Fertility after laparoscopic myomectomy of large uterine myomas: operative technique and preliminary results

OBJECTIVE: The purpose of this study was to evaluate indications and complications of laparoscopic myomectomy with regard to the reproductive outcome of infertile women with a large leiomyomatous uterus. METHODS: From January 1997 to July 1999, 144 patients underwent laparoscopic myomectomy for a myoma measuring > or = 5 cm in diameter. Indications for surgery were increase in size of myoma in infertile patients (70.8%), pain (44.4%) or abnormal bleeding (68%). Average size of myomas were 7.8 cm with a range of 5 cm to 18 cm. The myomas were intramural/submucosal (n = 108), subserosal (n = 15), intraligamentous (n = 14) and peduncolated (n = 7). The laparotomy conversion rate was 1.39% (n = 2); one case required a blood transfusion. Operating time ranged from 58 to 180 minutes with an average of 95 minutes. Average hospital stay was 2.6 days and the overall complication rate was 2.08%. Eighteen patients (12.5%) underwent second-look laparoscopy. The rate of postoperative adhesion was 33.3%; there were no adnexal adhesions. In all cases ultrasonography was done one day after the operation and five weeks postoperatively to compare wound healing, the last control showed an irregular hypodense area in only 14 patients (9.7%). RESULTS: Twenty-six patients operated on in 1997 went on to conceive: nine vaginal deliveries, 12 Caesarean sections, four miscarriages and one ectopic pregnancy. No uterine rupture was observed. The pregnancy rate for patients submitted to laparoscopic myomectomy in 1997 (n = 38) was 34.21% at six months (n = 13) and 55.26% (n = 21) at 12 months after the procedures. CONCLUSIONS: Our preliminary results confirm that conception occurs in the majority of infertile women with a large leiomyomatous uterus who undergo myomectomy and second-look laparoscopy leads to a low complication rate.     

Myomectomy during cesarean section and outside pregnancy. Different outcomes of scars

BACKGROUND: The purpose of this study is the comparison between the scar of myomectomy performed during cesarean section and out of the pregnancy. METHODS: Eighteen pregnant patients were submitted to cesarean section between 37 and 39 weeks of gestation for previous myomectomy. The previous myomectomy has been performed in 8 patients during a cesarean section, in 10 patients out of pregnancy; in all patients only one subserous-intramural myoma of uterine fundus or body with a maximum diameter of 4-5 cm has been excised. RESULTS: In myomectomies performed during cesarean section the scar appeared more linear, with good well defined limits, less wide and with modest introflection in comparison to surrounding myometrium. The myometrial thickness did not present variations and was well contracted. CONCLUSIONS: Our results show substantial differences: in fact, according to personal opinion, the different evolution of the healing process is due to variations occurring in pregnancy and particularly for local immunology system which in pregnancy is hyperactive. The presence and increased synthesis of immunological substances support a better healing with an optimal functional recovery.     

妊娠期子宫肌瘤剔除术86例Meta分析

目的 探讨妊娠期子宫肌瘤剔除术的手术指征、并发症、妊娠结局以及影响手术成功的因素。方法 检索Pubmed（1989年1月～2004年4月）有关妊娠期行子宫肌瘤剔除术文献资料，对文献质量进行评价并提取相关信息．总结妊娠期行子宫肌瘤剔除术者的肌瘤特点、手术指征、并发症、妊娠结局等。结果 妊娠期行子宫肌瘤剔除术的86例中绝大部分在孕中期进行（12～26周），主要手术指征为腹痛（64％，35／55）和肌瘤过大或生长过快（20％．11／55）．术中无出血过多、子宫切除的并发症，术后自然流产4例．活产率达92％．分娩方式以剖宫产为主，占75％（53／71）。结论 在严格掌握适应证的基础上，妊娠期仍可安全地行子宫肌瘤剔除术。     

Maternal and foetal activin A levels: associations with normal and abnormal labour

In pregnancy the feto-placental unit is the major source of activin A. However, the role(s) of activin A in late pregnancy remain uncertain and controversial. In particular, whether activin A levels alter in association with labour is unclear. In a cross-sectional cohort study, maternal serum samples were collected from women at term prior to elective Caesarean section (n=11), during labour prior to a spontaneous vaginal delivery (n=31), an instrumental vaginal delivery (n=16) or an emergent Caesarean section (n=7). Umbilical artery blood samples were collected from 75 pregnancies, after an elective Caesarean section (n=9), a normal vaginal delivery (n=37), an instrumental vaginal delivery (n=15) or an emergent Caesarean section (n=14). Levels of activin A were measured and compared according to modes of delivery. Maternal, but not foetal, serum activin A was increased significantly in women who were delivered by an intrapartum Caesarean section compared to other modes of delivery. Foetal, but not maternal, serum activin A was significantly correlated with umbilical artery pH. Maternal serum activin A is increased in women undergoing an intrapartum Caesarean section compared to either a vaginal delivery or an elective Caesarean section. The mechanism(s) underlying this observation are not clear.     

Maternal and foetal activin A levels: associations with normal and abnormal labour

In pregnancy the feto-placental unit is the major source of activin A. However, the role(s) of activin A in late pregnancy remain uncertain and controversial. In particular, whether activin A levels alter in association with labour is unclear. In a cross-sectional cohort study, maternal serum samples were collected from women at term prior to elective Caesarean section (n=11), during labour prior to a spontaneous vaginal delivery (n=31), an instrumental vaginal delivery (n=16) or an emergent Caesarean section (n=7). Umbilical artery blood samples were collected from 75 pregnancies, after an elective Caesarean section (n=9), a normal vaginal delivery (n=37), an instrumental vaginal delivery (n=15) or an emergent Caesarean section (n=14). Levels of activin A were measured and compared according to modes of delivery.Maternal, but not foetal, serum activin A was increased significantly in women who were delivered by an intrapartum Caesarean section compared to other modes of delivery. Foetal, but not maternal, serum activin A was significantly correlated with umbilical artery pH. Maternal serum activin A is increased in women undergoing an intrapartum Caesarean section compared to either a vaginal delivery or an elective Caesarean section. The mechanism(s) underlying this observation are not clear.     

Myomectomy during the first trimester associated with fetal limb anomalies and hydrocephalus in a twin pregnancy.

OBJECTIVES: To present the complications of a twin pregnancy after first trimester myomectomy and to discuss the possible etiologic relationship. CASE REPORT: A 44-year-old primigravida with a dichorionic-diamniotic twin pregnancy underwent myomectomy in another hospital at 12 weeks' gestational age. At 28 weeks the patient was referred to our unit because of ventriculomegaly and limb anomalies in the second twin. The patient underwent a Caesarean section at 37 weeks of gestation delivering twin A, a healthy female weighing 3235 g and twin B, a female weighing 2810 g with hydrocephalus and limb anomalies (clubfeet and hypoplasia of the nails and terminal phalanges). The placenta from twin A was normal, but in the placenta of twin B haemorrhage, thrombosis and infarction were noted. CONCLUSIONS: Despite several reports of myomectomy in pregnancy without any problems for mother and fetus, the authors believe that myomectomy - especially in the first trimester - may be associated with the type of problems observed in the present case. The pathophysiological relationship between placental trauma and haemodynamic alterations as a possible cause of the malformations in twin B is discussed.     

Laparoscopic myomectomy and pregnancy outcome in infertile patients

OBJECTIVE: To assess outcomes and pregnancy-related complications after laparoscopic myomectomy in infertile patients. DESIGN: Retrospective analysis. SETTING: Tertiary care advanced laparoscopic center. PATIENT(S): Twenty-eight infertile patients with at least one uterine leiomyoma of >5 cm in diameter. INTERVENTION(S): Laparoscopic myomectomy. MAIN OUTCOME MEASURE(S): Occurrence of pregnancy, delivery rate, and pregnancy-related complications. RESULT(S): The average size of the myomas removed was 6 cm (range, 4-13.3 cm). None of the procedures were converted to laparotomy. The postoperative rate of intrauterine pregnancy was 64.3% (n = 18), including 1 of 2 patients who underwent concomitant hysteroscopic myomectomy. Four patients had spontaneous abortions and 14 delivered viable term neonates. Six women had a vaginal delivery without complications and 8 had a cesarean section. No antepartum or intrapartum complications were reported. CONCLUSION(S): Laparoscopic myomectomy can be offered to patients who want to have children and who refuse to undergo an abdominal myomectomy. Patient selection as well as meticulous surgical technique are the key factors in achieving a successful outcome.     

围生期子宫肌瘤治疗策略

子宫肌瘤可对妊娠前、妊娠各期、分娩及产褥期造成一系列不利影响。如何提供孕前咨询、正确医疗指导和选择适宜治疗方案,是产科医生必须面临的问题。对于直径<5 cm的肌瘤,在围生期若无并发症均无需处理;有产科指征者可行剖宫产术,术中行子宫肌瘤剔除术是安全可行的。妊娠合并子宫肌瘤属高危妊娠,需加强监护,出现并发症应及时处理。     

Caesarean myomectomy--a safe procedure. A retrospective case controlled study.

Sixteen women, with uterine fibroids in pregnancy, who were treated by caesarean myomectomy, were compared retrospectively with 16 women, without uterine fibroids who had caesarean section during the same period. Myomectomy was performed at caesarean section after delivery of the baby and the placenta, with the administration of intravenous oxytocin. The fibroid defects were occluded with continuous interlocking and fixed sutures. Routine caesarean section was performed on the subjects in the control group. The comparative efficacy of the procedure was measured by comparing pre- and post-operative haemoglobin levels, measured blood loss, need for blood transfusion, post-operative febrile morbidity and length of hospital stay in both groups. Caesarean myomectomy resulted in a mean blood loss of 495 ml (range 200-1000 ml) compared with 355 ml (range 150-900 ml) in the control group (P =0.907). The caesarean myomectomy group had a mean fall in haemoglobin level of 1.7 g/dl compared with a fall of 1.4 g/dl in the control group. There were no significant differences between the groups in the need for blood transfusion, post-operative febrile morbidity or length of hospital stay. The results indicate that caesarean myomectomy is safe and offers no significant increased risk to the patient over caesarean section alone. This is beneficial to the health sector by the avoidance of an interval myomectomy hence justifying the cost effectiveness of the procedure.     

Prelabour Rupture of the Membranes at Term-No Advantage of Delaying Induction for 24 Hours

We performed a prospective randomized study to compare maternal and fetal outcomes in pregnancies with prelabour rupture of the membranes (PROM) at term with early induction of labour or expectant management, 126 women with singleton pregnancy, cephalic presentation and gestational duration > or = 37 weeks, were randomized either to immediate induction of labour with oxytocin (Group 1) (n=52), or conservative management (Group 2) (n=74). Women who constituted Group 2 were divided into 2 groups. The first group (Group 2A) (n=25) included women in whom spontaneous labour did not begin after a waiting period of 24 hours, in which case labour was induced with oxytocin i.e. expectant management. The second group consisted of women (Group 2B) (n=49) in whom labour began spontaneously within 24 hours. The base Caesarean section rate was significantly higher in Group 2 (28.4%) (p<0.05). The rates of Caesarean section in the Groups 1-2A-2B were 19.2%, 60%, and 12.2%, respectively for nulliparous and parous women together. The rate of fetal distress was significantly higher in Group 2 (p<0.05). For determining maternal outcomes, the other parameters such as clinical chorioamnionitis, fever before or during labour, receiving antibiotics before or during labour, postpartum fever, analgesia, anaesthesia did not differ in Groups 1 and 2. Women in Group 1 went into active labour sooner, had fewer digital vaginal examinations, had a shorter interval between membrane rupture and delivery, and spent less time in the hospital before delivery than those in Group 2 (p<0.05). Babies in Group 2 were more likely to receive antibiotics, and more likely to stay in an intensive care nursery for more than 24 hours, and more likely to receive ventilation after initial resuscitation than those babies in Group 1. For developing apnoea and hypotonia, there was no significant difference between Groups 1 and 2. However, for babies in Group 2A there was a significant difference. We conclude that immediate induction of labour with oxytocin does not increase the risk of Caesarean section, compared with a practice of expectant management. Women at term with prelabour rupture of the membranes should therefore be reassured that immediate induction with oxytocin currently appears to be the best policy with respect to maternal and neonatal morbidity.     

Bilateral ascending uterine artery ligation vs. tourniquet use for hemostasis in cesarean myomectomy. A comparison

OBJECTIVE: To comparatively investigate the effects of using bilateral ascending uterine artery ligation and tourniquet use on intraoperative and postoperative blood loss during myomectomy in cesarean cases. STUDY DESIGN: A total of 70 pregnant women diagnosed with myomas in the prenatal period were included in this randomized, prospective study. They were admitted to our department during the study period. Fifty-two patients who underwent cesarean myomectomy were randomly divided into 2 equal groups. In the first group bilateral ascending uterine artery ligation and myomectomy were performed after lower uterine segment transverse cesarean section. The second group served as the control group; myomectomy was performed with a tourniquet. For statistical analysis, Mann Whitney U, chi 2 and Wilcoxon Rank tests were used. Spearman correlation analysis (rs, n, p) was used for analysis of correlation between the duration of the myomectomy operation and blood loss and number of enucleated myoma nuclei during myomectomy. RESULTS: Total intraoperative blood loss, total operation duration, number of enucleated myoma nuclei (Mann Whitney U test) and febrile morbidity (chi 2 test) were similar in the 2 groups (P > .05). A significant positive correlation was established between the duration of the myomectomy operation and loss of blood and number of enucleated myoma nuclei during myomectomy (rs = .9, n = 52, P = .000). Urgent laparotomy and bilateral internal iliac artery ligation had to be performed in 1 patient in the tourniquet group who had a postoperative hemorrhage. CONCLUSION: Despite the fact that bilateral ascending uterine artery ligation and tourniquet use had similar outcomes with regard to intraoperative blood loss in cesarean myomectomy cases, the efficacy of ligation on blood loss in the postoperative period continues owing to its permanence. The tourniquet method is not effective in the postoperative period since the tourniquet is removed at the end of the operation. Therefore, bilateral ascending uterine artery ligation may be preferable in cesarean myomectomy cases.     

Uterine myomectomy in pregnant women

OBJECTIVE: To determine whether myomectomy during pregnancy in selected patients improves outcome. METHODS: Retrospective analysis of 18 patients who underwent myomectomy between the 6th and 24th week of gestational age. Surgical management of tumors was required on the basis of the characteristics of the myomas and symptoms. The dimensions and site of myomas, symptoms of the patients, time and mode of delivery, and pregnancy outcome were analyzed. RESULTS: One woman was lost to follow-up, and one suffered a miscarriage. The remaining 16 patients delivered healthy babies between the 36th and 41st week; 14 delivered by cesarean section, and 2 vaginally. CONCLUSION: We suggest that myomectomy during pregnancy may be considered safe in selected patients. Moreover, it permits good pregnancy outcome with healthy babies delivered at term.     

Fertility outcome: long-term results after laparoscopic myomectomy

From 1991 to 1998 ,29 patients desiring a pregnancy underwent laparoscopic myomectomy for symptomatic myomas measuring 5.4 ± 3.6 cm (mean ± SD) (median 5; range 1-9). The overall rate of intrauterine pregnancy was 65.5% (19 pregnancies; two patients had two pregnancies each). Results were analyzed in relation to different preoperative clinical conditions. Out of nine patients with other infertility factors associated with uterine myomas ,three (33.3%) became pregnant; out of 10 infertile patients with no other associated infertility factors ,seven (70%) became pregnant; out of 10 patients to whom myomectomy was performed for the rapid growth of the tumor or for myoma encroaching on the cavity ,nine (90%) had a pregnancy. Nine patients (73.4%) had a Cesarean section (one twice) ,four (26.6%) had spontaneous vaginal delivery ,one patient had a serious placental failure at the 28th week ,and four patients (19%) miscarried. Two pregnancies are still in progress (one in a patient with previous miscarriage). Out of 21 pregnancies ,the viable term delivery rate was 57.14%. No uterine ruptures were observed. The pregnancy rate after laparoscopic myomectomy was similar to that reported in other studies after laparotomic myomectomy. It is concluded that laparoscopic myomectomy is a reliable procedure even in the presence of multiple or enlarged myomas. Moreover ,our pregnancy rate and pregnancy outcome seem to indicate that both desire for pregnancy and infertility prior to surgery should not be exclusion criteria for the laparoscopic approach.     

Fertility outcome: long-term results after laparoscopic myomectomy.

From 1991 to 1998, 29 patients desiring a pregnancy underwent laparoscopic myomectomy for symptomatic myomas measuring 5.4 +/- 3.6 cm (mean +/- SD) (median 5; range 1-9). The overall rate of intrauterine pregnancy was 65.5% (19 pregnancies; two patients had two pregnancies each). Results were analyzed in relation to different preoperative clinical conditions. Out of nine patients with other infertility factors associated with uterine myomas, three (33.3%) became pregnant; out of 10 infertile patients with no other associated infertility factors, seven (70%) became pregnant; out of 10 patients to whom myomectomy was performed for the rapid growth of the tumor or for myoma encroaching on the cavity, nine (90%) had a pregnancy. Nine patients (73.4%) had a Cesarean section (one twice), four (26.6%) had spontaneous vaginal delivery, one patient had a serious placental failure at the 28th week, and four patients (19%) miscarried. Two pregnancies are still in progress (one in a patient with previous miscarriage). Out of 21 pregnancies, the viable term delivery rate was 57.14%. No uterine ruptures were observed. The pregnancy rate after laparoscopic myomectomy was similar to that reported in other studies after laparotomic myomectomy. It is concluded that laparoscopic myomectomy is a reliable procedure even in the presence of multiple or enlarged myomas. Moreover, our pregnancy rate and pregnancy outcome seem to indicate that both desire for pregnancy and infertility prior to surgery should not be exclusion criteria for the laparoscopic approach.     

Clinical analysis of pregnancy complicated by hypertension in the material of the Department of Obstetrics and Perinatology of the Pomeranian Academy of Medicine

OBJECTIVES: The aim of this study was retrospective analysis of arterial hypertension during pregnancy in the Department of Obstetrics and Perinatology of Pomeranian Academy of Medicine in Szczecin, and severe PIH intensive obstetrical care optimization. DESIGN: The retrospective analysis of 81 pregnancies complicated by arterial hypertension in the years 1995-2000 was performed. MATERIAL AND METHODS: The retrospective analysis of 81 pregnancies was performed. Patients were divided into two groups. In the first pregnancy was ended by caesarean section (n = 43), in the second by vaginal delivery. The mean gestational age, the way of delivery, accompanying diseases, uric acid levels, short term variability, Dawes - Reedman's criteria, presence of decelerations in CTG, Doppler PI, S/D, RI parameters in umbilical artery and cerebral arteries, presence of AEDVF and REDVF in umbilical artery were analyzed. RESULTS: Caesarean section was performed in 53.1% of all cases, in 46.9% vaginal delivery took place. Absolute range of short-term variability was more often less than 6 ms in caesarean section group (41.9%). Uric acid level was also higher in caesarean section group (p = 0.000194) CONCLUSIONS: 1. The caesarean rate in pregnancies complicated by arterial hypertension is over 50% and during severe PIH is approximately 100%. 2. Caesarean section takes place before estimated delivery date and indications to it are in most cases connected with a main disease 3. Short-term variability is lower among patients from caesarean section group. 4. Uric acid level is a relevant parameter of a degree of arterial hypertension, and the level is higher in first group. 5. Doppler velocimetry of umbilical artery and middle cerebral artery are valid part of obstetrical care among patients with PIH.     

Leiomyomas in pregnancy

OBJECTIVES: The problem of leiomyomas founded in pregnancy is reported. DESIGN: Diagnostic methods, indications and contraindications for the myomectomy and surgical technique are presented. MATERIALS AND METHODS: In years 1991-2000--185 pregnant women with leiomyomas diagnosed during pregnancy or caesarean section were treated. RESULTS: There were indications for the myomectomy during pregnancy in the group of 26 women, in next 55 women leiomyomas were diagnosed in the course of pregnancy but myomectomy was performed during caesarean section. In the other group of 104 pregnant women leiomyomas were found and enucleated first during caesarean section made on the other indications. CONCLUSIONS: It was observed that myomectomy during caesarean section and also in the course of pregnancy is a safe procedure when the indications and surgical technique are correctly made.     

Pregnancy and labor after uterine operations

OBJECTIVES AND DESIGN: In this study authors analyzed the obstetric history of patients, efficiency of operative treatment and number of obstetric failures, both before and after operation. A special attention was paid to obstetrical past and present history as well as difficulties and complications during the operation. MATERIALS AND METHODS: A group of 25 cases of pregnancy after a myomectomy, Strassmann's or Jones' operation were analyzed. All patients were in age 24-40, an average--33. RESULTS: In all 25 pregnant women authors found: breech presentation (1 case), ingrown placenta (1 case), 3 cases of solid intraperitoneal adhesions and 1 case of uterine cicatrix fissure. CONCLUSIONS: 1. Women after uterine operations require intensive care in pregnancy. 2. Caesarean section is the optimal method of delivery in women after uterine operations.     

The impact of leiomyomas on pregnancy

In this retrospective case control investigation, 51 pregnant patients who were diagnosed by ultrasound with uterine myomas were compared to 102 randomly selected control patients to determine if the ultrasound diagnosis of one or more leiomyoma is associated with increased untoward pregnancy outcomes compared to controls. Women with uterine myomas were older (p = 0.001), more likely to be African American (p = 0.001), and undergo Caesarean delivery (p = 0.03) than controls. However, when women who underwent abdominal delivery for previous myomectomy (n = 5) were excluded from analysis, there was no significant difference in the incidence of Caesarean delivery. Overall, there was no difference in the incidence of obstetric complications between groups even when the data was stratified for large and/or multiple leiomyomas. The discovery of uterine leiomyomas by gestational ultrasound does not appear to place the patient at increased risk for preterm labour, early delivery, or other untoward pregnancy outcomes.     

A modified suture technique for laparoscopic myomectomy

STUDY OBJECTIVE: The safety and efficacy of a modified laparoscopic suture performed by a surgeon assisted by an under-training assistant in the repair of uterine defect during laparoscopic myomectomy (LM) was evaluated. DESIGN: Prospective clinical study (Canadian Task Force classification II-2). SETTING: Tertiary care university hospital. PATIENTS: Sixty-two women scheduled for myomectomy because of symptomatic uterine myomas. INTERVENTION: Group A (n = 31): LM with a modified laparoscopic suture technique (the suture line was pulled out of the trocar, and tension of the suture was maintained by the surgeon's or assistant's hand). Group B (n = 31): LM with a traditional laparoscopic suture technique (intracorporeal continuous suturing with a string trimmed to 30 cm). MEASUREMENTS AND MAIN RESULTS: The median operative time (100 minutes vs 90 minutes, p = .436) and blood loss (200 mL vs 150 mL, p = .771) were slightly greater in the LM with a modified laparoscopic suture technique group (group A), although these differences were not statistically significant. The total specimen weight, number of myomas removed, and length of hospital stay were similar in both groups. No patients in either group had serious complications. CONCLUSION: A modified laparoscopic suture by controlling the tail of the suture with the surgeon's hand while sewing laparoscopically can achieve a good approximation of uterine defect and is an acceptable alternative to help laparoscopic surgeons performing surgery assisted by an under-training assistant to complete the procedure.     

Prospective evaluation for the feasibility and safety of vaginal birth after laparoscopic myomectomy

STUDY OBJECTIVE: To estimate the feasibility and safety of vaginal birth after laparoscopic myomectomy (LM). DESIGN: Prospective clinical study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: The study was performed on 1334 patients who underwent LM at our hospital from January 2000 through December 2005. INTERVENTIONS: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: The potential of a safe vaginal birth after LM was discussed with all 1334 patients before and after their LM. A strict protocol for a vaginal birth after LM was prepared using the criteria for a vaginal birth after cesarean section (CS). Of the 221 women who became pregnant after LM by December 2006, 111 were scheduled to deliver at our hospital. The findings at LM in these patients were as follows: mean diameter of the largest myoma (mean +/- SD, 95% CI), 66.1 +/- 18.8 (62.6-69.6) mm; and mean number of enucleated myomas, 3.5 +/- 3.6 (2.8-4.2). The endometrium was opened in 13 patients. Of the 111 patients, 82 patients opted for a vaginal delivery and 29 patients requested a CS. Of the 82 patients, 8 underwent an elective CS because of complications of pregnancy. Vaginal delivery was completed in 59 (79.7%) of the remaining 74 patients. The 15 patients who failed vaginal delivery underwent a CS: eleven because of failure to progress in labor or absence of spontaneous labor by 42 weeks of gestation; and 4 because of a nonreassuring fetal status during labor. No significant differences in delivery outcomes existed between the successful and failed group. None of the patients had a uterine rupture. CONCLUSION: Uterine rupture during pregnancy after LM is rare, and vaginal birth after LM appears to be safe in selected patients who meet our criteria.