Discuss rupture risk with myomectomy patients. (Uterine Rupture in Pregnancy).

BIG SKY, MONT. -- A documented conversation about the increased risk of uterine dehiscence is an essential part of preoperative counseling in all patients undergoing myomectomy, Dr. Joseph S. San-filippo said.

"Please, please document in your record before you walk into the operating room, in your preoperative informed consent, that you spoke with the patient about the potential for rupture, even without labor. Spell it out. Make it very clear. And document it," be said at an ob.gyn. update sponsored by the Geisinger Health System.

The incidence of uterine rupture at the incision line in pregnancy following laparoscopic myomectomy appears to be about 1 in 40. In contrast, the risk in women with no history of uterine surgery, while never well characterized, is probably in the range of 1 per 1,000-4,000, said Dr. Sanfilippo, professor of ob.gyn. at the University of Pittsburgh.

There are even documented cases of spontaneous uterine dehiscence at the incision line at 34 weeks' gestation in the absence of labor, he noted, Some investigators have used ultrasound to assess the uterine scar post myomectomy in an effort to determine which patients can safely undergo labor, but this hasn't worked out satisfactorily as a predictor. "There's no way to get a good handle on who's going to dehisce and who's not, so all comers need to be informed a priori of the potential," he said.

Dr. Sanfilippo noted that good approximation of the myometrial bed at closure reduces the risk of uterine rupture. For this reason, he favors laparoscopic-assisted myomectomy over an all-laparoscopic procedure. Laparoscopic-assisted myomectomy entails laparoscopic dissection of the uterine fibroids followed by their removal through a minilaparotomy incision, which is also used in dosing the myometrial bed.

"The key concept is, how can you best ...