Fibroid and pregnancy

1. Fibroid
and
pregnancy
Prof
Aboubakr
Elnashar
Benha university, Egypt
elnashar53@hotmail.com
ABOUBAKR ELNASHAR

2. 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

3. 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.
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4. 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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5. 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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6. 3 to 6 months postpartum
90%
regress in total fibroid volume
10%
increase in volume.
(Laughlin et al, 2011)
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7. 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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8. 3. Changes in Symptoms
90%
No symptoms during pregnancy.
10%
Symptoms
Pain
Pelvic pressure, and/or
Vaginal bleeding.
ABOUBAKR ELNASHAR

9. 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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10. 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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11. Ezzedine et al, 2016
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12. 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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13. Miscarriage rate:
1. Type
(Bajekal & Li , 2000)
Miscarriage rate (%)Fibroid (n)
40Submucosal (27)
33Intramural (44)
33Subserous (158)
16Control (2413)
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14. Abortion rate (%)Fibroid
34<7cm
29Control
2. Size
(Olivera et al,2003)
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15. 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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16. 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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17. 4.5x3.8 cm submucosal retroplacental uterine fibroid at 19
weeks of gestation.
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18. 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

19. 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.
ABOUBAKR ELNASHAR

20. 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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21. 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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22. 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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23. 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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24. The highest risk
submucosal
retroplacental fibroids
fibroid volumes >200mL (diameter of 7 to 8 cm).
(Exacousto, Rosati; 1993)
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25. 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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26. 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

27. 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

28. 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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29. 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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30. 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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31. ABOUBAKR ELNASHAR

32. 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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33. 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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34. (Zepiridis et al, 2016)
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35. 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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36. 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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37. 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

38. 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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39. 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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40. 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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41. 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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42. 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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43. 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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44. 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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45. 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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46. 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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47. 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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48. 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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49. III. DURING LABOUR
1. Vaginal delivery
Most women
Offer a trial of labor.
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50. 2. Cesarean delivery
Indications:
1. obstetrical indications
fetal 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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51. 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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52. 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

53. 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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54. Recent studies:
does not hazardous as was thought before.
(Awoleke et al, 2013)
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55. 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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56. 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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57. Myomectomy should be avoided:
1. Inaccessible myoma
2. Large fundal, intramural fibroids
3. Fibroid greater than 6 cm in diameter
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58. 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

59. 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.
ABOUBAKR ELNASHAR