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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
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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%.
ABOUBAKR ELNASHAR
3 to 6 months postpartum
90%
regress in total fibroid volume
10%
increase in volume.(Laughlin et al, 2011)
ABOUBAKR ELNASHAR
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}.
ABOUBAKR ELNASHAR
3. Changes in Symptoms
90%
No symptoms during pregnancy.
10%
Symptoms
Pain
Pelvic pressure, and/or
Vaginal bleeding.
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
3. EFFECT OF FIBROID ON PREGNANCY
Most pregnant women with fibroids:
do not have any complications during pregnancy(Segars et al, 2014)
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
Miscarriage rate:
1. Type
(Bajekal & Li , 2000)
Miscarriage rate (%)Fibroid (n)
40Submucosal (27)
33Intramural (44)
33Subserous (158)
16Control (2413)
ABOUBAKR ELNASHAR
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
ABOUBAKR ELNASHAR
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
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
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).
ABOUBAKR ELNASHAR
4. FETAL ANOMALIES
extremely rare.(Romero et al, 1981)
large submucosal fibroids: Spatial restriction
limb reduction defects
Congenital torticollis
head deformities
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
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}
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
II. DURING PREGNANCY
1. Fibroid pain
May require hospitalization
Supportive care
1. Acetaminophen (GRADE 2C23).
2. Opioids:
1. short-term use
2. standard doses
ABOUBAKR ELNASHAR
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}
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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).
ABOUBAKR ELNASHAR
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).
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
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).
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR
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
ABOUBAKR ELNASHAR
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}.
ABOUBAKR ELNASHAR
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)
ABOUBAKR ELNASHAR
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
ABOUBAKR ELNASHAR
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) .
ABOUBAKR ELNASHAR
Myomectomy should be avoided:
1. Inaccessible myoma
2. Large fundal, intramural fibroids
3. Fibroid greater than 6 cm in diameter
ABOUBAKR ELNASHAR
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.
ABOUBAKR ELNASHAR