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OBSTETRICS

The impact of fibroid characteristics on pregnancy outcome

Sarah-Jane Lam, MBBS, MRCOG; Sunayna Best, MBBS; Sailesh Kumar, FRCOG, FRANZCOG, DPhil(Oxon)
OBJECTIVE: The objective of the study was to assess the influence of

different characteristics of fibroids on pregnancy outcome.

STUDY DESIGN: We identified women with fibroids 4 cm or greater in
size on ultrasonography at the dating scan between January 2002 and
December 2012. The size (4-7 cm, 7-10 cm, >10 cm), number
(multiple/single), location (lower uterus/body of uterus), and type
(intramural, combination of intramural/subserosal, subserosal) were
ascertained. Medical records were reviewed to obtain pregnancy
outcomes (preterm delivery, birthweight, mode of delivery, estimated
blood loss, postpartum hemorrhage, and admission for fibroid-related
pain).
RESULTS: A total of 121 patients with 179 pregnancies were identi-

fied. Preterm delivery was more likely in those with multiple fibroids
compared with single fibroids (18% vs 6%; P .05). The location of

the fibroid had an important effect on the mode of delivery with a

higher cesarean section rate for fibroids in the lower part of uterus than
in the body of the uterus (86% vs 40%; P .01), a higher rate of
postpartum hemorrhage (22% vs 11%; P .03), and greater estimated blood loss (830 mL [SD, 551] vs 573 mL [SD, 383]; P .03).
Increasing size of fibroid was associated with greater rates of hemorrhage (11% vs 13% vs 36%; P .04), increased estimated blood
loss (567 mL [SD, 365] vs 643 mL [SD, 365] vs 961 mL [SD, 764];
P .01), and higher rates of admissions for fibroid-related pain (5% vs
23% vs 21%; P .01).
CONCLUSION: Different fibroid characteristics affect pregnancy

outcome in varying ways. This information can be used to aid counseling women antenatally and in risk-stratifying patients.
Key words: fibroid, leiomyoma, pregnancy

Cite this article as: Lam S-J, Best S, Kumar S. The impact of fibroid characteristics on pregnancy outcome. Am J Obstet Gynecol 2014;210:xx-xx.

ibroids, or leiomyomas, are benign

tumours of the smooth muscle layer
of the uterus. The precise etiology of
broids is still unknown, but it is clear
that estrogen and progesterone can
cause growth.1,2 They are common in
women of child-bearing age and have
an overall incidence of 40-60% by 35
years of age.3
Depending on the trimester of assessment and the size threshold, the
prevalence of broids in pregnancy
From the Centre for Fetal Care, Queen
Charlottes and Chelsea Hospital (all authors),
and Institute for Reproductive and
Developmental Biology, Imperial College
London (Dr Kumar), London, England, UK, and
Mater Research Institute/University of
Queensland, South Brisbane, QLD, Australia
(Dr Kumar).
Received Nov. 10, 2013; revised Jan. 28, 2014;
accepted March 31, 2014.
The authors report no conict of interest.
Reprints: Sailesh Kumar, FRCOG, FRANZCOG,
DPhil(Oxon), Mater Research Institute/University
of Queensland, Level 3, Aubigny Place,
Raymond Terrace, South Brisbane, Queensland
4101, Australia. skumar@mmri.mater.org.au.
0002-9378/$36.00
2014 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2014.03.066

varies between 1.2% and 10.7%.4-7

Visualization of broids in pregnancy
can be problematic, partly because of the
difculty of ultrasonography in
differentiating broids from physiological thickening of the myometrium.4,8 It
is therefore likely that the prevalence of
broids in pregnancy is underestimated.
Although the majority of women with
broids will have uneventful pregnancies, approximately 10-28% of women
will develop complications, usually in
the form of abdominal pain,9-12 caused
by broid red degeneration (necrosis of
the broid as it overgrows its blood
supply), torsion of pedunculated broids, or impaction.
There is conicting evidence on the
impact of broids on pregnancy, and the
mechanism by which broids inuence
adverse obstetric outcome is not clearly
understood. Some studies suggest that
there is an increase in the rates of miscarriage, preterm labor/delivery, and
hemorrhage.13
What is even less well described in the
literature is the effect of size, number,
location, and type of broid (ie, submucosal, intramural, or subserosal) on
complications during pregnancy and
obstetric outcome.

The aim of this study was to assess and

evaluate the impact of different characteristics of large broids (dened as
4 cm) on pregnancy outcome.

M ATERIALS

AND

M ETHODS

This was a retrospective observational

study of all pregnancies with uterine broids of 4 cm or greater detected on
booking (rst trimester) antenatal ultrasound performed by accredited
sonographers at a major tertiary referral
center (Queen Charlottes and Chelsea
Hospital) between January 2002 and
December 2012. Data were extracted
from the obstetric ultrasound database
(Astraia, Munich, Germany). The size
(4-7 cm, >7-10 cm, and >10 cm in the
greatest dimension), location (lower
uterus or body of uterus), and type
(submucosal, intramural, subserosal, or
varying combinations) of the broids as
well as whether they were single or
multiple (2 broids) were noted.
Obstetric and neonatal outcomes
were ascertained from the maternity
database and chart review. In particular,
the rates of preterm delivery (<37
weeks), postpartum hemorrhage (PPH)
(estimated blood loss of 1000 mL
for cesarean and vaginal delivery), and

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Obstetrics

antenatal admissions for abdominal pain

because of broids were collected. The
mode of delivery, estimated blood loss
at delivery, and birthweight were additional outcome measures that were
assessed. Because this study was part of
a clinical audit, formal research ethics
approval was not required.
Statistical analyses included the c2
test, Student t test, and analysis of variance. Signicant differences were considered at a value of P  .05.

R ESULTS
During the study period, 197 patients
were identied with broids of 4 cm
or greater conrmed on ultrasound. Of
these, data were available for only 121
patients with 179 pregnancies. There
were 136 live births, 22 miscarriages,
7 ectopic pregnancies, 2 stillbirths, 3
terminations of pregnancy, and 9 unknown outcomes. Of the 121 patients, 66
patients (55%) were of African/Caribbean origin, 39 (32%) were white, and
16 (13%) were Asian.
Forty-nine patients (40%) had a single
broid, whereas 72 patients (60%) had
multiple broids. Fibroids were found
to be subserosal in 30 patients (25%),
intramural in 40 patients (33%), a combination of intramural and subserosal in
43 patients (35.5%), submucosal in 1
patient (0.8%), and undocumented in
7 patients (5.7%). Twenty-three patients
(19%) were found to have broids in
the lower uterus or on/adjacent to the
cervix.
The median maternal age was 32 years
(range, 20e46 years). The overall median gestation at birth was 39 weeks
(range, 24e41 weeks). There were 18
preterm deliveries (less than 37 weeks)
(13%). The median birthweight was
3.169 kg (range, 0.62e5.728 kg). There
were 50 spontaneous vaginal deliveries
(50 of 136, 37%), 17 instrumental deliveries (17 of 136, 13%), and 69 cesarean
sections (69 of 136, 50%), of which 38
(55%) were elective and 31 (45%) were
emergency cases.
The indications for elective cesarean
sections included malpresentation (n
6, 16%), multiple pregnancy (n 2,
5%), previous cesarean section (n 13,
34%), placenta previa (n 4, 10%),

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TABLE 1
169
Relationship between number of fibroids and obstetric outcomes
170
Multiple fibroids
Single fibroid
171
Variable
(n [ 85)
(n [ 51)
P value
172
Mean birthweight, kg
3.00 (0.865)
3.18 (0.653)
> .5
173
Preterm labor, <37 of 40
15 (18%)
3 (6%)
.05
174
175
Mode of delivery
176
SVD
30 (35%)
20 (39%)
.65
177
Cesarean section
46 (54%)
23 (45%)
.31
178
Instrumental
9 (11%)
8 (16%)
.38
179
180
PPH
13 (15%)
6 (12%)
.57
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Mean EBL, mL
642 (426)
639 (480)
.2
182
10 (12%)
5 (10%)
.72
Admissions because
183
of fibroid pain
184
Data shown are mean (SD) or number (percentage).
185
EBL, estimated blood loss; n, number of live births; PPH, postpartum haemorrhage; SVD, spontaneous vaginal delivery.
186
Lam. Fibroids and pregnancy outcome. Am J Obstet Gynecol 2014.
187
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macrosomia (n 1, 3%), retroviral that was again not signicant (P > .5).
191
disease (n 1, 3%), oligohydramnios The rate of PPH was similar between the
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(n 1, 3%), and unknown in 3 cases 2 groups (15% (multiple broids) vs
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(8%). The presence of broids as the 12% (single broid, P .57), as was the
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primary indication for elective cesarean mean estimated blood loss between the
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section occurred in only 7 cases (18%). 2 groups (642 mL [SD, 425 mL] vs 639
196
The indications for emergency cesarean mL [SD, 480 mL]; P > .2). There were
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section included failure to progress (n similar rates of admissions (12% vs
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14, 45%), fetal distress (n 12, 39%), 10%; P .72) because of broid-related
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severe preeclampsia (n 3, 10%), and abdominal pain.
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unknown in 2 cases (6%).
201
The overall mean estimated blood loss Location of fibroids within the uterus
202
was 636 mL (SD, 445 mL), and there There was no difference in mean birth203
were 19 cases of PPH (19 of 136, 14%). weight with different locations of the
There were 15 admissions because of broid (Table 2). The location of broid T2 204
205
abdominal pain from broids (15 of 136, (lower uterus/cervix vs body of uterus)
206
11%).
did not have a statistically signicant
207
impact on the rate of preterm delivery
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Number of fibroids
(8% vs 14%; P .5). However, cases in
209
Patients with multiple broids (dened which the broids were in the lower part
210
as 2 or more broids) were signicantly of the uterus were signicantly more
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more likely to have a preterm birth likely to have a cesarean section (86% vs
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compared with women with a single 40%; P .01). Of those women with
213
broid (18% vs 6%; P .05) (Table 1). lower uterine broids who had a cesar- T1 214
Although the rate of cesarean section ean section, 8 of 26 (31%) had an
215
was higher (55% vs 45%) in women emergency cesarean section and 18 of 26
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with multiple broids compared with (69%) had elective cesarean sections
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those with a single broid, this differ- (4 because of broids, 6 of malpre218
ence was not signicant (P .31). The sentation, 5 for previous caesarean sec219
mean birthweight was 3.00 kg (SD, 0.865 tion, 2 for placenta previa, and 1 for
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kg) in women with multiple broids multiple pregnancy).
221
The mean estimated blood loss was
compared with 3.18 kg (SD, 0.653 kg) in
222
women with single broids, a difference higher in those women with broids in

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TABLE 2

Relationship between location of fibroids within the uterus and obstetric

outcomes
Variable

Lower uterus/cervix
(n [ 31)

Body of uterus
(n [ 104)
3.08 (0.827)

P value

Mean birthweight, kg

3.00 (0.597)

.50

Preterm labor, <37 of 40

3 (8%)

15 (14%)

.50

4 (13%)

46 (44%)

.0015

26 (84%)

42 (40%)

< .001

1 (3%)

16 (15%)

.073

Mode of delivery
SVD
Cesarean section
Instrumental
PPH
Mean EBL, mL
Admissions because
of fibroid pain

8 (22%)

11 (11%)

830 (551)

573 (383)

2 (5%)

13 (12.5%)

.03
.03
.35

Data shown are mean (SD) or number (percentage).

EBL, estimated blood loss; n, number of live births; PPH, postpartum haemorrhage; SVD, spontaneous vaginal delivery.
Lam. Fibroids and pregnancy outcome. Am J Obstet Gynecol 2014.

the lower part of the uterus (830 mL

[SD 551 mL]) compared with broids
in the body of the uterus (573 mL [SD
383 mL]; P .03), and the incidence of
PPH was signicantly increased when
the broids were in the lower part of the
uterus (22% vs 11%; P .03). There
were no signicant differences found

between the different locations of broids for the rates of admissions for
broid-related pain (5% [lower uterus]
vs 12.5% [body of uterus]; P .35).

Type of fibroid
There was no difference in birthweight
or the rates of preterm delivery between

TABLE 3

Relationship between type of fibroid and obstetric outcomes

Variable

Intramural
(n [ 43)

Subserosal/
intramural
(n [ 51)

Subserosal
(n [ 32)

P value

Mean birthweight, kg

3.08 (0.677)

3.03 (0.890)

3.05 (0.821)

.96

Preterm labor,
<37 of 40

5 (12%)

9 (18%)

4 (12.5%)

.67

SVD

19 (44%)

14 (27%)

15 (47%)

.12

Cesarean section

20 (47%)

31 (61%)

11 (34%)

.059

4 (9%)

6 (12%)

6 (19%)

.46

4 (9%)

7 (14%)

2 (6%)

.53

507 (312)

.09

2 (6%)

.36

Mode of delivery

Instrumental
PPH
Mean EBL, mL
Admissions because
of fibroid pain

751 (582)
7 (16%)

606 (364)
5 (10%)

Data shown are mean (SD) or number (percentage).

EBL, estimated blood loss; n, number of live births; PPH, postpartum haemorrhage; SVD, spontaneous vaginal delivery.
Lam. Fibroids and pregnancy outcome. Am J Obstet Gynecol 2014.

Research

279
subserosal and intramural broids
280
(Table 3). However, although women T3 281
with intramural broids had substan282
tially higher rates of cesarean sections
283
compared with women in whom the
284
broids were solely subserosal, this dif285
ference was not signicant (47% [intra286
mural], 61% [combination of intramural
287
and subserosal] vs 34% [subserosal];
288
P .059). Fibroids that were solely sub289
serosal were associated with a lower
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blood loss than those that were intra291
mural. This difference was, however,
292
not statistically signicant (507 mL [SD,
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312 mL] [subserosal] vs 606 mL [SD,
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364 mL] [combination of intramural and
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subserosal] and 751 mL [SD 582 mL]
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[intramural]; P .09).
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There was no signicant effect on the
298
rates of PPH (9% ([intramural] vs 14%
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[combination of intramural and sub300
serosal] vs 6% [subserosal]; P .53)
301
and admissions for broid-related ab302
dominal pain (16% (intramural) vs 10%
303
(combination of intramural and sub304
serosal) vs 6% (subserosal); P .36).
305
306
Size of fibroid
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Fibroid size was categorized into 3
308
groups (4-7 cm, 7-10 cm, and >10 cm).
309
Fibroid size did not affect the mean
310
birthweight, the rate of preterm de311
livery, or the mode of delivery (Table 4). T4 312
However, the rates of PPH were higher
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(11% [4-7 cm] vs 13% [7-10 cm] vs
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36% [>10 cm]; P .04), and mean
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estimated blood loss was greater (567
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mL [SD, 365 mL] [4-7 cm] vs 643 mL
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[SD, 365 mL] [7-10 cm] vs 961 mL [SD,
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764 mL] [>10 cm]; P .01) with
319
increasing size of the broid. Smaller
320
broids (ie, 4-7 cm in size) were less
321
likely to result in admissions for broid322
related pain (5% [4-7 cm] vs 23% [7-10
323
cm] vs 21% [>10 cm]; P .01).
324

C OMMENT
There are inconsistent data regarding the
impact of broids on pregnancy and
even less information on how different
characteristics of broids inuence obstetric outcome. This large retrospective
study attempts to address this.
Diagnosis of small broids (<5 cm)
by ultrasound is known to be inaccurate,
especially in pregnancy, because of the

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Obstetrics

TABLE 4

Relationship between size of fibroid and obstetric outcomes

Variable
Mean birthweight, kg

4-7 cm
(n [ 91)

>10 cm
(n [ 14)

P value

2.90 (0.482)

3.13 (0.895)

.43

10 (11%)

7 (23%)

1 (7%)

.2

SVD

38 (42%)

7 (23%)

5 (36%)

.15

Cesarean section

44 (48%)

17 (55%)

8 (57%)

.72

9 (10%)

7 (22%)

1 (7%)

.15

10 (11%)

4 (13%)

5 (36%)

.04

Preterm labor,
<37 of 40

3.10 (0.767)

7-10 cm
(n [ 31)

Mode of delivery

Instrumental
PPH
Mean EBL, mL
Admissions because
of fibroid pain

567 (365)
5 (5%)

643 (365)
7 (23%)

961 (764)
3 (21%)

.01
.01

Data shown are mean (SD) or number (percentage).

EBL, estimated blood loss; n, number of live births; PPH, postpartum haemorrhage; SVD, spontaneous vaginal delivery.
Lam. Fibroids and pregnancy outcome. Am J Obstet Gynecol 2014.

difculty in distinguishing broids from

physiological thickening of the myometrium. In this study we included only
broids larger than 4 cm in size so that
our ndings would have greater clinical
relevance. We concentrated on important outcomes, such as preterm delivery,
intrauterine growth restriction, mode of
delivery, and postpartum hemorrhage.
Furthermore, we have tried to correlate
these outcomes with different aspects of
broids (size, location, type, number),
which thus far has not been clearly
elucidated from previous studies.
The overall rate of preterm delivery in
this study was 13% (18 of 136), and the
rate of cesarean section was 51% (69 of
136), which is consistent with previously
published data.13 However, there was a
high rate of PPH in our cohort (14%, 19
of 136), compared with 2.5%, as suggested in the systematic review by Klatsky et al.13 This difference could be
explained by differing denitions of
PPH or varying institutional reporting
rates. In our series, the rate of admissions from broid-related pain was 11%
(15 of 136), similar to that previously
reported by other authors.10-13 Our
data also conrm that the rate of fetal
growth restriction in pregnancies is not
increased in pregnancies complicated
with broids.

We found preterm delivery was signicantly more likely with multiple broids than if the broids were solitary
(18% vs 6%; P .05), which was also
described by Lev-Toaff et al.11 However,
the location within the uterus, the size,
and the type of broid was not found
to inuence the rate of preterm delivery,
ndings that have not previously been
reported.
Cesarean section was signicantly
more likely if the broids were in the
lower part of the uterus, which is
consistent with ndings by Lev-Toaff
et al11 and Vergani et al.14 However,
our ndings did not show a relationship
between the mode of delivery and the
number of broids, which conicts with
previously reported ndings.7,11
Although some studies12,14 suggested
that larger broids were more likely to
be associated with operative delivery,
we could not demonstrate a similar association. In fact, our data support the
conclusions of a study by Roberts et al15
in which multiple or larger broids were
not associated with increased risk of
cesarean section. Furthermore, current
obstetric practice is that large broids or
the presence of multiple broids are not
an immediate contraindication to a trial
of labor,16 and our results support this
rationale.

Although the risk of hysterectomy

has been demonstrated to be higher in
women with broids,13,17,18 the data on
the risk of PPH are not consistent, with
some studies demonstrating no increase
in the rates of hemorrhage.15,19 The results from our study suggest that only the
size and its location within the uterus
inuences the risk of hemorrhage. This
association of different features of broids with PPH has not been previously
shown before and may be useful in
providing information to women and
can also aid clinical practice in helping
to identify those most at risk of PPH.
Pain is the most common complication of broids during pregnancy that
women report. Our data show that
abdominal pain from broids requiring
admission was more likely with
increasing broid size, which is consistent with previous reports.10,17 No correlation was found with the type,
number, or location of broid.
Women should be reassured that the
majority of pregnancies with broids
have good maternal and neonatal outcome. This large retrospective study
provides more detail into how pregnancy
outcome is inuenced by different
characteristics of broid. The presence
of multiple broids is associated with a
signicantly higher rate of preterm delivery and may warrant increased surveillance. How broids increase the risk
of preterm delivery is, however, unclear.
Mode of delivery and rates of hemorrhage were found to be inuenced by
the location of broids in the lower part
of the uterus. The rates of PPH and
estimated blood loss as well as pain were
also positively correlated with the increasing size of the broid. Such information may be useful in counseling
patients and in the risk stratication of
pregnancies and labor.
As with previous publications on this
topic, our study does have some limitations. These include the accuracy of
the measurement and determination of
broid type and localization on ultrasound. Missing data were also a problem
in this study because a number of patients delivered elsewhere and it was
not possible to obtain their obstetric
outcome. Our statistical power to fully

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examine the association between characteristics of broids and pregnancy

outcome may have been limited by the
small sample size. We also cannot rule
out the potential effect of residual confounders. Nevertheless, this study provides clinically useful data that may be
of help to other practitioners.
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Schectman JM. High cumulative incidence of
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