Fibroid

and

pregnancy

Prof

Aboubakr

Elnashar

Benha university, Egyptelnashar53@hotmail.com

ABOUBAKR ELNASHAR

CONTENTS

1.PREVALENCE

2.EFFECT OF PREGNANCY ON FIBROID

3.EFFECT OF FIBROID ON PREGNANCY

I. FOETAL

II. MATERNAL

4.MANAGEMENT:

I. BEFORE PREGNANCY

II. DURING PREGNANCY

III. DURING LABOUR

CONCLUSION

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1. PREVALENCE

1.6% and 10.7%

depending upon

population under investigation

trimester

size threshold of fibroid

Increases with

age

parity

in African American women than in white or

Hispanic women.

Prolonged duration of breast feeding

small but statistically significant reduction in

prevalence.ABOUBAKR ELNASHAR

2. EFFECT OF PREGNANCY ON FIBROID

1. Changes in Size

During Pregnancy

Pregnancy-related increases in

steroid hormone levels

uterine blood flow

Common belief:

fibroids increase in size throughout gestation.:

Not confirmed

Remain stable across gestation

(<10% change in volume): 50% to 60% of cases

Increase: 22% to 32%

Decrease: 8% to 27%.(Rosati et al, 1999)

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Fibroids which increase in size:

do not grow continuously throughout gestation.

Most of the growth occurs in the first trimester

little if any further increase in size during the second

and third trimesters.

Larger fibroids (>5cm)

more likely to grow

Smaller fibroids

More likely to remain stable.

The mean increase in fibroid volume during pregnancy

12%

very few fibroids increase by >25%.

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3 to 6 months postpartum

90%

regress in total fibroid volume

10%

increase in volume.(Laughlin et al, 2011)

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2. Degeneration and torsion

10% of pregnant women with fibroids.(Hasan et al, 1999)

Rapid fibroid growth:

relative decrease in perfusion: ischemia and

necrosis (red degeneration)

release of prostaglandins

Pain(De Carolis et al, 2004)

Pedunculated fibroids

might also cause pain

{torsion and necrosis}.

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3. Changes in Symptoms

90%

No symptoms during pregnancy.

10%

Symptoms

Pain

Pelvic pressure, and/or

Vaginal bleeding.

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Pain

most common symptom.

correlates with size

high with fibroids >5cm

Timing:

in the late first or early second trimester

Caused by

1. greatest fibroid growth

2. degeneration.

3. Torsion

4. partial obstruction of the vessels supplying the

fibroid as the uterus enlarges.(Parker, 2007)

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3. EFFECT OF FIBROID ON PREGNANCY

Most pregnant women with fibroids:

do not have any complications during pregnancy(Segars et al, 2014)

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Ezzedine et al, 2016

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I. Foetal

1. Miscarriage

Submucosal fibroids.

Common

Intramural fibroids

controversial

Subserosal and pedunculated fibroids

unlikely to cause such complications.

Multiple fibroids.

Increase risk of miscarriage(Benson et al, 2001)

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Miscarriage rate:

1. Type

(Bajekal & Li , 2000)

Miscarriage rate (%)Fibroid (n)

40Submucosal (27)

33Intramural (44)

33Subserous (158)

16Control (2413)

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Abortion rate (%)Fibroid

34<7cm

29Control

2. Size

(Olivera et al,2003)

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Abortion rate (%)Number of fibroids

34<3

60>3

18Control

3. Number:

(Feliciani et al, 2003)

>3 fibroids (3-5 cm) are associated with increased

risk of abortion

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Mechanisms

1. Large submucosal fibroids:

interfere with placentation and the development of

normal uteroplacental circulation by

compressing the decidualized endometrium:

decidual atrophy

distortion of the vascular architecture of the

decidua

2. Rapid fibroid growth:

increased uterine contractility

impaired placental function: disrupt placentation

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4.5x3.8 cm submucosal retroplacental uterine fibroid at 19

weeks of gestation.

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2. Preterm labor and birth

Small increase

(OR) 1.9; 95% CI, 1.5-2.313] and(Klatasky et al, 2008)

High risk:

1. multiple fibroids

2. placentation adjacent to or overlying the fibroid

3. fibroid size >5cm.

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Mechanism;

1. Fibroid uteri is less distensible than

Non fibroid uteri: premature uterine contractions and

cervical change.

2. Decrease in oxytocinase activity in the gravid

fibroid uterus: higher concentrations of oxytocin.

Not consistent across the literature.(Robert et al, 1999)

fibroids is not considered an indication for

sonographic cervical length measurements during

pregnancy.

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3. Malpresentation

Large submucosal fibroids that distort the

uterine cavity:

consistently associated with fetal malpresentation(OR 2.9;95% CI, 2.6-3.2).(Klatsky et al, 2008)

Significant increase in breech presentation at term (OR 1.5; 95% CI, 1.3-1.9).

(Stout et al, 2005)

Increased risk

1. multiple fibroids

2. fibroid located behind the placenta or in the

lower uterine segment

3. Large fibroid(>10cm).

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4. FETAL ANOMALIES

extremely rare.(Romero et al, 1981)

large submucosal fibroids: Spatial restriction

limb reduction defects

Congenital torticollis

head deformities

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5. Fetal growth restriction

Small effect on fetal growth(OR 1.4; 95% CI, 1.1-1.713)

(Robert et al, 1999)

Large submucosal (volume >200 mL) or

Retroplacental fibroid

higher rate of SFGA(Rosati et al, 1992)

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II. Maternal:

1. Antepartum bleeding and placental abruption

Antepartum bleeding

more common (Coronado et al, 2000)

Not confirmed (Klatsky et al, 2008)

Abruption

increased 3-fold (OR 3.2; 95% CI, 2.6-4.0).

(Klatsky et al, 2008)

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The highest risk

submucosal

retroplacental fibroids

fibroid volumes >200mL (diameter of 7 to 8 cm).(Exacousto, Rosati; 1993)

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2. Dysfunctional labor

increased incidence (Coronado et al, 2000)

Intramural fibroids

affect the force of uterine contractions

disrupt the coordinated spread of the contractile

wave(Vergani et al, 1984)

Not confirmed(Qidwai et al, 2006)

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3. Cesarean delivery

increased risk(OR 3.7;95%CI,3.5-3.913),

especially lower uterine segment fibroid(Csoronado et al, 2000)

Causes:

1. malpresentation

2. dysfunctional labor

3. mechanical obstruction

4. placental abruption

most of these studies

were biased in their selection of cases:

definitive causal association remains unproven.

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4. Postpartum hemorrhage

an increased risk(Qidwai et al, 2006)

Especially if the fibroids

1. large (>3cm)

2. located behind the placenta

3. delivery is by cesarean.

other studies

no association(Robert et al, 1999)

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5. Preterm premature rupture of Membranes

Pooled cumulative data

no increase the risk

may even slightly decrease the risk.(Klatsky et al, 2008)

individual studies

conflicting results.(Stout et al, 2010)

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6. Placenta previa

Most studies that adjusted for maternal age and prior

uterine surgery

failed to show any association(Coronado et al, 2000)

2 large series

an increased rate (1.4% vs. 0.5% in controls;3.8%vs.2.0% in controls).

did adjust for prior cesarean delivery and

myomectomy.

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7. Pre-eclampsia

The majority of studies

no association (Coronado et al, 2000)

Multiple fibroids

significantly more likely to develop preeclampsia

than those with a single fibroid (45% vs. 13%).(Robert et al, 1999)

{Disruption of trophoblast invasion by the multiple

fibroids: inadequate uteroplacental vascular

remodeling}

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8. Other complications

rare

1. disseminated intravascular coagulation

2. spontaneous hemoperitoneum,

3. uterine incarceration

4. Urinary tract obstruction with urinary retention

5. or acute renal failure

6. deep vein thrombosis

7. puerperal uterine inversion.(Lee et al, 1998)

8. Pyomyoma (suppurative leiomyoma) (Mason, 2005)

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4. MANAGEMENT

I. BEFORE PREGNANCY

Indications for preconception myomectomy

Made on a case-by-case basis

Age

Reproductive history

Severity of symptoms

Size

Site.

No good data that preconception myomectomy will

improve pregnancy success or the take-home baby

rate.

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(Zepiridis et al, 2016)

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II. DURING PREGNANCY

1. Fibroid pain

May require hospitalization

Supportive care

1. Acetaminophen (GRADE 2C23).

2. Opioids:

1. short-term use

2. standard doses

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3. NSAIDs

48-hour course

when the pain is not controlled by these initial

measures

ibuprofen or

Indomethacin: 25 mg orally every 6 h for 48 h

should be limited to pregnancies <32 w

{inducing premature closure of the ductus arteriosus,

neonatal pulmonary hypertension, oligohydramnios,

and fetal/neonatal platelet dysfunction}

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If NSAIDs are continued for>48h

weekly sonographic assessment for

oligohydramnios and

narrowing of the fetal ductus arteriosus

If either of these findings is noted,

NSAIDs should be discontinued.

Repeat courses can be given as needed for

recurrent episodes of pain.

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4. Epidural analgesia

for treatment of severe fibroid pain refractory to other

therapies

should be used only as a last resort.(Kwon et al, 2014)

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2. Fibroids prolapsing into the vagina

Elective removal

best avoided as the risks likely outweigh the

benefits.

{Removal: excessive hemorrhage,rupture of

membranes, and/or pregnancy loss}.

Transvaginal resection

may be safe if there is an easily accessible

pedunculated fibroid on a thin stalk.

Indications of removal:

1. Clinically significant bleeding

2. excessive pain, urinary retention, and (rarely)

infection

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3. Indications for myomectomy during pregnancy

Best avoided

unless the procedure cannot be safely delayed

1. Hemorrhage

2. uterine rupture

3. miscarriage, or

4. Preterm Delivery(Celik et al, 2002)

Uncontrollable hemorrhage during myomectomy

may necessitate hysterectomy.

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Rarely

myomectomy of a pedunculated or subserosal

fibroid has been performed antepartum for

management of

acute abdomen or

intractable pain.

This is absolutely contraindicated

if entry into the uterine cavity will be required.

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4. Management of pregnant women with a prior

myomectomy

The risk of uterine rupture

After abdominal myomectomy:

2.5% (1 of 40 pregnancies)(Brown, 1965)

No uterine ruptures in 120 patients

No uterine ruptures in176 women(Georgakopoulos, Bersis, 1981)

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After laparoscopic myomectomy

higher than after open myomectomy

{technical challenge of laparoscopic suturing}.(Matsunaga et al, 2004)

may occur in the third trimester before the onset of

labor.(Dubuisso et al, 2000)

only 1 uterine rupture in 211 deliveries(Dubuisso et al, 2000)

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Timing of scheduled cesarean delivery

before the onset of labor

If the uterine integrity was significantly compromised

uterine cavity was entered

large number of myomas were removed

(GRADE 2C23).

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ASRM 2013: women with previous myomectomy

1. Cesarean delivery

1. between 37 w 0 days and 38 weeks 6 days of

gestation

2. consideration of delivery as early as 36 w is

reasonable for women with

prior extensive myomectomy

(analogous to a patient with prior classic

hysterotomy).

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3. For patients who have had a myomectomy that was

unlikely to have significantly compromised the uterus:

trial of labor with

continuous intrapartum fetal monitoring

early access to obstetric anesthesia

ability to perform an emergent cesarean delivery,

if it becomes necessary

(GRADE 2C23).

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4. Patients who have had a pedunculated subserosal

fibroid removed:

would not be expected to have compromised the

integrity of the myometrium

do not require special monitoring during labor.

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5. Prior hysteroscopic removal of a submucosal

Fibroid:

may increase the risk of abnormal placentation,

especially placenta accreta.

Although the risk of placenta accreta after prior

myomectomy appears to be low, (Gyamfi-Bannerman et al, 2012)

an ultrasound examination is recommended in

the late second or early third trimester to look for

evidence of abnormal placentation

(GRADE 2C23).

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III. DURING LABOUR

1. Vaginal delivery

Most women

Offer a trial of labor.

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2. Cesarean delivery

Indications:

1. obstetrical indicationsfetal malpresentation

failure to progress,

nonreassuring fetal testing

2. large cervical fibroids

3. lower uterine segment fibroids

that distort the uterine cavity and

located between the fetal head and the cervix.

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Precautions:

Hemoglobin level of at least 9.5 to10 mg/dL

±

use of a cell saver, and availability of blood

products in the operating room

Preoperative placement of bilateral iliac artery

balloon catheters

Skin incision:

vertical

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Uterine incision:

Classic or even

posterior hysterotomy

obtain adequate exposure when the fibroids are

located in the lower uterine segment.

Avoid transecting a fibroid during hysterotomy

{as the incision may be impossible to close without

first removing the tumor}.

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3. Myomectomy during CS

Old studies

should be avoided if at all possible given the high

rate of complications.

9 myomectomies

3 (33%) complicated by severe hemorrhage

requiring puerperal hysterectomy.(Exacousto et al, 1993)

5 myomectomies:

4 pedunculated fibroids were removed without

difficulty

removal of the single nonpedunculated fibroid

was associated with severe hemorrhage.(Hasan et al, 1993)

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Recent studies:

does not hazardous as was thought before.(Awoleke et al, 2013)

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Myomectomy may be considered:

1. Careful patient selection

1. Pedunculated myoma

2. Accessible subserous myoma less than 6 cm

3. Myoma in lower segment to avoid upper

segment incision

4. Intrmaural myoma may be removed with

caution to close the hysterotomy.

2. Full consent

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3. Adequate experience

4. Well equipped tertiary hospital

better anaethesia

availability of blood .

5. Efficient haemostatic measures

UAL, UAE, 20 units oxytocin, Misopristol

6. The baby must be delivered prior to myomectomy .(Lolis et al ., 2003; Hassiakos et al ., 2006 ; Adensiyun et al., 2009 ;

Agarwal 2010; Awoleke 2013) .

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Myomectomy should be avoided:

1. Inaccessible myoma

2. Large fundal, intramural fibroids

3. Fibroid greater than 6 cm in diameter

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CONCLUSIONS

Uterine fibroids are common in reproductive age

women.

Most women with fibroids will have an uneventful

pregnancy.

Multiple fibroids, large size (>3cm), and submucosal

and retroplacental location are risk factors for adverse

pregnancy events, including

Miscarriage

placental

Abruption

preterm labor and birth.

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Myomectomy should be avoided during pregnancy

because of the risk of significant morbidity.

Most women with fibroids will have a successful

vaginal delivery and should therefore be offered a trial of

labor.

Cesarean delivery should be reserved for standard

obstetrical indications.

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