Uterine rupture during induced labor after myomectomy and risk of lawsuits

Rising myomectomy rates in the world represent an important obstetric issue: uterine scarring and possible uterine rupture-related complications. Fibroids constitute one of the most frequent gynecologic pathology associated with infertility, and myomectomy is considered an effective-treatment. However abdominal, hysteroscopic and laparoscopic (traditional or robotic) myomectomy unavoidably produces a scarred uterus and increases the risk of uterine rupture in pregnancy, which generally occurs in the third trimester (after 36 weeks) or during labor and delivery. The incidence of uterine rupture reported in literature is very low (ranging from 1/40000 and 1/50000)1 . Although myomectomy cannot be considered a prophylactic measure prior to conception, in the last 30 years an increasingly high number of women aged from 35 to 50 has required a myomectomy before undertaking a pregnancy, especially with IVF techniques2,3. Literature reports favorable short-term outcomes in laparoscopic myomectomy in comparison with laparotomic myomectomy but there are no available data on long-term results in women with scarring uterus, particularly with reference to uterine rupture4. A recent Cochrane review suggests that laparoscopic myomectomy is a procedure associated with less subjectively reported postoperative pain, lower postoperative fever and shorter hospital stay compared with all types of open myomectomy; yet, no evidence shows a difference between laparoscopic and open myomectomy on rates of uterine rupture5. Only SOGC guideline on the management of uterine leiomyomas mentions the issue of uterine rupture during pregnancy after myomectomy6. Uterine rupture during pregnancy after myomectomy has been reported to possibly be linked to the absence of multi-layer closure in cases of deep intramural leiomyoma, lack of deep suturing or to the excessive use of electrosurgical energy7 . The literature data suggest that induction of labor are associated with an increased risk of uterine rupture among women with scarred uterus, and this association are highest when prostaglandin E gel, especially misoprostol, are used8,9. There is no consensus as to the optimal interval between myomectomy and conception. Several authors report that the mean interval between laparoscopic myomectomy and pregnancy was 14 months, and only 3 (0.6%) cases of uterine rupture occurred during pregnancy. In analysis, by reviewing the published cases of uterine rupture, we found that the mean diameter, myoma number and type, and the rate of uterine suture were similar between the ruptured cases and all of our cases of laparoscopic myometctomy10. To date, available literature is inconsistent on evidence-based management, according to RCOG Green Top Guideline No. 45 “Birth after previous cesarean birth”, which states that there is insufficient and conflicting information on whether the risk of uterine rupture is increased in women with previous myomectomy11. Ultimately, uterine rupture represents an uncommon event. Yet, it may cause catastrophic maternal and fetal complications (such as severe post-hemorrhagic anemia, major puerperal infection, hysterectomy with fertility loss, and maternal and fetal death)12, which are significantly higher in women with uterine rupture than in women without uterine rupture. In case of hysterectomy, the women become eligible for ARTs (Assisted Reproduction Technologies) or for uterine transplant13,14. Moreover, such outcomes are hardly acceptable by those who are affected by them within the context of a natural event such as birth, therefore the risk of litigation is high.