Fibroid Myomectomy & VBAC
Jun 02, 2011 06:09 PM
My reproductive endocrinologist discovered a fibroid during an early ultrasound with Baby #1. It was pedunculated, and off the back side of the uterus attached near the LUS.
Baby #1 Utterly boring and normal pregnancy. 1 1/2 weeks overdue. Very high. Low Bishop's score. PROM. I was 3-3-1 when we left for the hospital after ten or so hours after the rupture. When I got to the hospital labor stopped. I was using a midwifery practice, and was given up to 24 hours of my rupture of membranes for labor to resume, at which point I would be augmented. I ended up being augmented for about 24 hours. 4 cm. I consented to an epidural. Pitocin dialed up a few times. I gained another centimeter after 2 1/2 total days of labor. FTP @ 5 cm. C-section. Baby was 9 lbs 11 oz. Lots of blood loss, fibroid was about the size of a russet potato. I asked if they would remove it during the section, and they declined.
Baby #2 at a delivery interval of 23 months. HBAC planned with CNM. Boring and normal pregnancy once again. Uterine scar measurement at 37 weeks was 3.5 mm. Went into labor about a week after the due date. Progressed easily to 10 cm within seven hours. CNM said I was complete but that the baby was incredibly high. Bouncing off her fingers she said. She said I had lots of room for him to come down. Pelvis was adequate and open. I was dilating off my bag of waters - not from his head. Did some crazy stuff at home to try bring him down. With history of scar on my uterus and no descent after four more hours, she recommended transferring. Transferred to hospital and gave it another four or so hours. No descent. Pitocin. Epidural. Broke my water. Lots and lots and lots of fluid. No head. My midwife and hospital midwife both agreed after 24 hours of no change that a c-section was indicated. I requested my fibroid be removed. Denied again. Baby was 9 lbs 3 oz, posterior with a deflexed neck. My midwife said in 25 years she had only ever seen something like that in one other client. She encouraged me to investigate a fibroid removal if it could be done laparascopically and if I wanted to have another child and a chance at a vaginal birth.
We are now considering baby #3. Baby #2 is one year old. We would hope to space at least two years to get a good delivery interval. I consulted with a surgeon who said I'm a perfect candidate for a laparascopic removal of my fibroid. It is on the small side of large when I'm not pregnant and very large during pregancy. (I had an US during pregnancy #1 and it was very good sized.) He was an ob/gyn before focusing on surgery. He said the fibroid could have contributed to my posterior babies and challenging births. I asked him if removing the fibroid would preclude me from another VBAC. He said he would have no issue with writing a letter post surgery supporting another VBAC since the uterus itself wouldn't be cut - just the stalk clipped to remove the fibroid from its surface. I do have other symptoms from this fibroid, which are minor, but annoying. Occasional pain during intercourse, and frequent urinary urges especially at night. It would be nice to get rid of those complaints. However, to be honest, I would be having this fibroid removed mainly to have a chance at a VBAC with a third child. I've read research that indicates unplanned cesareans are performed at a rate of 50% in those with fibroids versus 30%.
Since I've used midwives with both of my births, I'm not aware of the culture surrounding fibroid removals and vaginal birth. Is it common that an ob/gyn would discourage or refuse a VBA2C after a fibroid removal? What are your thoughts based on what I'm considering to avoid a third c-section? I feel the risk of a third c-section is greater than a laparoscopic removal of a fibroid. Of course there are no guarantees that the fibroid is the reason for my difficult births. Also, what are the rupture statistics after two c-sections? I may consider another home birth, especially given how quickly and easily I progressed in my second birth. Thanks for any insight or information you can offer me.
Jun 08, 2011 03:55 PM
Realistically, I have to say your chances of finding an ob willing to attend a VBAC after 2 cesareans and a uterine surgery are not good regardless of whether the surgery involved cutting into the uterus. Few obs agree to VBACs even in optimal cases these days, let alone women with obstetric histories such as yours. Not that it isn't worth it to try and find one. A recent systematic review of the literature of women planning VBAC after two cesareans reported a pooled scar rupture rate of 1.4% among 16 studies (5666 women). That rate will be affected, though, by whether labor is induced or augmented and whether you had single-layer uterine closure at your last cesarean. The same review reported a pooled VBAC rate of 72%, although the range was 45% to 89%, which gives you an idea of the degree to which care provider practices and beliefs affect vaginal birth rates. I can't help but think, though, that removing a physical impediment to the baby's getting into the anterior position and descending into the pelvis has to make a major difference in your odds of vaginal birth.
Jun 13, 2011 03:05 PM
First, I want to thank you for your generosity in responding to these forum questions. You are an invaluable resource to have such direct access to. Thank you.
With my first section, I was repaired with a single layer. Of course, I didn't even know to ask for a double layer repair. I was more savvy with the second section and requested a double layer repair - despite the surgeon's insistence it was irrelevant. So, I did get that double layer with round #2.
How do rupture rates change for a second VBAC with a double layer repair? I know scar measurements weren't conclusive with my birth last year based on the research. Any new stats available related to scar measurements at 37 weeks?
Jun 14, 2011 03:21 AM
You are welcome! I am not aware of any studies looking at a single-layer repair followed by a double-layer repair at the next cesarean. I would think, though, since they would be cutting through the old scar, that the last closure is the one that counts. I assume by scar measurements you mean measuring scar thickness. Here is what I have on that from the VBAC chapter manuscript for the forthcoming new edition of Obstetric Myths Versus Research Realities:
Thin uterine scar: Both a systematic review of scar thickness and rupture prediction (12 studies, 1834 women) and the AHRQ (2010) systematic review (3 studies) reject using scar thickness as a predictor because studies do not establish a cut-off with good positive predictive value.44, 55 A major problem noted by the scar thickness reviewers was that most investigators measured uterine dehiscence, but the predictive value of defect (overall rate 6.6%; range 1-46%), for rupture is unknown. Both reviewers note that other factors such as uterine closure or previous vaginal birth will influence scar rupture rates.44, 55
Guise JM, Eden K, Emeis C, et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep) 2010(191):1-397.
Jastrow N, Chaillet N, Roberge S, et al. Sonographic lower uterine segment thickness and risk of uterine scar defect: a systematic review. J Obstet Gynaecol Can 2010;32(4):321-7.
The problem is that while a thicker scar is a good predictor that the scar will not give way in labor, a thinner scar isn't a good predictor that it will.
All Times America/New_York
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