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Uterine fibroids affect almost one in two patients, causing many pelvic problems and requiring pharmacologic and surgical treatment. For many years, the importance of the fibroid was emphasized as uterine pathology, without focusing on the complex myometrial biology peripheral to fibroid. Moreover, the traditional surgical technique in fibroid removal has not been investigated for years. In recent years, on the contrary, morphological, neuroendocrine and anatomical studies have demonstrated the importance of a biological and surgical structure surrounding myoma, rich in neurotransmitters and neurofibres, the myoma pseudocapsule. This structure is formed in the womb peripheral to fibroid onset, it separates the fibroid from the myometrium and acts as a tissue regenerator after the removal of the fibroid from the uterus. The translation of scientific research on pseudocapsules into surgical practice has allowed us to identify new techniques of myomectomy, removing the myoma inside the pseudocapsule and promoting the pseudocapsules sparing surgery. All this to favor the subsequent biological process of uterine scarring and healing, by activating the neurotransmitters and neurofibres present in the myometrial fovea. The correct healing after fibroid removal restores the uterine anatomy, with a positive impact on subsequent reproductive function, reducing problems related to the muscle scar.

Introduction. Although uterine myomas are becoming more common in pregnancies due to advanced maternal age, the literature lacks reports on complications, such as hysterectomy following cesarean myomectomy (CM). The aim of this work was to describe when CM is inevitable, complicated by severe intrapartum hemorrhage and requiring a hysterectomy. Case outline. A pregnant, with a term pregnancy and large multiple myomas, was referred for elective cesarean section (CS). During the CS, forced enucleation of a 100 mm anterior and left myoma previa (pre-fetal extraction) was necessary, and a 2,800 g neonate was delivered through the lower uterine segment incision. After the delivery and another CM, it was necessary to stop a massive hemorrhage from the myometrial myoma bed. Following provisory suturings of the hysterotomies, an urgent hysterectomy was performed with left salpingo-oophorectomy, due to a large hematoma in the left retroperitoneal space. The patient’s further recovery was uneventful and she was discharged with her baby on the sixth postoperative day. The histopathology report revealed a 135 × 190 × 150 mm uterus, weighing together with the enucleated myomas and left adnexa 5,000 g in total. The weight of the enucleated myomas was 1,670 g. The histopathological examination also showed 12 intramural and subserous myomas in the myometrium, ranging 30–190 mm. Conclusion. Large myomas, especially previa, may present a serious problem for fetal extraction during a CS. Therefore, the authors suggest an informed consent for CM, in patients who should undergo a CS. Additionally, such patients should be counseled about the possibility of an intrapartum hysterectomy.