FIBROIDS COMPLICATING PREGNANCY

BYR.MADHAVA MANOJ

INCIDENCE AND PREVALENCE

Incidence : 1 in 1000.Prevalence : Highest in black women -18 percent

Lowest in whites - 8 percent

EFFECTS OF FIBROID ON PREGNANCY

May be none Abortion (submucous fibroid) Pressure symptoms due to impaction of

(a) Bladder - retention of urine (b) Rectum - constipation

Red degeneration Malpresentation (Four fold risk) Preterm labor and prematurity Non-engagement of the presenting part

EFFECTS ON LABOR

May be unaffected Uterine inertia Dystocia Obstructed labor Postpartum hemorrhage due to atonicity or adherent

placenta Difficult cesarean section (Eight fold risk)

EFFECTS ON PUERPERIUM

Subinvolution Inversion of uterus Secondary PPH Sepsis Lochiometra and pyometra.

EFFECTS OF PREGNANCY ON FIBROID

Changes in size – increases (?) Changes in position Changes in shape - becomes flattened Degenerative changes specially, red degeneration Torsion of pedunculated subserous fibroid Infection and polypoidal changes are more in

puerperium.

EFFECTS OF PREGNANCY ON FIBROID

Changes in size – increases (?) Fibroid is an estrogen dependant tumor. Pregnancy is a progesterone predominant state. So how does fibroid increases in size during pregnancy?

EFFECTS OF PREGNANCY ON FIBROID

Actually, most fibroids do not increase in size during pregnancy.

69% - had no increase in fibroid volume throughout pregnancy

31% - noted increase in fibroid volume, greatest increase before 10th week of gestation and a reduction to baseline value 4 weeks after delivery

EFFECTS OF PREGNANCY ON FIBROID

The main reason for the fibroid to increases in size during pregnancy is due to Increased vascularity Edema Hypertrophy and hyperplasia of the fibromuscular

tissues.

It is often difficult to diagnose a fibroid during pregnancy because of Marked softening Alteration in the shape (flattening)

In early months, fibroid is diagnosed but pregnancy is missed whereas in later months, pregnancy is diagnosed but the fibroid is missed.

DIAGNOSIS

Ultrasonography confirms the diagnosis with certainity.

DIAGNOSIS

USG showing uterine fibroid

If ultrasonographic findings are unclear, Magnetic Resonance

Imaging can be done

DIAGNOSIS

MRI showing degenerating fibroid

In uncomplicated tumor, fibroid is often confused with Ovarian tumor Retroverted gravid uterus Non gravid half of uterus didelphys

DIAGNOSIS

BASIC PRINCIPLE

Avoid treatment whenever possible.

TREATMENT

DURING PREGNANCYUncomplicated :

Usual antenatal care is followed. All cases to be assessed at 38

weeks to formulate the method of delivery. Acute pain following red degeneration

Conservative management

TREATMENT

DURING LABORFibroid situated above the presenting part:

Usually results in uneventful vaginal deliveryFibroid situated below the presenting part:

Spontaneous vaginal delivery may occur. If it fails, cesarean section is to be done.

TREATMENT

Fibroid in lower uterine segment Cervical fibroid, even if it is small Fibroid impacted in pelvis Malpresentation Obstetric complications

INDICATION FOR ELECTIVE CESAREAN SECTION

Cesarean delivery for a large leiomyoma in the lower uterine segment

TECHNICAL ASPECTS ON ELECTIVE CESAREAN SECTION

Myomectomy should be avoided during cesarean section

Be alert for postpartum hemorrhage and retained placenta.

Reverts to a smaller size during puerperium