Obstetric complications of fibroid

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Obstetric complications of fibroid
Dr.Uma Gupta MD,FICMCH. Associate Professor,Dept
of Obstetrics Gynecology Eras Lucknow Medical
College.Lucknow umankgupta_at_yahoo.com Dr.N.K.Gupta
,MS,M.Ch. Professor,Dept of Surgery,Eras
Lucknow Medical College.Lucknow. drnkgupta2000_at_yah
oo.com
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Introduction

• Uterine fibroids - common tumors of the uterus.
  Found in approximately 25 to 35 of reproductive
  age women
• As more women choose to delay childbearing,
  issue of fibroids in pregnancy is likely to face
  with increasing frequency.
• Buttram VC, Reiter RC. Uterine leiomyomata
  etiology, symptomatology, and management. Fertil
  Steril 1981 36433-45.

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Introduction

• Prevalence of fibroids in pregnancy ranges from
  0.09 to 3.9.
• Contrary to popular belief, most of the studies
  refute the commonly held belief that fibroids
  continue to increase in size throughout
  gestation.

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Complications of fibroids in pregnancy

• fibroids in pregnancy is associated with an
  antepartum complication rate of 10 to 40.

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• approximately 90 of fibroids exhibited no
  significant
• change in size during pregnancy
• The mean increase in fibroid volume during
  pregnancy is
• 12, and few fibroids increase by more than 25
  .
• Muram D, Gillieson MS, Walters JH. Myomas of the
  uterus in pregnancy ultrasonographic follow-up.
  Am. J Obstet Gynecol 198013816-9.
• Rosati P J Ultrasound Med 199211511-5.

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Natural history -effect of pregnancy on fibroid

• Three subsequent prospective studies confirmed
  that most uterine fibroids
• 49-60 had a negligible change in volume
  throughout pregnancy (defined as lt10)
• 22 to 32 exhibited an increase in growth,
• 8 to 27 exhibited a decrease in size 1,2,3.
• 1.Lev-Toad AS et al Radiology 1987164375 -80.
• 2.Aharoni A, et al. Br J Obstet Gynaecol
  198895510-3.
• 3.Rosati P et al J Ultrasound Med 199211511-5.

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Natural history

• Those fibroids which increase in size in
  pregnancy - when does most of the growth occur
  and how large?
• Fibroid growth occurs most commonly in the first
  trimester, less in second and third trimesters.
• Larger fibroids (gt5 cm in diameter) are more
  likely to grow, whereas smaller fibroids are more
  likely to remain stable in size.
• If smaller fibroids increase in size, they do so
  in the first and second trimesters and decrease
  in size in the third trimester.
• Strobelt N et al. J Ultrasound Med
  199413399-401.
• Lev-Toad AS, et al. Radiology 1987164375 -80.

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Complications associated with fibroids in
pregnancy Antepartum complications

• Spontaneous abortion
• Threatened abortion
• Preterm labor
• Premature rupture of membranes Placental
  abruption
• Pain
• Preeclampsia

• Intrauterine growth restriction
• Malpresentation
• Disseminated intravascular coagulation
• Radiculopathy
• Acute renal failure
• Uterine incarceration

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Intrapartum/postpartum complications

• Dysfunctional labor
• Cesarean delivery
• Postpartum hemorrhage
• Retained placenta
• Postpartum sepsis

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Fetal complications

• Decreased Apgar score
• Fetal anomalies
• Limb reduction
• Head deformities Congenital torticollis
• Congenital torticollis

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Pregnancy loss

• The uterine fibroids increase the risk for
  spontaneous abortion and cause recurrent
  pregnancy loss a, b
• Large submucosal fibroids that distort the
  uterine cavity consistently have been associated
  with pregnancy loss(b,c.)
• a.Probst TM.Semin Reprod Med 200018341-50
• b.Winer-Muram HT et al. Can Med Assoc .1
  1983128949-50
• c.Muram D, Am. J Obstet Gynecol 198013816-9.

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Pregnancy loss

• Mechanisms suggested for fibroids and spontaneous
  pregnancy loss.
• A large submucosal fibroid that projects into the
  uterine cavity may compress the underlying
  endometrium and lead to endometrial dysfunction.
• it may distort the vascular architecture that
  supplies and drains the endometrium at that site.

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Pregnancy loss

• Mechanisms suggested for fibroids and spontaneous
  pregnancy loss.
• 3. If the embryo chooses to implant at site of
  fibroid, it may interfere with normal
  placentation and development of the definitive
  uteroplacental circulation and lead to
  spontaneous pregnancy loss d.
• 4. Rapid fibroid growth with or without
  degeneration may lead to increased uterine
  contractility or altered placental oxytocinase
  activity e, both or which may disrupt
  placentation and lead to spontaneous abortion
• d. Gabbe SG et al. Obstetrics normal and problem
  pregnancies. 3rd edition. Philadelphia Churchill
  Livingstone 1986.
• e.Wallace EE Obstet Gynecol Clin North
  Amer.199522 791 - 9.

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• Threatened abortion

• First trimester bleeding was more common in women
  who had uterine fibroids compared with those who
  did not (OR, 1.82 95 CI, 1.05-3.20) f .
• The location of fibroid in relation to placenta
  is important determinant
• 72 of patients with retro placental fibroids
  reported vaginal bleeding compared
• 9 patients who had non-retro placental
  fibroids g.
• f. Coronado GD et al Obstet Gynecol 200095764-9
  
• g.Winer-Muram HT J Can Assoc Radiol
  198435168-70.

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• Preterm labour and birth

• increased risk for preterm labor with fibroids
  larger than 3 cm 32 and 6 cm in diameter 16
  as compared with controls. , especially true if
  multiple fibroids are present or if placentation
  occurs adjacent to or overlying a fibroid.

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• Preterm labour and birth

• Various theories - proposed biologic basis of
  PTL in pregnancy with uterine fibroids
• i)fibroid uteri are less distensible than are
  nonfibroid uteri, which leads to premature labor
  and delivery in the same way that women who have
  congenital Mullerian abnormalities are at risk
  for PTLd.
• ii) decreased oxytocinase activity in the gravid
  fibroid uterus, may result in a localized
  increase in oxytocin levels and predisposition to
  premature contractions g.
• d. Gabbe SG et al. Obstetrics normal and problem
  pregnancies. 3rd edition. Philadelphia Churchill
  Livingstone 1986.
• g. .Blum M. Comparative study of serum CAP
  activity during pregnancy in malformed and normal
  uterus. J Prenatol Med 19786165-8.

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Preterm premature rupture of membranes

• Literature describing the association of
  uterine fibroids and preterm premature rupture of
  membranes (pPROM) is conflicting. One study f
  reported that women with uterine fibroids were
  twice as likely to have pPROM than who had no
  fibroids (OR, 1.79 95 CI, 1.2-2.69).
• f. Coronado GD, Obstet Gynecol 200095764-9.

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Preterm premature rupture of membranes

• The greatest risk for pPROM is in women in whom
  the fibroid is in direct contact with the
  placenta however, no increased risk for pPROM
  in women who had uterine fibroids are also
  reported h.
• h. Roberts WE et al. Aus NZ J Obstet Gynaecol
  19993943-7.

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Placental abruption

• Among 93 patients (pregnancy with fibroid), 14
  (15.1) had one or more fibroids that were retro
  placental in location. Significantly, 8/14 (57)
  subsequently developed placental abruption(i).
• 7.5 had an abruption compared with only 0.9 of
  the controls (Plt.001). Sub analysis of the data
  suggested that submucosal and retroplacentally
  located fibroids and fibroids with volumes
  greater than 200 mL (corresponding to 7-8 cm
  diameter) had the highest risk for abruption.
• i. Rice JP. Am J Obstet Gynecol 19891601212-6.

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Placental abruption

• The explanation for the increased risk for
  abruption in setting of uterine fibroids is
  related to placental perfusion i.
• Blood flow is reduced significantly in fibroids
  and in the myometrium adjacent to fibroids. Thus,
  implantation in the endometrium overlying a
  fibroid may lead to placental ischemia and
  decidual necrosis, making it more susceptible to
  abruption(j).
• i. Rice JP. Am J Obstet Gynecol 19891601212-6.
• j. Forssman L. Acta Obstet Gynecol Scand
  197655101-4.

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Placenta previa

• The presence of uterine fibroids was believed to
  lead to preferential placentation in the lower
  uterine segment however, subsequent studies
  failed to show association f,g.
• f. Coronado GD et al Obstet Gynecol 200095764-9
  
• g. Vergani P et al. Am J Prenatol 199411356-8.

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PAIN

• Pain is one of the most frequent complications of
  fibroids in pregnancy.
• 5 to 15 of women with fibroids require
  hospitalization during their pregnancy for
  abdominal pain k.
• This risk for pain increases with size,
  especially high in fibroids gt than 5 cm in
  diameter 6.
• Fibroid pain likely results from decreased
  perfusion in the setting of rapid growth leading
  to ischemia and necrosis (degeneration) with
  release of prostaglandins i. This hypothesis
  is supported -as fibroid pain typically presents
  in the late first or early second trimester,
  which corresponds to the period of greatest rate
  of fibroid growth.
• i. Rice JP. Am J Obstet Gynecol 19891601212-6.
• K. Phelan JP. Obstet Gynecol Clin North Amer
  199522801-5.

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PAIN

• Management of fibroid pain during pregnancy
• REST
• HYDRATION
• ANALGESIC (eg, acetaminophen) 7.
• INTRACTABLE fibroid pain that is refractory
  to this regimen has included NSAIDs,
• ANTEPARTUM MYOMECTOMY,
• even termination of pregnancy 6, 10, and
  37.
• Ibuprofen, a nonselective cyclooxygenase
  inhibitor, reported to be an effective agent,
  and resulted in a dramatic relief.
• i. Rice JP. Am J Obstet Gynecol 19891601212-6.
• l.Exacoustos C, Obstet Gynecol 19938297-101.

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Preeclampsia

• Investigators suggested that the increased risk
  of preeclampsia was due to disruption of
  trophoblast invasion by the multiple fibroids,
  which leads to inadequate uteroplacental vascular
  remodeling, and ultimately predisposes later
  development of preeclampsia(h)
• h. Roberts WE et al. Aus NZ J Obstet Gynaecol
  19993943-7.

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Intrauterine growth restriction

• Recent literature suggests no association with
  intrauterine growth restriction (IUGR) m, that
  large fibroids (gt200 mL) may be associated with
  delivery of small-for-gestational age infants
• m. Koike T et al. J Obstet Gynaecol Res
  199925309-13. .

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fetal anomalies

• Several case reports described an association
  between large submucosal uterine fibroids and
  fetal anomalies,
• limb reduction defects,
• congenital torticollis,
• head deformities n.
• The dominant lesion was caudal dysplasia
• n. Matsunaga E Teratology 19802161-9.

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malpresentation

• Large submucosal fibroids that distort the
  uterine cavity - associated consistently with
  fetal malpresentation i,l.
• If the uterus had multiple fibroids or if there
  was a fibroid located behind the placenta or in
  the lower uterine segment k.
• i.Rice JP. Am J Obstet Gynecol 19891601212-6.
• K. Phelan JP. Obstet Gynecol Clin North Amer
  199522801-5.
• l.Exacoustos C, Obstet Gynecol 19938297-101.

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Dysfunctional labor

• Fibroids decrease the force of uterine
  contractions or disrupt the coordinated spread of
  the contractile wave, and thereby, lead to
  dysfunctional labor g. trend toward prolonged
  labor.
• g. Vergani P et al. Am J Prenatol 199411356-8.

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Cesarean delivery

• literature is consistent - the presence of
  uterine fibroids is associated with an increased
  risk for cesarean delivery f,g.
• The proposed increase in CS rate is due to
  increased risk for malpresentation, dysfunctional
  labor, and placental abruption.
• An increased rate of CS delivery if the fibroids
  were located in the lower uterine segment f
• f. Coronado GD et al Obstet Gynecol 200095764-9
• g. Vergani P et al. Am J Prenatol 199411356-8.

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postpartum haemorrhage

• Increased risk for PPH in pregnancies complicated
  by uterine fibroids 9,29, especially if (gt3 cm)
  located behind the placenta k.
• The risk for PPH in these women may be increased
  further by cesarean delivery. Pathophysiologically
  , predispose PPH by decreasing force
  coordination of uterine contractions, leads to
  uterine atony o
• K. Phelan JP. Obstet Gynecol Clin North Amer
  199522801-5.
• o. Szamatowicz J,. Acta Obstet Gynecol Scand
  199776973-6.

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fetal outcome

• Studies compared 5-minute Apgar scores in infants
  - delivered by women who did and did not have
  uterine fibroids.
• No significant difference between these groups

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Other complications

• Less common complications of pregnancy
• disseminated intravascular coagulation
• spontaneous hemoperitoneum
• uterine inversion
• uterine incarceration
• acute renal failure
• and urinary retention p.q.
• p. Monga AK Br J Urol 199677606-7.
• q. Feusner AH.Ann Emerg Med 1997,30821 -4.

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• Preconception myomectomy

• Literature suggests - large fibroids submucosal
  or retroplacental in location are more related
  to pregnancy complications
• It is difficult to predict which fibroids will
  grow in pregnancy or where the placenta will
  implant.
• Decision / to recommend prophylactic myomectomy
  is individualized (patient's age/ reproductive
  history/size/location)

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Antepartum myomectomy

• Numerous case series suggested - myomectomy can
  be performed safely in first and second
  trimesters in carefully selected patients g.
• In select patients - pedunculated or subserosal
  fibroids, antepartum myomectomy is a reasonable
  option if fibroid pain is severe and refractory
  to medical management. r.
• g. Vergani P et al. Am J Prenatol 199411356-8
• r. Niebly JR. Am J Obstet Gynecol 1986155747-9.

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Preconception Myomectomy

• It improves reproductive outcome (individual
  basis)
• In women with recurrent pregnancy loss - large
  submucosal fibroids, and no other identifiable
  cause for recurrent miscarriage
• Antepartum myomectomy is reserved for women
• subserosal or pedunculated fibroids
• intractable fibroid pain (unresponsive to
  medical therapy)
• who are in the first or second
  trimester of pregnancy.
• Myomectomy at the time of cesarean
  delivery-(should be pursued with caution - only
  in select patients.)

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Intrapartum myomectomy

• Performing a myomectomy at cesarean delivery has
  been discouraged. 54.
• Favorable results are reported with removal of
  pedunculated fibroid at CS.
• Decision to proceed with myomectomy at the time
  of CS should be approached with caution, and
  limited to patients who have symptomatic
  pedunculated fibroids.
• s. Michalas SP. Hum Report 1995101869-70.

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thank you