Pregnancy and delivery after myomectomy for large fibroids: utilization of trial of labor and obstetric outcomes in a single-center cohort study

PURPOSE: To quantify obstetric outcomes after prior myomectomy in a tertiary center and to explore whether operative and clinical characteristics are associated with uterine rupture. METHODS: Single-center retrospective cohort of deliveries following laparotomic or laparoscopic myomectomy between August 2015 and January 2023. We extracted demographic, surgical, and obstetric data from electronic records, and analyzed only the first consecutive post-myomectomy pregnancy per patient. RESULTS: Sixty-three women delivered after prior myomectomy. 75.5% underwent laparotomic myomectomy and the remainder laparoscopic. The mean largest myoma diameter was 9.6 ± 3.4 cm; 66.7% were intramural. Uterine cavity entry occurred in 30.4%. Trial of labor after myomectomy was attempted in four patients (6.3%) and was successful in three. Two patients had placenta accreta spectrum (3.2%), and two required transfusions for postpartum hemorrhage. One full-thickness uterine rupture was identified incidentally at a planned elective cesarean at 37.4 weeks (1/63; 1.6%) in an asymptomatic patient not in labor. A short myomectomy-to-pregnancy interval showed an association with rupture: < 3 months (OR 103.0, 95% CI 2.85-3728.2; p = 0.007) and < 6 months (OR 25.9, 95% CI 1.94-716.8; p = 0.037). No other variables reached statistical significance, although the analysis was underpowered to assess additional predictors. CONCLUSION: Uterine rupture after myomectomy was rare (1.6%) in our cohort and was associated with a short myomectomy-to-pregnancy interval. However, as this association is based on a single event, it should be interpreted with caution and considered hypothesis-generating. Despite the low absolute risk, and consistent with literature supporting TOLAM in selected patients, TOLAM was markedly underutilized in our center, highlighting a practice gap that may be addressed through more standardized counseling and delivery planning in tertiary settings.