Perfect Prenatal

Had a great prenatal yesterday. The day had a bit of a rough start, because Erik had peed his bed, and then still was half asleep, so I had to clean him up and decided to try to get him back to sleep. This all made things take a lot longer than planned, so I barely made it to the prenatal in time. Actually had two peanutbutter sandwiches in the car instead of a nice, leisurely sit-down breakfast :-)

I took the letter I am going to send to the 'She needs a c-section!' ob, so I could get her input on it. She thought it was a good letter, and hoped I could convince him. I don't even really care anymore, I am not going to have a c-section anyway, but I think it is important to present my side of the story to him and to try to convince him. Not as much for me even, but also for the moms who come after me, and might not get pushed into c-section just because of a myomectomy.

This is what I wrote to the ob

Dear xxx,

I would like to present my case in favor of a normal vaginal birth after my myomectomy, as opposed to a planned cesarean. When I was in the beginning stages of my pregnancy, I believed that there was a relatively high risk of uterine rupture because of my myomectomy.After working through a lot of medical research studies, and finding no evidence of a higher risk of uterine rupture during labor, I don't believe this anymore.

After hours of research, I have found no reports of uterine rupture during vaginal birth after myomectomy. In fact, I have found researchers who feel that scheduling a cesarean due to previous myomectomy is not justified. There are case reports of uterine rupture, but most of those were between 26 and 34 weeks of pregnancy, some even earlier. So a planned cesarean would not have prevented those ruptures. It seems that the 'high risk' period for rupture is late 2nd, early 3rd trimester, when the pressure on the uterus is high. Labor doesn't seem to be as risky.

Here is a short summary of what I have found. I am including all the abstracts of those studies in this package, so you can read more about them. I am in the process of obtaining the full text of the articles that still have question marks, so I can get the right numbers for those too.

#PG = number of pregnancies in this study
#vb = number of vaginal births
#cs = number of c-sections
#UR = number of uterine ruptures

Study	Date	#PG	#vb	#cs	#UR
Campo S, Campo V, Gambadauro P	2003	25	15	10	0
Soriano D, Dessolle L, Poncelet C, Benifla JL, Madelenat P, Darai E.	2003	52	?	?	0
Landi S, Fiaccavento A, Zaccoletti R, Barbieri F, Syed R, Minelli L.	2003	76	31	26	0
R. Seracchioli, S. Rossi, F. Govoni, E. Rossi, S. Venturoli, C. Bulletti and C. Flamigni	2000	47	13	34	0
Malzoni M, Rotond M, Perone C, Labriola D, Ammaturo F, Izzo A, Panariello S, Reich H	2003	26	9	12	0
Di Gregorio A, Maccario S, Raspollini M.	2002	105	?	?	0
Seinera P, Farina C, Todros T.	2000	65	9	45	0
Tomialowicz M, Florjanski J, Zimmer M.	2000	267	?	?	0 in myo group
Dubuisson JB, Fauconnier A, Deffarges JV, Norgaard C, Kreiker G, Chapron C.	2000	145	58	42	3, but 0 during TOL
Nezhat CH, Nezhat F, Roemisch M, Seidman DS, Tazuke SI, Nezhat CR.	1999	42	6	22	0
Darai E, Dechaud H, Benifla JL, Renolleau C, Panel P, Madelenat P.	1997	19	8	3	0
Roemisch M, Nezhat FR, Nezhat A.	1996	31	5	14	0
Dubuisson JB, Chapron C, Chavet X, Gregorakis SS.	1996	7	3	4	0
TOTALS		888	157+?	212+?	3 total, but none during TOL

As you can see, there were exactly 3 ruptures in those 888 pregnancies, and those were at 25 weeks, 32 weeks and 34 weeks of pregnancy. All cases had a favorable outcome for mom and baby. As you also can see, there were no cases of uterine rupture during labor in those studies.

I know that there aren't big studies on that, but still, I think that those studies do support that a vaginal birth after a myomectomy is a reasonable option. An interesting quote from Dubuisson, Fauconnier,et al. 2000 [1]. is "Systematic recourse to Caesarean after LM, as recommended by some authors for cases of intramural or deep subserous myoma (Friedmann et al., 1996; Stringer and Strassner, 1996; Seinera et al., 1997; Nezhat et al., 1999), does not appear justified in our opinion. In our study, a trial of labour was accepted for 72% of patients, because similarly to other teams (Daraï et al., 1997; Ribeiro et al., 1999) we made no particular recommendations concerning the type of birth after LM. A large number of these patients had intramural or deep subserous myomas. The trials of labour resulted in no complications and, in particular, no cases of uterine rupture."

Another reason that a c-section would not be optimal is that we hope to have more babies after this, and a c-section would increase the risks for future babies. Mankuta, Leshno, et al., 2003 [2], state "The risk of perinatal death associated with labor after previous cesarean section appears higher than with a repeated cesarean section. On the other hand, repeated cesarean sections are associated with increased maternal morbidity and mortality from placental pathologic conditions (previa or accreta) on subsequent pregnancies." and "The model favors a trial of labor if it has a chance of success of 50% or above and if the wish for additional pregnancies after a cesarean section is estimated at near 10% to 20% or above because the delayed risks from a repeated cesarean section are greater than its immediate benefit. The model was robust over a wide range of assumptions."

After all my research, and weighing the risks and benefits of a vaginal birth versus a planned cesarean, I have determined that vaginal birth is the less risky option for me. I hope that all this evidence will convince you that I can have a complication free, normal vaginal birth. If you have any more questions or concerns, please let me know.


Sincerely,



[1] Mankuta DD, Leshno MM, Menasche MM, Brezis MM.
Vaginal birth after cesarean section: trial of labor or repeat cesarean section? A decision analysis
Am J Obstet Gynecol. 2003 Sep;189(3):714-9.

[2] Jean-Bernard Dubuisson, Arnaud Fauconnier, Jean-Valère Deffarges, Christian Norgaard, Gustavo Kreiker and Charles Chapron
Pregnancy outcome and deliveries following laparoscopic myomectomy
Human Reproduction, Vol. 15, No. 4, 869-873, April 2000



OK, if that doesn't convince him, at least I have done my darnedest best to change his opinion. We'll see what happens.

Back to the prenatal. I had lost one pound, which is amazing, because I feel like I am eating all the time. My fundal height had increased 2.5 cm in 2 weeks though, so I am 32 cms now, right on track with how many weeks I am. Blood pressure was 104 over 60 something, urine was ok, and the baby's heart rate was 148 bpm. Baby had turned head down! Of course, he still has room and time to do somersaults, but for now he is in the right position. Well, partly, because he was posterior, but lots of time for that to change too.

So happy that this pregnancy is going so well!