A Dynamic, Intraoperative-Triggered Strategy for Early Bilateral Uterine Artery Ligation During Cesarean Myomectomy in Pregnancies with Giant Fibroids in High-Risk Locations: A Retrospective Case Series of Ten Patients

Pregnancy is a time of profound physical change, but for a small number of expectant mothers, the uterus itself holds a hidden challenge: large, benign growths known as fibroids. While most fibroids are small and cause no trouble during pregnancy, some grow to a massive size and settle in precarious spots, such as behind the placenta or deep within the muscle wall. When a woman with such a growth needs a cesarean section, the surgeon faces a difficult dilemma. Removing the baby is straightforward, but removing the fibroid at the same time carries a significant risk of severe bleeding. The uterus is a highly vascular organ, meaning it is packed with blood vessels, and cutting into it while it is full of blood can lead to a rapid, uncontrollable loss of blood that is difficult to stop. For decades, doctors have debated whether it is safe to remove these growths during delivery, often hesitating because the potential for disaster is so high.

The core of the problem lies in timing and prediction. Traditionally, surgeons try to guess the risk before the operation even begins, using scans to label a patient as "high risk" or "low risk." If a patient is labeled high risk, the surgical team might prepare for the worst, but this static label cannot account for the dynamic reality of the surgery itself. A tumor that looks manageable on a scan might start bleeding fiercely the moment it is touched, while a seemingly dangerous one might stop bleeding on its own. The challenge for the medical team is knowing exactly when to switch from careful observation to aggressive intervention to stop the bleeding before it becomes life-threatening.

A team of researchers at Beijing Shijitan Hospital recently explored a new way to handle this uncertainty. Instead of relying solely on preoperative labels, they developed a strategy that waits for the surgery to begin and then reacts to the actual behavior of the bleeding. They focused on ten women who were carrying singleton pregnancies and had at least one giant fibroid, defined as being eight centimeters or larger, located in a high-risk area. The team implemented a dynamic protocol where the decision to perform a specific life-saving maneuver was not made in the planning room, but in the operating theater, the moment the surgeon recognized that bleeding was accelerating.

The maneuver in question is the ligation, or tying off, of the uterine arteries. These are the main vessels that supply blood to the uterus. By tying them off early, the surgeon can drastically reduce the blood flow to the area where the fibroid is being removed, effectively starving the wound of the blood that would otherwise flood it. However, this is a permanent change to the blood supply, so the researchers were careful not to do it unless it was absolutely necessary. Their rule was simple: if the bleeding was active and speeding up, they would tie off the arteries immediately, before the situation spiraled out of control. They did not wait for the patient to lose a dangerous amount of blood; they acted at the first sign that the bleeding was becoming unmanageable.

To test this approach, the researchers looked back at the records of ten consecutive patients managed under this new protocol between 2022 and 2025. The group included women with fibroids ranging from five to thirty centimeters in diameter. The team found that three of these women met the criteria for the emergency intervention. In these cases, the surgeons recognized that the bleeding was accelerating and tied off the uterine arteries right away. Remarkably, even though these women had the largest fibroids in the group, with an average size of nearly eighteen centimeters, their total blood loss remained manageable. The average amount of blood lost by this group was 343 milliliters, and none of them required a blood transfusion.

The other seven women in the study did not need this aggressive step. Their bleeding was either minimal or could be controlled with other, more targeted techniques depending on where the fibroid was located. For example, one woman had a fibroid that had twisted and caused pain before delivery, so it was removed via a minimally invasive laparoscopic surgery weeks earlier. Another had a fibroid that prolapsed after birth and was removed vaginally. The remaining women had their fibroids removed during the cesarean section using specific techniques suited to their tumor's position, such as pulling on the cervix or tying off the stalk of the growth. Across the entire group of ten women, the average blood loss was only 256.5 milliliters, and not a single patient needed a blood transfusion. There were no cases of severe hemorrhage, no need to remove the uterus, and no infections.

The researchers are careful to note that this study is a preliminary look at a new idea, not a final proof that the method is perfect for everyone. The group was small, and there was no comparison group of women who followed the old, standard methods. Because of this, the authors describe their findings as a hypothesis-generating story rather than a definitive solution. They emphasize that the decision to tie off the arteries was based on the surgeon's real-time judgment of the bleeding, a judgment that they later checked against a known benchmark for dangerous blood loss. In the three cases where the arteries were tied, the bleeding rate was estimated to have exceeded 150 milliliters per minute, a speed at which a person could lose half their blood volume in just twenty minutes if left untreated.

This approach offers a middle ground between two extremes. On one side is the fear of operating on a pregnant uterus with a large fibroid, which has led some doctors to avoid removing the growth entirely. On the other side is the risk of waiting too long to stop the bleeding, which can lead to a catastrophic loss of blood. The new strategy suggests that surgeons can be prepared for the worst without assuming the worst will happen. By waiting for the actual bleeding to dictate the plan, they can reserve the most aggressive measures for the moments when they are truly needed.

The implications of this work extend beyond the operating room, particularly for regions where blood banks are scarce or unreliable. In many parts of the world, a shortage of donated blood means that a severe hemorrhage can be fatal simply because there is no blood available to replace what is lost. A surgical technique that can prevent bleeding from reaching a critical level without needing specialized equipment or blood products could be a vital tool for saving lives in these settings. The researchers suggest that their method, which relies on a simple suture to stop the flow of blood, could be especially valuable in environments where a transfusion is not a guaranteed option.

While the study is small, it provides a clear example of how medical decision-making can shift from rigid preoperative labels to flexible, real-time responses. The team found that by watching the bleeding closely and acting quickly when it accelerated, they could keep blood loss low and avoid the need for transfusions in all ten cases. They acknowledge that larger studies with more patients and a control group are needed to confirm whether this strategy is consistently safe and effective. For now, the work stands as a promising suggestion that a dynamic, physiology-driven approach might offer a safer path for women facing the complex challenge of removing giant fibroids during a cesarean delivery.