EXPERIENCE WITH SPONTANEOUS DELIVERY IN WOMEN WITH A UTERINE SCAR AFTER MYOMECTOMY

Objective. To define clinical and morphological criteria for scar consistency after sustained myomectomy for the formation of groups of pregnant and parturient women for further vaginal delivery and to reveal the expediency of hormonal rehabilitation with the drospirenone-containing contraceptive Midiana in the postoperative period. Subjects and methods. A prospective study of 115 pregnant and parturient women with a uterine scar after preceding myomectomy and 60 patients after experienced myomectomy who underwent hormone rehabilitation with Midiana. The study involved morphometry and examination of the state of microcirculation and a cytogram of tissue leukocytes in the uterine scar and marginal tissues in women; ultrasound study in patients with the intact uterus and in parturients after myomectomy. Results. After laparotomic myomectomy, by suturing the bed with a double-row synthetic stitch, and after laparoscopic myomectomy, by extracorporeally applying stitches, the myometrial scar is a thin scar with the parallel arrangement of fibers and with solitary hemorrhages. Dilated plethoric vessels were well visualized. The cellular component was presented by solitary lymphocytes and neutrophils. The border between the myometrium and scar after laparatomic and laparoscopic myomectomy, by suturing the bed was characterized by plethora and bleeding. With laparoscopic myomectomy and bed coagulation, there was a chaotic fiber alignment and extensive hemorrhages in the scar tissues. The vascular component appeared as abundant vessels with sclerosed walls. Noteworthy is the higher numerical density of all white blood cells, neutrophils in particular, as well as red blood cells. After laparoscopic myomectomy with bed coagulation, the border between the myometrium and scar clearly demonstrated as large vessels with sclerosed walls, plethora, and bleeding, and a multitude of minor vessels resembling granulation tissues. Spontaneous labor occurred in 35 (51.5%) of the 68 patients with a uterine scar who had been managed for vaginal delivery. Repeat cesarean section was performed in 33 (48.5%) women. Threatening metrorrhexis was one of the reasons for emergency abdominal delivery with the sutured bed with a double-row synthetic stitch only in 18.2 and 15.4% of the women, respectively; and that after lararoscopic myomectomy with bed coagulation was in 33.3% in the parturient women. Conclusion. Reproductive-aged women should undergo laparotomic or laparoscopic myomectomy, but by obligatorily extracorporeallly suturing the bed with a double-row stitch. Bed coagulation is impermissible since the risk for histopathic metrorrhexis is high during pregnancy. It is also demonstrated that it is basically expedient to use hormonal rehabilitation with the drospirenone-containing contraceptive Midiana after myomectomy. Slight and transient side effects are successfully replaced by qualitative uterine involution, which creates favorable conditions for scar healing and opens up new avenues for spontaneous labor after conservative plastic surgery.

uterine scar, myomectomy, bed suturing, bed coagulation, hormonal rehabilitation