Is Myomectomy Safe during Cesarean Section - A Prospective Cohort Study

One of the most common obstetric interventions that are conducted globally is cesarean section, and both developed and developing nations show an ever-growing trend. Generally, uterine fibroids (leiomyomas) are rare and are found in between 3-12% of pregnancies, and their incidental finding during cesarean section emerges as a major surgical dilemma on the best approach to manage them [1].

Conventionally, myomectomy during cesarean section has been discouraged because of the perceived significant risk of uncontrolled bleeding, long surgical duration and high chances of hysterectomy, thus its avoidance in all other scenarios except in a few situations [1].

This traditional view has since been questioned in recent years. The data of tertiary care indicate that cesarean myomectomy is safe when done on properly selected individuals and does not pose any significant risk of increasing the morbidity in the course of surgery or postoperative periods. Research has shown similar results with regard to blood loss, duration of operation and hospital stay on comparison with the use of cesarean section alone, and it appears that the procedure can be conducted in regulated conditions [2]. This changing literature indicates a slow change in practice of surgery where absolute contraindication is replaced with selective acceptance.

Individualized clinical decision-making has also been highlighted by professional organizations. Although there are no conclusive consensus guidelines, the suggested recommendations are based on the fact that the size, number, and location of the fibroid, and the experience of the surgeon performing the cesarean care ought to determine a case of myomectomy [3]. This highlights the role of situational clinical judgment where there are no standardized guidelines.

More recent reports have indicated positive maternal outcomes where cesarean myomectomy is performed such as a decrease in the need of subsequent surgical intervention as well as an increase in overall patient satisfaction. These results imply that, even aside the safety issue, the process can have applied advantages, namely, the elimination of the necessity of the second operation and further exposure to anesthesia [4]. In addition, the development of surgical procedures such as uterine isthmic circumferential suturing and other hemostatic procedures have helped to reduce intraoperative bleeding and enhanced safety in surgical practice [5].

These observations have been strengthened by systematic reviews and meta-analyses, which suggest that cesarean myomectomy is not found to be associated with a high risk of major complications when undertaken by trained doctors. Rather, it can be a safe and useful alternative to interval myomectomy especially in resource restricted locations where access to repeat surgery can be limited [6]. Still, there are fears over possible implications on future pregnancies and long-term reproductive consequences.

It is also necessary to consider the bigger obstetric picture since even cesarean birth is linked to higher risks of further pregnancies, such as placenta previa, placenta accreta spectrum, and poor maternal perinatal outcomes. These hazards require meticulous assessment in the case when other interventions are carried out simultaneously because they can affect the short-term and long-term health of the mother [7]. Thus, to make informed clinical decisions, it is necessary to determine the safety profile of cesarean myomectomy.

In comparison studies in clinical practice, no significant differences between cesarean myomectomy and cesarean section alone in terms of intraoperative blood loss, blood transfusion, or postoperative complication have been found, thus indicating its possible safety in the identified cases [8]. Economically, procedure amalgamation can also decrease the total expense of healthcare by preventing readmission and surgery, which is in line with the cost-effectiveness studies carried out in gynecological surgery [9]. Moreover, the current development of surgical management of fibroids, such as minimally invasive and robotic treatments, can be viewed as a wider trend of maximizing patient outcomes by means of better methods and innovation [10].

Although these are promising results, the literature that has been published is mainly retrospective analysis and experiences of single centers, and there is not much prospective cohort evidence of this nature. The lack of consensus on the safety and feasibility of cesarean myomectomy is also attributed to variability in the study design, method of patient selection and expertise in surgery. In this regard, the current prospective cohort study was formulated to conduct a systematic assessment of maternal and surgical outcomes that were linked to myomectomy performed during cesarean section, and the intention of the study was to come up with quality evidence that could help elucidate its safety and guide clinical practice.

This was a prospective cohort study performed at the Gynecology Operation Theatre of the Department of obstetrics and gynecology, Memon Medical institute Hospital Karachi Pakistan, This research was conducted in a duration of Three months from 21^st July 2025- to 20^th October 2025, following the consent of the synopsis of the research by the College of Physicians and Surgeons Pakistan (CPSP). Participants were recruited through the use of a non-probability consecutive sampling method.

Ethical approval was obtained by the study after getting the Institutional Review Board (IRB/MMIH/2023/17) date 25-07-2023 of Memon Medical Institute Hospital in addition to the College of Physicians and Surgeons Pakistan (CPSP). All the participants provided their informed consent in writing before being enrolled into the study and the study was conducted in compliance with the principles of the Declaration of Helsinki.

Open Epi online software was used in calculating the sample size, where the given hypothesized frequency of unsafe myomectomy is 5% (assuming that 95% procedures are safe), where the confidence interval was 95% and the absolute precision was 5%. The sample size was calculated to be 73 participants [7]. This was calculated using the standard formula: n = [DEFF × Np(1−p)] / [(d²/Z²1−α/2 × (N−1) + p(1−p)], with the design effect considered 1.

The study involved all women aged 18 to 45 years of any gravidity and parity who underwent myomectomy during the cesarean section (elective or emergency lower segment cesarean section) and were diagnosed with uterine fibroid during pregnancy through ultrasound. Women having known bleeding/ coagulation problems and those having seedling fibroids were not included.

Operationally, safety of myomectomy was defined on the basis of intraoperative and post operation parameters. Some of the intraoperative complications were perforation of the posterior uterine wall, pulmonary embolism, and bleeding. The extent of blood loss was measured intraoperative by the number of surgical sponges soaked and measured in milliliters in the form of a vacuum suction container since the time of surgery up to the time on discharge. The loss of less than 1000 ml of blood was deemed to be a safe procedure. The level of Hemoglobin was checked 24 hours after surgery to further determine safety.

The data were obtained among the eligible participants who were reported to the outpatient department and admitted to undergo cesarean section. Baseline demographic and clinical factors, such as age, gravidity, parity, gestational age, maternal weight and size, quantity and location of fibroids (based on ultrasound and clinical assessment) as well as comorbidity (high blood pressure and diabetes mellitus) were noted. Laboratory parameters such as hemoglobin, total leukocyte count, and platelet count before operative were recorded. Intraoperative information (duration of the operation (time taken after the uterine incision is closed after birth of the baby to removal of fibroid and abdominal), estimated blood loss, and intraoperative issues) were noted. The operating surgeon tested the level of hemoglobin 24 hours after the surgery at the hospital.

Statistical Package for the Social Sciences (SPSS) version 24.0 was used to input and analyze all the data. The quantitative variables like the maternal age, gestational age, weight-fibroid size, hemoglobin levels, total leukocyte count, platelet count, and blood loss were in the form of the mean and standard deviation when the variable was normally distributed. The Shapiro-Wilk test was used to test the normality. In the case of skewed data, median and the interquartile range were presented. Frequencies and percentages were used to present qualitative variables like site of fibroid and intraoperative complications. The outcomes were compared using various demographic and clinical variables and then adjusting them because of the potential effect modifiers. Chi-square test and independent sample t-test were used respectively, and p-value less than 0.05 is statistically significant.

A total of 120 adolescents were enrolled and randomized equally into two groups: the digital CBT group (n = 60) and the control group receiving standard counseling (n = 60). All participants completed the baseline assessments, and 112 (93.3%) completed the post-intervention follow-up. Demographic characteristics such as age, gender distribution, and baseline severity scores were comparable between both groups (Table 1).

Following the 8-week intervention, significant improvements were observed in the digital CBT group. The mean PHQ-9 score in the intervention group decreased from 15.4 ± 2.5 at baseline to 7.6 ± 2.2 post-intervention (p < 0.001). In contrast, the control group showed a smaller reduction from 15.1 ± 2.3 to 12.2 ± 2.0 (p = 0.04). The between-group difference was statistically significant (p < 0.001) (Table 2).

Similarly, BDI-II scores dropped significantly in the intervention group (27.3 ± 4.5 to 13.4 ± 3.1), while the control group showed a modest reduction (26.9 ± 4.7 to 21.8 ± 3.8). The intervention group also reported improved anxiety scores on the GAD-7 scale (13.5 ± 2.6 to 6.9 ± 2.3), compared to the control group (13.1 ± 2.4 to 10.2 ± 2.5) (Table 2). Quality of life, as assessed by KIDSCREEN-27, improved more significantly in the digital CBT group (mean score increase from 58.4 ± 6.1 to 72.3 ± 5.5) than in the control group (60.1 ± 5.8 to 64.2 ± 5.1) (p < 0.01).

Table 1. Baseline Characteristics of Participants

Table 2. Pre- and Post-Intervention Outcome Measures

These findings suggest that digital CBT significantly reduces depressive and anxiety symptoms and improves quality of life compared to standard counseling methods among adolescents (Table 2).

A total of 73 women meeting the inclusion criteria were enrolled. The mean maternal age was 32.4 ± 5.6 years, with a median gravidity of 2 (range 1–3) and median parity of 1 (range 0–2). (Table I).

Table I. Baseline Demographic and Clinical Characteristics by Blood Loss (n = 73)

*Chi-square test; continuous variables analyzed with t-test or Mann–Whitney.

The majority of women had a single fibroid, most commonly located on the anterior wall. Neither the number nor the location of fibroids was associated with higher blood loss (Table II).

Table II. Fibroid Characteristics by Blood Loss (n = 73)

*Chi-square test; continuous variables analyzed with t-test or Mann–Whitney.

Of the 73 procedures, 68 (93.2%) were classified as safe, defined by blood loss <1000 mL without major intraoperative complications. Operative time was longer in unsafe procedures but did not reach statistical significance (p = 0.21). No intraoperative complications were reported in either group (Table III).

Table III. Intraoperative and Postoperative Outcomes by Safety (n = 73)

*Chi-square test for categorical, t-test for continuous variables.

Hemoglobin measured 24 hours postoperatively was significantly lower in Blood loss ≥1000 mL (n = 5). Total leukocyte count and platelet count did not differ significantly between groups (p = 0.42 and 0.28, respectively) (Table IV).

Table IV. Postoperative Laboratory Outcomes by Safety (n = 73)

This prospective study of 73 women who received cesarean myomectomy showed that most of the women had one anterior wall fibroid, and the size of the largest fibroid was 5.6 cm in the median.

Our findings showed that bigger fibroid size had a significant correlation with greater blood loss but the number and location of the fibroid were not important. In general, the proportion of safe procedures was 93.2% and only 5 cases were associated with blood loss ≥1000 mL, increase in hemoglobin drop and need of blood transfusion. Intraoperative complications were not mentioned, which is in line with prior evidence about the safety of cesarean myomectomy with regard to the selected patients [11-12].

Sundermann et al. [11] noted that uterine fibroids have a role in preventing favorable obstetric outcomes, such as preterm birth, and the importance of clinical attention is evident. Brennan et al. [12] and Huang et al. [13] proved cesarean myomectomy could be performed in case of large fibroids with the help of the careful hemostatic techniques, which supports our results that the majority of procedures were safe despite the size of fibroids.

The study by Dey et al. [14] showed that there are few perioperative complications when appropriately selected patients have the corresponding zero intraoperative events. The reliability of our data could be enhanced by systematic reporting and standardized outcome assessment [15], which is part of the PRISMA 2020 statement.

Our low complication rates were supported by Mishra et al. [16] and Sharma et al. [17] who also reported positive maternal outcomes with cesarean myomectomy using tertiary care. The idea of personalized risk evaluation in the choice made between cesarean section and delayed myomectomy was discussed by Tinelli et al. [18], which is how we categorize safe and unsafe operations with regard to blood loss.

Ma et al. [19] highlighted perioperative risk in combined procedures with large or multiple fibroids, which follows our conclusion that the large size of the fibroid was related to unsafe outcomes. Lastly, Li et al. [20] affirmed that fibroids can cause adverse maternal outcomes but our study focused on the intraoperative and immediate postoperative parameters thus pointing out that cesarean myomectomy can be safely conducted with proper planning.

Our study has strengths such as prospective data collection, straining by blood loss, and postoperative laboratory assessment. Our results suggest comprehensive preoperative evaluation of fibroid features, careful intraoperative hemostasis, and the accessibility of blood products in order to reduce the risk in the perioperative period. To perfect the choice criteria and maximize maternal outcomes, more extensive studies should be conducted.

Limitations of study: This research has a number of limitations. First, the sample size was quite small especially in the sample of unsafe procedures which could compromise the statistical power to identify association with infrequent complications. Second, the case under investigation was carried out in one tertiary care facility, and the results might not be applicable to other locations. Third, the maternal and neonatal outcomes were not evaluated in the long term, and it could be limited to intraoperative and postoperative parameters. Lastly, the observational study design is incapable of making a causal conclusion on how the fibroid attributes affected blood loss or operative morbidity.

Cesarean myomectomy is a safe procedure that can be implemented in well-selected women especially those with single and moderate-sized fibroids. An increased size of fibroids is linked to the high probability of excessive blood loss and transfusion. Most of the procedures can be performed without any intraoperative complications with a careful surgical procedure, proper hemostatic precautions taken, and with blood transfusion prepared. Risk stratification based on preoperative evaluation of fibroid characteristics is necessary and additional, multicenter, and large-scale studies are justified to enhance patient selection and perioperative outcomes.

1.     Garg P, Bansal R. Cesarean myomectomy: a case report and review of the literature. J Med Case Rep. 2021;15:193. doi:10.1186/s13256-021-02785-7

2.     Sakinci M, Turan G, Sanhal CY, et al. Analysis of myomectomy during cesarean section: a tertiary center experience. J Invest Surg. 2022;35(1):23–29. doi:10.1080/08941939.2020.1810832

3.     Society of Obstetricians and Gynaecologists of Canada. Society of Obstetricians and Gynaecologists of Canada. 2022.

4.     Kusuma AANGJ. Benefits and safety of myomectomy during cesarean section. Maj Obstet Ginekol. 2024;32(1):39–43. doi:10.20473/mog.V32I12024.39-43

5.     Yıldırım MA, Kurkut B, Boza B, Polat İ. Outcomes of cesarean myomectomy using uterine isthmic circumferential technique. J Matern Fetal Neonatal Med. 2026;39:2601929. doi:10.1080/14767058.2025.2601929

6.     Goyal M, Dawood AS, Elbohoty SB, et al. Cesarean myomectomy in the last ten years: a true shift from contraindication to indication: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021;256:145–157. doi:10.1016/j.ejogrb.2020.11.008

7.     Gaffur R, Mchome B, Ndaninginan LL, et al. Association between first birth caesarean delivery and adverse maternal–perinatal outcomes in the second pregnancy: a registry-based study in Northern Tanzania. BMC Pregnancy Childbirth. 2022;22:411. doi:10.1186/s12884-022-04719-7

8.     Ghasemian Dizaj Mehr S., Taher F., Ayatolahi H. Clinical Safety Outcomes Following Myomectomy during Cesarean Delivery: A Comparative Study. J Obstet Gynecol Cancer Res, 2025; 10(9): 697-703. doi: 10.24200/jogcr.10.9.6973

9.     Yang J, Fan X, Gao J, Li D, Xu Y, Chen G. Cost-effectiveness analysis of total laparoscopic hysterectomy versus total abdominal hysterectomy for uterine fibroids in Western China: a societal perspective. BMC Health Serv Res. 2022;22(1):252. doi:10.1186/s12913-022-07644-9

10.   Sini I, Birowo P, Hapsari K, Handayani N, Indra BD. Robotic myomectomy for a non-pregnant reproductive-age woman with severe acute urinary retention: a case report. Urol Case Rep. 2020;33:101423. doi:10.1016/j.eucr.2020.101423

11.   Sundermann AC, Aldridge TD, Hartmann KE, Jones SH, Torstenson ES, Edwards DR. Uterine fibroids and risk of preterm birth by clinical subtypes: a prospective cohort study. BMC Pregnancy Childbirth. 2021;21(1):560. doi:10.1186/s12884-021-03968-2

12.   Brennan LC, Werger M, Ivanisevic S, Han S, Tannenbaum E, Hobson SR, et al. Cesarean myomectomy for large uterine fibroids: surgical outcomes from a single-center case series. Int J Gynaecol Obstet. 2026;172(2):1198–1201. doi:10.1002/ijgo.70445

13.   Huang Y, Ming X, Li Z. Feasibility and safety of performing cesarean myomectomy: a systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2022;35(13):2619–2627. doi:10.1080/14767058.2020.1791816

14.   Dey T, Cole MG, Brown D, et al. Caesarean myomectomy in pregnant women with uterine fibroids. Cochrane Database Syst Rev. 2025;1:CD016119. doi:10.1002/14651858.CD016119

15.   Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev. 2021;10(1):89. doi:10.1186/s13643-021-01626-4

16.   Mishra D, Singh S, Shubham S. Outcomes of cesarean myomectomies performed at a tertiary care hospital in North India: a series of 10 cases. Cureus. 2025;17(2):e79465. doi:10.7759/cureus.79465

17.   Sharma M, Sharma G, Varshney S. A prospective study of simultaneous myomectomy with cesarean section at a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol. 2023;12(4):1056–1060. doi:10.18203/2320-1770.ijrcog20230812

18.   Tinelli A, Nezhat CH, Likić-Ladjević I, Andjić M, Tomašević D, Papoutsis D, et al. Myomectomy during cesarean section or non-caesarean myomectomy in reproductive surgery: this is the dilemma. Clin Exp Obstet Gynecol. 2021;48(6):1250–1258. doi:10.31083/j.ceog4806199

19.   Ma D, Zhang H, Chen M, Liu F, Wang S, Zhang Y, et al. Combined cesarean section and myomectomy increases perioperative risks and affects postpartum recovery in women with uterine fibroids during late pregnancy: a retrospective cohort study. Am J Transl Res. 2025;17(9):7249–7259. doi:10.62347/IIYZ3609

20.   Li H, Hu Z, Fan Y, Hao Y. The influence of uterine fibroids on adverse outcomes in pregnant women: a meta-analysis. BMC Pregnancy Childbirth. 2024;24(1):345. doi:10.1186/s12884-024-06545-5