarean section.

What did we do?

We searched for studies that investigated the use of caesarean myomectomy and caesarean section alone in pregnant women with fibroids undergoing caesarean section. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size.

What did we find?

We found 23 studies including 7504 women. The largest study included 2565 women and the smallest 50 women. The studies were conducted in high-income or upper-middle-income countries around the world (meaning they had good or excellent medical facilities); most were done in Turkey. Five studies only included women pregnant with one baby, and one study only included women pregnant with twins. Most studies did not say if the caesarean sections were chosen by the women or done as emergency procedures. Only four studies reported how they were funded.

What are the limitations of the evidence?

We are very uncertain of the effect of caesarean myomectomy on the need for blood transfusion, risk of bleeding, length of hospitalisation, length of operation, risk for major surgery at time of procedure, and risk of fever in the days following birth. Several factors affected our confidence in the evidence. First, the differences between the groups could have been due to differences between the women rather than between the treatments. Second, many of the studies had a small number of women. Third, some results varied between studies. There were no results for haemoglobin (a protein in red blood cells that helps carry oxygen around the body) or future fertility.

Overall, this means it is not possible to generate any meaningful conclusions on the benefits and harms of caesarean myomectomy with any certainty because the studies either did not report information that we could use, or produced findings in which we had very little confidence. Further research is needed from well-designed studies on the use of caesarean myomectomy, especially in poorer countries.

How up to date is this evidence?

The evidence is up to date to 2 February 2024.

Authors' conclusions: 

The 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.

Read the full abstract...
Objectives: 

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

Search strategy: 

We 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.

Funding: 

This 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.