Fibroid complicating pregnancy

1. FIBROIDS COMPLICATING PREGNANCY
By - Dr. Milan Kharel

2. Definition
 “A benign(non-caseous) tumor arising from the smooth
muscles layer and accompanying connective tissue of the
uterus”
 fibroid is chiefly composed of smooth muscle fibres & a small
amount of connective tissue.
 The name fibroid is a misnomer, more appropriate term for
this tumor of smooth muscle is Myoma or Leiomyoma.

3. Classification of fibroids
• Intramural fibroids
• Subserosal fibroids
• Submucous fibroids
Within Body of
uterus
Cervical
Intraligamentary

4. INCIDENCE AND PREVALENCE
Incidence in pregnancy : 1 in 1000.
Prevalence : Highest in black women -18 percent
Lowest in whites - 8 percent

5. EFFECTS OF FIBROID ON
PREGNANCY
 May be none
 Abortion (submucous fibroid)
 Pressure symptoms due to impaction of
(a) Bladder - retention of urine
(b) Rectum - constipation
 Red degeneration
 Malpresentation (Four fold risk)
 Preterm labor and prematurity
 Non-engagement of the presenting part

6. EFFECTS ON LABOR
 May be unaffected
 Uterine inertia
 Dystocia
 Obstructed labor
 Postpartum hemorrhage due to atonicity or adherent
placenta
 Difficult cesarean section (Eight fold risk)

7. EFFECTS ON PUERPERIUM
 Subinvolution
 Inversion of uterus
 Secondary PPH
 Sepsis
 Lochiometra and pyometra.

8. EFFECTS OF PREGNANCY ON
FIBROID
 Changes in size – increases (?)
 Changes in position
 Changes in shape - becomes flattened
 Degenerative changes specially, red degeneration
 Torsion of pedunculated subserous fibroid
 Infection and polypoidal changes are more in
puerperium.

9. EFFECTS OF PREGNANCY ON
FIBROID
 Changes in size – increases (?)
 Fibroid is an estrogen dependent tumor.
 Pregnancy is a progesterone predominant state.
So how does fibroid increases in size during pregnancy?

10. EFFECTS OF PREGNANCY ON
FIBROID
 Actually, most fibroids do not increase in size during
pregnancy.
 69% - had no increase in fibroid volume throughout
pregnancy
 31% - noted increase in fibroid volume, greatest increase
before 10th week of gestation and a reduction to baseline
value 4 weeks after delivery

11. EFFECTS OF PREGNANCY ON
FIBROID
 The main reason for the fibroid to increases in size
during pregnancy is due to
 Increased vascularity
 Edema
 Hypertrophy and hyperplasia of the fibromuscular
tissues.

12. RED DEGENERATION OF FIBROID

13. RED DEGENERATION
• Red degeneration (carneous degeneration) occurs in
a large fibroid mainly during second half of pregnancy
and puerperium. Partial recovery is possible and as
such called necrobiosis.
Red degeneration is a result of softening of the surrounding
supportive connective tissue, the capillaries tend to rupture and
blood effuses out into the myoma causing a diffuse reddish
discolouration of the same.

14. Clinical features of Red Degeneration
These patients typically present with acute lower abdominal pain, with
may be severe and is often associated with nausea, vomiting and even
fever.
Examination may show a tender palpable mass in the uterus. In severe
cases, there may be signs of localized peritonism.

15. Naked eye appearance of the tumor shows dark
areas with cut section revealing raw-beef appearance
often containing cystic spaces.
The odor is often fishy due to fatty acids.
Color is due to the presence of hemolysed red cells and
hemoglobin.
Microscopically, evidences of necrosis are present.
Vessels are thrombosed but extravasation of blood is
unlikely.
Gross Appearance:

16. Diagnosis
1. Ultrasound scanning is the primary modality of diagnosis,
and typically shows a fibroid corresponding to the area of
tenderness over the uterus. Most often, the degenerating
fibroid has a mixed echogenic appearance.
2. MRI : Where sonography is inconclusive, abdominal MRI
may be considered. In red degeneration, the typical finding
is an uterine fibroid with increased T1 signal intensity.

17. Treatment
Red degeneration is a self-limiting condition and is almost always
managed conservatively.
The pain should be managed symptomatically, with either NSAIDs or
opioids. Where opioids are ineffective, a 24 to 48 hour course of
indomethacin has been shown to be efficacious.
Note that NSAIDs are best avoided during the third trimester, as there is
an increased risk of premature closure of the ductus arteriosus and
oligohydramnios

18. It is often difficult to diagnose a fibroid during pregnancy
because of
 Marked softening
 Alteration in the shape (flattening)
 In early months, fibroid is diagnosed but pregnancy is
missed whereas in later months, pregnancy is
diagnosed but the fibroid is missed.
DIAGNOSIS

19.  Ultrasonography
confirms the diagnosis with
certainity.
DIAGNOSIS
USG showing uterine fibroid

20. If ultrasonographic findings are
unclear,
 Magnetic Resonance
Imaging can be done
DIAGNOSIS
MRI showing degenerating fibroid

21. In uncomplicated tumor, fibroid is often confused with
 Ovarian tumor
 Retroverted gravid uterus
 Non gravid half of uterus didelphys
DIAGNOSIS

22. BASIC PRINCIPLE
 Avoid treatment whenever possible.
TREATMENT

23. DURING PREGNANCY
Uncomplicated :
Usual antenatal care is followed.
All cases to be assessed at 38 weeks to
formulate the method of delivery.
 Acute pain following red degeneration
Conservative management
TREATMENT

24. DURING LABOR
Fibroid situated above the presenting part:
Usually results in uneventful vaginal delivery
Fibroid situated below the presenting part:
Spontaneous vaginal delivery may occur.
If it fails, cesarean section is to be done.
TREATMENT

25.  Fibroid in lower uterine segment
 Cervical fibroid, even if it is small
 Fibroid impacted in pelvis
 Malpresentation
 Obstetric complications
INDICATION FOR ELECTIVE
CESAREAN SECTION
Cesarean delivery for a large leiomyoma in
the lower uterine segment

26. TECHNICAL ASPECTS ON
ELECTIVE CESAREAN SECTION
Myomectomy should be avoided during cesarean section
Be alert for postpartum hemorrhage and retained placenta.
Reverts to a smaller size during puerperium

27. DC Dutta’s – Textbook of
Gynecology : 6th edition
Shaw’s Textbook of Gynaecology :
15th edition
DC Dutta’s – Textbook of
Obstetrics : 6th edition