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  1. 1. MYOMA AND PREGNANCY
  2. 2. Nomenclature Fibroid--------Fibroids Myoma--------Myomata FibromyomaFibromyomata Leiomyoma---Leiomyomata
  3. 3. Fibroids (leiomyomas) are benign smooth muscle cell tumors of the uterus. Although they are extremely common, with an overall incidence of 40% to 60% by age 35 and 70% to 80% by age 50, the precise etiology of uterine fibroids remains unclear.
  4. 4. 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 uterine corpus
  5. 6. The diagnosis of fibroids in pregnancy is neither simple nor straightforward. Only 42% of large fibroids ( 5 cm) and 12.5% of smaller fibroids (3-5 cm) can be diagnosed on physical examination.
  6. 7. The ability of ultrasound to detect fibroids in pregnancy is even more limited (1.4%-2.7%) primarily due to the difficulty of differentiating fibroids from physiologic thickening of the myometrium.
  7. 8. Reflecting the growing trend of delayed childbearing, the incidence of fibroids in older women undergoing treatment for infertility is reportedly 12% to 25%. Despite their growing prevalence, the relationship between uterine fibroids and adverse pregnancy outcome is not clearly understood.
  8. 9. the majority of fibroids (60%-78%) do not demonstrate any significant change in volume during pregnancy. 22% to 32% of fibroids increase in volume & the growth was limited almost exclusively to the first trimester, especially the first 10 weeks of gestation.
  9. 10. In the second trimester, small fibroids grow whereas large fibroids (> 6cm) remain unchanged or decrease in size but all decrease in size in the third trimester. The majority of fibroids show no change during the puerperium, although 7.8% will decrease in volume by up to 10%.
  10. 11. Pain Pregnancy loss Preterm labor and birth Placental abruption Placenta previa PPH Dysfunctional labor Malpresentation Malposition Cesarean delivery
  11. 12. The risk and type of complication appear to be related to the: 1. Size, 2. Number, and 3. Location of the myomas.
  12. 13. If the placenta implants over or in close proximity to a myoma, there may be an increased risk of: 1. Miscarriage. 2. Preterm labour. 3. Abruption. 4. Prelabour rupture of membranes. 5. Intrauterine growth restriction.
  13. 14. Fibroids located in the lower uterine segment may increase the likelihood of : 1. Fetal malpresentation, 2. Caesarean section, and 3. Postpartum hemorrhage.
  14. 15. American Journal of Obstetrics & Gynecology, Vol. 198, PC Klatsky et al, Fibroids and reproductive outcomes: a systematic literature review from conception to delivery," pp. 357- 366.
  15. 16. Most common complication. Causes Red degeneration. Tortion. Impaction.
  16. 17. Theories. rapid fibroid growth results in the tissue outgrowing its blood supply change in the architecture (kinking) of the blood supply to the fibroid leading to ischemia and necrosis the pain results from the release of prostaglandins from cellular damage within the fibroid.
  17. 18. Multiple fibroid increase risk. Submucosal or interstitial. Unclear mechanism?? Increase uterine contractility. Compressive effect. Affection of blood supply to developing placenta.
  18. 19. More common if the placenta implants close to the fibroid.
  19. 20. Evidence not consistent across the literature Increased risk if placenta is adjacent to or overlies a fibroid Decreased oxytocinase activity higher oxytocin levels premature contractions . Fibroid uteri are less distensible, once uterus grows to a certain point contractions.
  20. 21. Conflicting evidence Submucosal, retroplacental & volumes > 200 cm3 are independent. Abnormal placental perfusion: decreased blood flow to endometrium overlying fibroid placental ischemia, decidual necrosis abruption (?)
  21. 22. Placenta previa is a less common outcome and was positively associated with fibroids in 2 studies (Qidwai IG et al 2006, Vergani P et al 2007 ). Two other studies found no association with placenta previa, making this association difficult to ascribe to fibroids as advanced maternal age and prior uterine surgery were not considered (Coronado GD et al 2000, Vergani P et al 1994)
  22. 23. Although cumulative data and a population-based study suggested that women with fibroids are at slightly increased risk of delivering a growth-restricted infant, these results were not adjusted for maternal age or gestational age.
  23. 24. Rarely, large fibroids can compress and distort the intrauterine cavity leading to fetal deformities. A number of fetal anomalies have been reported in women with large submucosal fibroids, including dolichocephaly , torticollis and limb reduction defects. (Chuang J et al 2001)
  24. 25. Increases risk 13% vs 4.5%. (Klatsky PC et al 2008) Risk factors : Large fibroids. Multiple fibroids. Fibroids in the lower uterine segment
  25. 26. Greater risk: retroplacental or cesarean delivery. Decreased force and coordination of contractions uterine atony Be prepared.
  26. 27. Retained placenta was more common in women with fibroids, but only if the fibroid was located in the lower uterine segment.
  27. 28. Varying evidence Decreased force of contractions Asymmetric wave of contractile force across uterus
  28. 29. Consistent evidence. 48.8% versus 13.3%. (Klatsky PC et al 2008) Location in lower uterine segment due to higher risk of malpresentation, dysfunctional labor & abruption.
  29. 30. Despite the increased risk of cesarean, the presence of uterine fibroidseven large fibroids should not be regarded as a contraindication to a trial of labor.
  30. 31. Rare. However, several studies have reported that antepartum myomectomy can be safely performed in the first and second trimester of pregnancy. Acceptable indications include intractable pain from a degenerating fibroid or from tortion.
  31. 32. Obstetric and neonatal outcomes in women undergoing myomectomy in pregnancy are comparable with that in conservatively managed women except increasing rate of C.S. (De Carolis S et al 2001, Celik C et al 2002)
  32. 33. Well-substantiated risk of severe hemorrhage requiring blood transfusion, uterine artery ligation, and/or puerperal Hysterectomy. It should only be performed if unavoidable to facilitate safe delivery of the fetus or closure of the hysterotomy. Pedunculated subserosal fibroids can also be safely removed.
  33. 34. Myomectomy remains the standard of care for treating symptomatic fibroids in women desiring fertility & this item regard as relative contraindication of uterine artery embolization. Nevertheless, successful pregnancies have been reported.
  34. 35. the outcomes of pregnancies suggest a modest trend toward increasing risk of preterm delivery, postpartum hemorrhage, and abnormal placentation. Sixty eight percent of the patients underwent C.S.; however, the majority of these cesareans were elective without a trial of labor. (Walker WJ et al 2006, Pron G et al 2005)