Uterine Leiomyomata in Pregnancy

Uterine Leiomyomata in Pregnancy

Ruth Stefanski, PGY-1

January 12, 2010

Ruth Stefanski, PGY-1

January 12, 2010

ObjectivesObjectives

Discuss case of patient in labor with fibroids

Review clinical manifestations Discuss possible complications of

fibroids during labor and delivery Review management of fibroids in

pregnancy

Discuss case of patient in labor with fibroids

Review clinical manifestations Discuss possible complications of

fibroids during labor and delivery Review management of fibroids in

pregnancy

CaseCase

27 y/o G2P0010 presented at 41weeks 1 day by LMP 3/14/09 c/w 7 wk Sono. EDD 12/19/09. Pt presented for post-dates IOL. +FM, -VB/LOF/ctx.

PNI: 1. Subserosal myoma, anterior left uterus. On 6/18/09 U/S: 17x15x14cm. On 12/10/09 U/S: 12.4x12.9x13cm 2. Multiple UTI’s, on suppression therapy 3. GBS bacteruria 4. Anemia, on Iron supplements

27 y/o G2P0010 presented at 41weeks 1 day by LMP 3/14/09 c/w 7 wk Sono. EDD 12/19/09. Pt presented for post-dates IOL. +FM, -VB/LOF/ctx.

PNI: 1. Subserosal myoma, anterior left uterus. On 6/18/09 U/S: 17x15x14cm. On 12/10/09 U/S: 12.4x12.9x13cm 2. Multiple UTI’s, on suppression therapy 3. GBS bacteruria 4. Anemia, on Iron supplements

Case, ContinuedCase, Continued

OB Hx: 2008 TOP at 8wks GYN Hx: 13/regular/3-5. No STI’s. 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.

OB Hx: 2008 TOP at 8wks GYN Hx: 13/regular/3-5. No STI’s. 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.

Case, ContinuedCase, Continued

PE: 114/70 P:101 Gen: NAD CV: RRR, S1S2 Pulm: CTAB

Abd: gravid, large palpable fibroid left fundal region 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

PE: 114/70 P:101 Gen: NAD CV: RRR, S1S2 Pulm: CTAB

Abd: gravid, large palpable fibroid left fundal region 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

Case, Continued Case, Continued

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

1. Admit to L&D, NPO, IVF, check labs 2. Labor: Pt’s cervix unfavorable, placed Cytotec

25mg PV for ripening. Consider Pitocin 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: …..

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

1. Admit to L&D, NPO, IVF, check labs 2. Labor: Pt’s cervix unfavorable, placed Cytotec

25mg PV for ripening. Consider Pitocin 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: …..

Patient was concerned about how this would effect her labor and delivery

Reported pain at site of fibroid with fetal movement and with contractions

What do we need to know to care for this patient?

Patient was concerned about how this would effect her labor and delivery

Reported pain at site of fibroid with fetal movement and with contractions

What do we need to know to care for this patient?

DefinitionsDefinitions

Uterine leiomyomata = benign smooth muscle tumors of the uterus

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

distort uterine cavity, <50% protruding into serosal surface

Submucosal: develop from myometrial cells just below endometrium, often protrude into and distort uterine cavity

Subserosal: originate from serosal surface of uterus, >50% protrudes out of serosal surface

Cervical: located in the cervix, rather than uterine corpus

Uterine leiomyomata = benign smooth muscle tumors of the uterus

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

distort uterine cavity, <50% protruding into serosal surface

Submucosal: develop from myometrial cells just below endometrium, often protrude into and distort uterine cavity

Subserosal: originate from serosal surface of uterus, >50% protrudes out of serosal surface

Cervical: located in the cervix, rather than uterine corpus

Clinical ManifestationsClinical Manifestations

Abnormal uterine bleeding Menorrhagia

submucosal

NOT intermenstrual bleeding

Pelvic pressure and pain

Abnormal uterine bleeding Menorrhagia

submucosal

NOT intermenstrual bleeding

Pelvic pressure and pain

Clinical, ContinuedClinical, Continued

Reproductive difficulty: infertility and loss Obstruction of implantation Impaired placental growth at myoma site Increased uterine contractility Location, location, location

Submucosal or intramural that protrudes into cavity

Reproductive difficulty: infertility and loss Obstruction of implantation Impaired placental growth at myoma site Increased uterine contractility Location, location, location

Submucosal or intramural that protrudes into cavity

Complications during PregnancyComplications during Pregnancy Pregnancy loss Preterm labor and

birth Placental abruption Placenta previa Pain

Pregnancy loss Preterm labor and

birth Placental abruption Placenta previa Pain

PPH Dysfunctional labor Malpresentation Malposition Cesarean delivery

PPH Dysfunctional labor Malpresentation Malposition Cesarean delivery

Preterm Labor and BirthPreterm Labor and Birth

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 (?)

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 (?)

Placental AbruptionPlacental Abruption

Conflicting evidence Submucosal, retroplacental Abnormal placental perfusion:

decreased blood flow to endometrium overlying fibroid placental ischemia, decidual necrosis abruption (?)

Conflicting evidence Submucosal, retroplacental Abnormal placental perfusion:

decreased blood flow to endometrium overlying fibroid placental ischemia, decidual necrosis abruption (?)

Placenta previaPlacenta previa

Most studies have shown no association (adjusting for maternal age and prior uterine surgery)

One study by Qidwai et al. reported increased rate (also adjusted for prior C/S and myomectomy)

Most studies have shown no association (adjusting for maternal age and prior uterine surgery)

One study by Qidwai et al. reported increased rate (also adjusted for prior C/S and myomectomy)

PainPain

Reduced perfusion with rapid growth of fibroid

Ischemia, necrosis, release of prostaglandins

Reduced perfusion with rapid growth of fibroid

Ischemia, necrosis, release of prostaglandins

Postpartum HemorrhagePostpartum Hemorrhage

Greater risk: retroplacental or cesarean delivery

Decreased force and coordination of contractions uterine atony

Be prepared: PPH precautions

Greater risk: retroplacental or cesarean delivery

Decreased force and coordination of contractions uterine atony

Be prepared: PPH precautions

Dysfunctional LaborDysfunctional Labor

Varying evidence Decreased force of contractions Asymmetric wave of contractile force

across uterus

Varying evidence Decreased force of contractions Asymmetric wave of contractile force

across uterus

Malpresentation, MalpositionMalpresentation, Malposition

Consistent evidence

Distorted shape of uterine cavity

Consistent evidence

Distorted shape of uterine cavity

Cesarean Delivery Cesarean Delivery

Consistent evidence Location in lower

uterine segment Due to higher risk of

malpresentation, dysfunctional labor, abruption

Consistent evidence Location in lower

uterine segment Due to higher risk of

malpresentation, dysfunctional labor, abruption

EvidenceEvidence

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 and delivered viable infants

Presence of fibroids associated with increased risk of: Cesarean delivery, breech presentation, malposition,

preterm delivery, placenta previa, severe PPH No association between fibroids and:

PROM, operative vaginal delivery, chorioamnionitis, endomyometritis

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 and delivered viable infants

Presence of fibroids associated with increased risk of: Cesarean delivery, breech presentation, malposition,

preterm delivery, placenta previa, severe PPH No association between fibroids and:

PROM, operative vaginal delivery, chorioamnionitis, endomyometritis

Management during pregnancy, labor & delivery

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 of fibroids, fetal presentation, placental position

• Monitor labor curve

1. Keep in mind complications above• Counsel patient on risks of loss, preterm

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

• Ultrasonography: size & location of fibroids, fetal presentation, placental position

• Monitor labor curve

Management, Continued 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 <32 weeks GA due to premature closure

of ductus arteriosus, neonatal pulmonary HTN, oligohydramnios, platelet dysfunction

If continued >48 hours, weekly sonos for assessment of these findings is recommended; if present, d/c or reduce to 25mg q12h

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 <32 weeks GA due to premature closure

of ductus arteriosus, neonatal pulmonary HTN, oligohydramnios, platelet dysfunction

If continued >48 hours, weekly sonos for assessment of these findings is recommended; if present, d/c or reduce to 25mg q12h

Management, ContinuedManagement, Continued

3. Myomectomy Preconception: inadequate data to support Antepartum: pregnancy is contraindication to

myomectomy; however some case series have suggested it may be safe in 1st and 2nd trimesters Intractable pain Largest series showed lower rates of

spontaneous abortions, preterm birth, and puerperal hysterectomy; but higher rate of cesarean section for those who underwent antepartum myomectomy

3. Myomectomy Preconception: inadequate data to support Antepartum: pregnancy is contraindication to

myomectomy; however some case series have suggested it may be safe in 1st and 2nd trimesters Intractable pain Largest series showed lower rates of

spontaneous abortions, preterm birth, and puerperal hysterectomy; but higher rate of cesarean section for those who underwent antepartum myomectomy

Myomectomy, ContinuedMyomectomy, Continued

• Intrapartum: due to the increased risk of hemorrhage, elective myomectomy at time of cesarean is strongly discouraged• only indication = if the presence of the fibroid

makes adequate closure of the uterine incision impossible

• Intrapartum: due to the increased risk of hemorrhage, elective myomectomy at time of cesarean is strongly discouraged• only indication = if the presence of the fibroid

makes adequate closure of the uterine incision impossible

Case Re-visitedCase Re-visited

Patient made adequate cervical change with Cytotec

Received epidural for pain management, started on Pitocin

AROM at 5am, clear fluid Around 8am, started having variable decels At 10:45am, recurrent decels, Pitocin

stopped, pt allowed to labor down

Patient made adequate cervical change with Cytotec

Received epidural for pain management, started on Pitocin

AROM at 5am, clear fluid Around 8am, started having variable decels At 10:45am, recurrent decels, Pitocin

stopped, pt allowed to labor down

Case Re-visited, ContinuedCase Re-visited, Continued

NSVD with compound presentation of right hand and midline episiotomy “to facilitate delivery”

Peri-urethral laceration and episiotomy repaired without complications

EBL 400cc, no PPH recorded in chart

Postpartum course uncomplicated

NSVD with compound presentation of right hand and midline episiotomy “to facilitate delivery”

Peri-urethral laceration and episiotomy repaired without complications

EBL 400cc, no PPH recorded in chart

Postpartum course uncomplicated

SummarySummary

Overall, good maternal and neonatal outcomes are expected in pregnant women with uterine fibroids

Several obstetric complications may be more common in pregnancies with fibroids, but there is conflicting evidence on many of these

More research is needed

Overall, good maternal and neonatal outcomes are expected in pregnant women with uterine fibroids

Several obstetric complications may be more common in pregnancies with fibroids, but there is conflicting evidence on many of these

More research is needed

ReferencesReferences 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 in

Pregnancy. 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 and Gynecology. 2006 February; 107 (2): 376-82.

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 in Pregnancy. 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 and Gynecology. 2006 February; 107 (2): 376-82.