P R A C E O R Y G I N A L N E Cesarean myomectomy and possible risk factors for admission to intensive care unit a retrospective study Miomektomia podczas cięcia cesarskiego i możliwe czynniki ryzyka przyjęcia do oddziału intensywnej terapii badanie retrospektywne 1 1 Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia. 2 Laboratory of Hygiene, Department of Biological and Environmental Sciences and Technologies, Faculty of Sciences, University of Salento, Lecce, Italy 3 Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy Department of Obstetrics and Gynecology Vito Fazzi Hospital, Lecce, Italy 4 International Translational Medicine and Biomodeling Research Group Department of Applied Mathematics, Moscow Institute of Physics and Technology, Moscow State University Russia Abstract Objectives: Cesarean myomectomy (CM) allows to remove fibroids and to restore uterine anatomy during delivery, combining two operations in one. It was opposed in the past due to surgical risks, although many reports showed that CM was not associated with increased morbidity. The risk for admission to an intensive care unit (ICU) following CM - as an objective indicator of maternal morbidity, potentially resulting in greater morbidity for patients, increased length of hospital stay, and higher hospital costs has been poorly evaluated in the literature. The aim of our investigation is to estimate risk factors for ICU admission after CM. Material and methods: The patients were subdivided into two groups: 57 women who were postoperatively admitted to the ICU (study group), and 45 women not treated in the ICU (control group). The p-value of <0.05 was considered as statistically significant. Results: Data showed no statistically significant differences with regard to demographic factors, comorbidity and indications for cesarean section, as well as experience of the surgeon, number of hysterotomies, and incidence of emergency CS between the two groups. The most common reason for admission to the ICU was intraoperative hemorrhage (61.40%). As for the surgical characteristics, the study group showed significant increase in the rates of intraoperative transfusion (p=0.000) and intraoperative hemorrhage (p=0.000), as well as prolongation of surgical time (p=0.002). Myoma type and size were also significantly different between the groups (p=0.003 and p=0.000, respectively). Conclusions: The most important factor contributing to ICU admission after CM is intraoperative hemorrhage in case of bigger myomas and prolonged surgeries. Key words: myomectomy / cesarean section / cesarean myomectomy / / intensive care admission / myoma / / Corresponding author: Radmila Sparić, MD, MSc Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Višegradska 26, 11000 Belgrade, Serbia Tel.: +381 (0) 66 8301 332 Fax: +381 (0)11 361 5603 Email: radmila@rcub.bg.ac.rs Otrzymano: 03.03.2015 Zaakceptowano do druku: 01.04.2015 Nr 10/2015 Polskie Towarzystwo Ginekologiczne 731
P R A C E O R Y G I N A L N E Streszczenie Cel pracy: Miomektomia podczas cięcia cesarskiego (CM) pozwala na usunięcie mięśniaków i zachowanie anatomii macicy podczas porodu, łączy dwie operacje w jedną. W przeszłości nie zalecana z uwagi na ryzyko okołooperacyjne, jednak doniesienia nie potwierdzają zwiększonej chorobowości związanej z CM. Ryzyko przyjęcia do oddziału intensywnej opieki medycznej (ICU) w związku z CM jako obiektywny wskaźnik chorobowości matek, przedłużony pobyt w szpitalu i wyższe koszty leczenia szpitalnego są słabo przeanalizowane w piśmiennictwie. Celem naszego badania było oszacowanie czynników ryzyka przyjęcia do ICU po CM. Materiał i metoda: Pacjentki podzielono na dwie podgrupy: 57 kobiet przyjętych do ICU po operacji (grupa badana) i 45 kobiet nieleczonych w ICU (grupa kontrolna). Jako istotne statystycznie przyjęto p <0.05. Wyniki: Dane dotyczące czynników demograficznych, chorób współistniejących i wskazań do cięcia cesarskiego, jak również doświadczenie chirurga, liczba histerotomii i obecność pilnych wskazań do cięcia cesarskiego nie wykazały istotnych statystycznie różnic między dwiema grupami. Najczęstszą przyczyną przyjęcia do oddziału intensywnej opieki medycznej był krwotok śródoperacyjny (61.40%). Grupa badana cechowała się zwiększoną ilością śródoperacyjnych transfuzji krwi (p=0.000) i śródoperacyjnych krwotoków (p=0.000), jak również wydłużeniem czasu operowania (p=0.002). Typ i rozmiar mięśniaka były także istotnie różne w obu grupach (p=0.003 i p=0.000, odpowiednio). Wnioski: Najważniejszym czynnikim ryzyka przyjęcia do ICU po CM jest krwotok śródoperacyjny w przypadkach większych mięśniaków i przedłużonego czasu operacji. Słowa kluczowe: / / / / / / Introduction Objectives Material and methods 732 Polskie Towarzystwo Ginekologiczne Nr 10/2015
P R A C E O R Y G I N A L N E t t Results Discussion Nr 10/2015 Polskie Towarzystwo Ginekologiczne 733
P R A C E O R Y G I N A L N E Table I. not transferred to ICU, postoperatively treated at the ward, as group II. Indication for admission to the ICU in the study group Indication No. of patients Intraoperative hemorrhage 35 Intensive monitoring 16 Postoperative hemorrhage 4 Febrile morbidity with bacteremia 1 Intestinal sub-occlusion 1 Patient characteristics Characteristics Group I Group II p Age (years) 34.68±4.72 34.30±4.37 0.665 a Number of abortions 1.61±0.88 1.51±0.87 0.557 a Parity 1.16±0.41 1.18±0.44 0.815 a Gestational age (weeks of gestation) 38.75±2.11 39.29±1.50 0.154 b Cephalic 42 37 Fetal presentation Breech 9 6 Oblique 2 1 0.646 Transverse 4 1 Presence of comorbidity Characteristic Group I Group II p Previous myomectomy 7 1 0.061 Previous laparotomy 11 6 0.723 Indications for cesarean section Indication for CS Group I Group II P Disproportion 7 7 Previous cesarean 2 3 Previous myomectomy 6 1 Hypertension 7 2 Fetal malpresentation 7 7 0.549 1 3 Myoma previa 10 7 Fetal indications 8 7 Other (non-obstetric) indications 9 8 Surgery characteristics Characteristic Group I Group II P Duration of surgery (min.) 73.68±21.22 61.33±15.93 0.002 b Surgeon s years of practice (year) 16.58±6.55 17.04±6.71 0.725 a Number of incisions 2.09±0.66 2.44±0.80 0.282 a Incidence of emergency CS 25 14 0.188 Incidence of intraoperative transfusion 28 3 0.000 Incidence of intraoperative hemorrhage 35 4 0.000 Myoma characteristics Characteristics Group I Group II P Number of myoma (n) 1.95±1.44 1.64±1.09 0.246 b Myoma size (mm) 67.33±36.54 40.76±22.92 0.000 b Myoma type Myoma localization a Unpaired Student t test b Welch t test Pedunculated 8 1 Subserous 15 26 Intramural 9 2 Multiple 25 16 Fundal 5 3 Anterior wall 32 29 Posterior wall 13 10 Isthmicocervical 4 1 Cornual 3 2 0.003 0.800 734 Polskie Towarzystwo Ginekologiczne Nr 10/2015
P R A C E O R Y G I N A L N E Conclusions Conflict of interests Authors contribution: 1. Radmila Sparić conception and design, acquisition, analysis and interpretation of data, drafting the article, revising the article critically for important intellectual content. 2. Marcello Guido conception and design, acquisition, analysis and interpretation of data, drafting the article, revising the article critically for important intellectual content. 3. Andrea Tinelli conception and design, acquisition, analysis and interpretation of data, drafting the article, revising the article critically for important intellectual content. Nr 10/2015 Polskie Towarzystwo Ginekologiczne 735
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