A survey on the current practice of indicating an elective cesarean after a previous myomectomy

Objective: The objective of this study was to evaluate the attitude of obstetricians/gynecologists toward indicating an elective cesarean delivery in pregnant patients with a previous myomectomy. Materials and Methods: Web-based multiple-choice questions survey evaluating the attitude to indicate a cesarean with a composite summated score (range 56–280) from a 56-item Likert scale: score 56–112: weak attitude, 113–168: moderate, 169–224: strong, and 225–280: very strong. The reliability of the score (internal consistency) was evaluated with Cronbach’s alpha coefficient. The association between the score and participants’ characteristics was determined with a bivariate analysis followed by linear regression analysis. The “global importance” of each risk factor was defined as the prevalence of the answers: “moderately important”, “very important”, and “extremely important” on the Likert scale. Factors with a “global importance” >75% were considered “crucial” in influencing the choice to indicate a cesarean. Results: One-hundred-twenty obstetricians/gynecologists responded (response rate 70.6%). The mean±SD composite summated score was 137±31; 30 (25.0%) participants presented a "weak attitude to cesarean", 68 (56.7%) a "moderate attitude", 22 (18.3%) a "strong attitude", and none a "very strong attitude". The Cronbach’s alpha was 0.934 (high internal consistency). A self-reported number of myomectomies performed per year >50 was associated with a lower score (-25 points, 95% CI −50 to −1, p=0.04). Eight criteria resulted “crucial” in indicating a cesarean: opening of the endometrial cavity, monopolar electrosurgery, time surgery-pregnancy <6months, 2+ previous myomectomies, hematoma formation in the surgical wound, 3+ removed fibroids, and a FIGO4 or FIGO3 removed fibroid. Conclusions: Obstetricians/gynecologists are cautious to indicate a cesarean in pregnant patients with a previous myomectomy, except for cases at hypothetic high-risk for uterine rupture, mainly supported by weak evidence. Information to patients and among clinicians is crucial to avoid inappropriate cesarean indications.