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 UTIs, 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 STIs. 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: Pts 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.