Fibroids in Pregnancy

8/13/2019 Fibroids in Pregnancy

1/29

Uterine Leiomyomata in

Pregnancy

Ruth Stefanski, PGY-1

January 12, 2010


2/29

Objectives

Discuss case of patient in labor withfibroids

Review clinical manifestations Discuss possible complications of

fibroids during labor and delivery

Review management of fibroids inpregnancy


3/29

Case

27 y/o G2P0010 presented at 41weeks 1 dayby LMP 3/14/09 c/w 7 wk Sono. EDD12/19/09. Pt presented for post-dates IOL.+FM, -VB/LOF/ctx.

PNI: 1. Subserosal myoma, anterior leftuterus. On 6/18/09 U/S: 17x15x14cm. On12/10/09 U/S: 12.4x12.9x13cm 2. Multiple UTIs, on suppression therapy

3. GBS bacteruria

4. Anemia, on Iron supplements


4/29

Case, Continued

OB Hx: 2008 TOP at 8wks

GYN Hx: 13/regular/3-5. No STIs. No cysts.

+fibroids as above. H/o ASCUS pap. PMH: fibroid as above, anemia

PSH: D&C x1

Meds: PNV, Iron

All: NKDA

FH: MGM with DM, No HTN/cancer

SH: lives with 2 sisters, no h/o

DV/Depression/Anxiety. No toxic habits.


5/29

Case, Continued

PE: 114/70 P:101

Gen: NAD CV: RRR, S1S2 Pulm: CTAB

Abd: gravid, large palpable fibroid left fundalregion Extrem: no edema B/L

FHT: B/l 150, moderate variability, +accels,no decels

SVE: 2/50/-3

Toco: no ctx Sono: vertex

EFW: 3900gm

Labs: WBC: 10 H/H: 11.4/33.1 Plt: 214


6/29

Case, Continued

A/P: 27 y/o G2P0010 at 41weeks 1 dayadmitted for post-dates IOL.

1. Admit to L&D, NPO, IVF, check labs 2. Labor: Pts cervix unfavorable, placed

Cytotec 25mg PV for ripening. ConsiderPitocin for augmentation of ctx as needed.

3. Fetus: Category 1 EFM

4. Analgesia per patient request

5. GBS+: PCN prophylaxis in active labor

6. Anemia: f/u CBC, continue Iron

7. Myoma: ..


7/29

Patient was concerned about how thiswould effect her labor and delivery

Reported pain at site of fibroid with fetalmovement and with contractions

What do we need to know to care for

this patient?


8/29

Definitions

Uterine leiomyomata= benign smooth muscletumors of the uterus

Described based on location in the uterus: Intramural: develop from within uterine wall, do not

distort uterine cavity, 50% protrudes out of serosal surface

Cervical: located in the cervix, rather than uterinecorpus


9/29


10/29

Clinical Manifestations

Abnormal uterine bleeding

Menorrhagia

submucosal

NOT intermenstrual bleeding

Pelvic pressure and pain


11/29

Clinical, Continued

Reproductive difficulty: infertility andloss

Obstruction of implantation Impaired placental growth at myoma site

Increased uterine contractility

Location, location, location Submucosal or intramural that protrudes into

cavity


12/29

Complications during

Pregnancy Pregnancy loss

Preterm labor and

birth Placental abruption

Placenta previa

Pain

PPH

Dysfunctional labor

Malpresentation Malposition

Cesarean delivery


13/29

Preterm Labor and Birth

Evidence not consistent across the literature

Increased risk if placenta is adjacent to or

overlies a fibroid Decreased oxytocinase activityhigher

oxytocin levelspremature contractions (?)

Fibroid uteri are less distensible, once uterusgrows to a certain pointcontractions (?)


14/29

Placental Abruption

Conflicting evidence

Submucosal, retroplacental

Abnormal placental perfusion:decreased blood flow to endometriumoverlying fibroidplacental ischemia,

decidual necrosisabruption (?)


15/29

Placenta previa

Most studies haveshown no association(adjusting for maternal

age and prior uterinesurgery)

One study by Qidwai etal. reported increased

rate (also adjusted forprior C/S andmyomectomy)


16/29

Pain

Reduced perfusion

with rapid growth offibroid

Ischemia, necrosis,release of

prostaglandins


17/29

Postpartum Hemorrhage

Greater risk: retroplacental or cesareandelivery

Decreased force and coordination ofcontractionsuterine atony

Be prepared: PPH precautions


18/29

Dysfunctional Labor

Varying evidence

Decreased force of contractions

Asymmetric wave of contractile forceacross uterus


19/29

Malpresentation, Malposition

Consistentevidence

Distorted shape ofuterine cavity


20/29

Cesarean Delivery

Consistent evidence

Location in lower

uterine segment Due to higher risk of

malpresentation,dysfunctional labor,

abruption


21/29

Evidence

2006 Qidwai GI, Caughey AB, Jacoby AF: Retrospective cohort study comparing pregnancy

outcomes in women with and without fibroids who

underwent a routine 2nd trimester sonogram anddelivered viable infants

Presence of fibroids associated with increased riskof:

Cesarean delivery, breech presentation, malposition,preterm delivery, placenta previa, severe PPH

No association between fibroids and: PROM, operative vaginal delivery, chorioamnionitis,

endomyometritis


22/29

Management during

pregnancy, labor & delivery1. Keep in mind complications above

Counsel patient on risks of loss, preterm

labor, PPH, C/S, dysfunctional labor, pain,etc.

Ultrasonography: size & location offibroids, fetal presentation, placentalposition

Monitor labor curve


23/29

Management, Continued

2. Pain Management Primary intervention: supportive care and

Acetaminophen Secondary: narcotics or NSAIDs

Indomethacin 25mg PO q6h x 48hours(studied by Dildy et al.) Limited to 48 hours, weekly sonos forassessment of these findings is recommended; ifpresent, d/c or reduce to 25mg q12h


24/29

Management, Continued

3. Myomectomy

Preconception: inadequate data to support

Antepartum: pregnancy is contraindication tomyomectomy; however some case series havesuggested it may be safe in 1st and 2nd trimesters

Intractable pain

Largest series showed lower rates ofspontaneous abortions, preterm birth, andpuerperal hysterectomy; but higher rate ofcesarean section for those who underwentantepartum myomectomy


25/29

Myomectomy, Continued

Intrapartum: due to the increased risk ofhemorrhage, elective myomectomy at time

of cesarean is strongly discouraged only indication = if the presence of the fibroid

makes adequate closure of the uterine incisionimpossible


26/29

Case Re-visited

Patient made adequate cervical change withCytotec

Received epidural for pain management,started on Pitocin

AROM at 5am, clear fluid

Around 8am, started having variable decels

At 10:45am, recurrent decels, Pitocinstopped, pt allowed to labor down


27/29

Case Re-visited, Continued

NSVD with compoundpresentation of righthand and midline

episiotomy to facilitatedelivery

Peri-urethral lacerationand episiotomy repaired

without complications EBL 400cc, no PPH

recorded in chart

Postpartum course

uncomplicated


28/29

Summary

Overall, good maternal and neonataloutcomes are expected in pregnant womenwith uterine fibroids

Several obstetric complications may be morecommon in pregnancies with fibroids, but thereis conflicting evidence on many of these

More research is needed


29/29

References

Bajekal N, Li TC. Fibroids, infertility, and pregnancy wastage.Human Reproduction Update 2000 Nov-Dec; 6 (6): 614-20.

Coronado GD, Marshall LM, Schwartz SM. Complications inPregnancy. Labor, and Delivery with Uterine Leiomyomas: A

Population-Based Study. Obstetrics and Gynecology 2000; 95: 764-9. Dilby GA et al. Indomethacin for the treatment of symptomatic

leiomyoma uteri during pregnancy. American Journal of Perinatology

1992; 9:185. Klatsky PC, Tran MD, Caughey AB, Fujimoto VY. Fibroids and

reproductive outcomes: a systematic literature review from conception

to delivery. American Journal of Obstetrics and Gynecology 2008;

198: 357-66. Qidwai GI, Caughey AB, Jacoby AF. Obstetric outcomes in women

with sonographically identified uterine leiomyomata. Obstetrics andGynecology. 2006 February; 107 (2): 376-82.

Fibroids in Pregnancy

Documents

Transcript of Fibroids in Pregnancy