Download Uterine Leiomyomata In Pregnancy – Resident Presentations

Uterine Leiomyomata in
Pregnancy
Ruth Stefanski, PGY-1
January 12, 2010
Objectives
 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
Case
 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, 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.
Case, 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
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: …..
 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?
Definitions
 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 Manifestations
 Abnormal uterine bleeding
 Menorrhagia
 submucosal
 NOT intermenstrual bleeding
 Pelvic pressure and pain
Clinical, 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
Complications during
Pregnancy
 Pregnancy loss
 Preterm labor and
birth
 Placental abruption
 Placenta previa
 Pain





PPH
Dysfunctional labor
Malpresentation
Malposition
Cesarean delivery
Preterm 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 (?)
Placental Abruption
 Conflicting evidence
 Submucosal, retroplacental
 Abnormal placental perfusion:
decreased blood flow to endometrium
overlying fibroid  placental ischemia,
decidual necrosis abruption (?)
Placenta 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)
Pain
 Reduced perfusion
with rapid growth of
fibroid
 Ischemia, necrosis,
release of
prostaglandins
Postpartum Hemorrhage
 Greater risk: retroplacental or cesarean
delivery
 Decreased force and coordination of
contractions  uterine atony
 Be prepared: PPH precautions
Dysfunctional Labor
 Varying evidence
 Decreased force of contractions
 Asymmetric wave of contractile force
across uterus
Malpresentation, Malposition
 Consistent
evidence
 Distorted shape of
uterine cavity
Cesarean Delivery
 Consistent evidence
 Location in lower
uterine segment
 Due to higher risk of
malpresentation,
dysfunctional labor,
abruption
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 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
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
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, 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
Myomectomy, 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
Case 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
Case 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
Summary
 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
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 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.