Large Uterine Fibroids In Pregnancy With Successful Caesarean Myomectomy
Okon A. Okon
1Department of Obstetrics & Gynecology, Faculty of Medicine, University of Calabar, Calabar, Cross River State, Nigeria
Academic Editor:
Abstract
Uterine fibroid is the commonest benign tumour of the female reproductive tract. It occurs in 2040% of women, whereas the estimated incidence in pregnancy is 0.13.9%. Uterine fibroid in pregnancy is usually asymptomatic with complications occurring in 1030% of cases. The first line of management is conservative with counselling for myomectomy after delivery. However, in the presence of intractable symptoms, both antepartum myomectomy and caesarean myomectomy have been reported to be successfully performed in carefully selected cases. We report a case of large subserous uterine fibroid in pregnancy that was referred to our centre at 14 weeks of gestation. She developed generalized body weakness, backache, and breathlessness at 27 weeks gestation. Thus, she was admitted and managed conservatively for eight weeks with significant relief of symptoms. She eventually had a caesarean myomectomy at 35 weeks of gestation the outcome was a live female baby with a birth weight of 2.3kg and a large subserous fibroid weighing 9.5kg. We can therefore say that caesarean myomectomy can be safely performed in carefully selected cases.
1. Introduction
2. Presentation of Case
3. Discussion
4. Conclusion
Data Availability
Availability of data is not required.
Conflicts of Interest
References
Copyright
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Signs And Symptoms Of Fibroids
While many women notice mild or no symptoms with fibroids, some women experience a variety of noticeable symptoms, such as:
Heavy bleeding
Some women who develop fibroids may have very heavy bleeding during menstruation. Heavy bleeding often occurs in tandem with painful periods and cramps. Irregular or excessively heavy bleeding may lead to anemia and other complications.
Feeling of fullness
One symptom of fibroids is a sensation of fullness in the lower stomach area. This is often accompanied by significant bloating of the lower abdomen.
Excessive urination
Some women who have fibroids may notice that they have a frequent urge to urinate.
Pain during sex
One of the most common signs or symptoms of fibroids is pelvic pain during sex. The pain may range from constant to intermittent and from a dull ache to sharp pain.
Lower back pain
Lower back pain especially recurring pain can be an indicator of fibroids in the uterus or cervix.
Pregnancy complications
FiResearch shows that women who have fibroids may be up to six times more at risk for needing a cesarean section than women who do not. Beyond this, fibroids can cause a number of complications during pregnancy and labor, such as:
- Miscarriage
- Affect on the babys birthing position
- Damage to the placenta
- Women who have a mother or sister with fibroids
- Women who have not yet been pregnant
- Black women
Understanding Uterine Fibroid Size: How Big Is Too Big
Uterine fibroid size can vary from less than an inch to larger than a grapefruit. So, do all fibroids need to be removed?
For the vast majority of patients, the answer is no. Watchful waiting is the usual course of treatment for most fibroids, particularly if they arent causing any symptoms.
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What Are The Effects Of Pregnancy On Fibroids
The majority of fibroids dont change in size during pregnancy, but some do. In fact, of uterine fibroids may grow in the first trimester, according to a 2010 review. Fibroid growth is possibly influenced by estrogen, and estrogen levels rise during pregnancy. This may lead to growth.
Still, for other women, fibroids may actually shrink during pregnancy. In a 2010 study, researchers found that of fibroids that were present before a pregnancy decreased in size after delivery.
What Are Uterine Fibroids Definition
Uterine fibroids are benign, monoclonal, well-delimited, encapsulated tumors originating from the cervixs smooth muscle cells or uterine body. It is one of the most common benign tumors of the female genital area, which occurs in 20-40% of women of reproductive age.
Initially, fibroids grow from muscle cells of the uterine wall. According to recent studies, this disease affects about 70% of women. Most of them do not even know about it.
In most cases, nodular fibroids of the uterus develop asymptomatically and slowly. Its value can range from a few millimeters to 30 cm in diameter. It rarely transforms into a malignant tumor.
However, in the United States, uterine fibroids are a disease that causes 200,000 hysterectomies per year.
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Can Fibroids Affect Your Chances Of Getting Pregnant
About 80% of women will have had a fibroid by the time they turn 50. Theyre common growths that develop in the uterus, and theyre generally painless. But sometimes fibroids can interfere with fertility and make it more difficult to get pregnant.
At our comprehensive OB/GYN clinics in Cranston, Providence, and Smithfield, Rhode Island, A. Michael Coppa, MD and our team are here to help you navigate infertility and have a healthy pregnancy. Talk to Dr. Coppa about how fibroids might impact your chances of getting pregnant.
Q: Can Fibroids Affect Your Fertility
A: Most fibroids dont, but some can depending on their size and location interfere with the sperms ability to get to the egg, fertilization or the implantation of an embryo. Fibroids can also get in the way during a pregnancy if theyre positioned in the uterus where the baby needs to be. In most instances, though, doctors will advise leaving fibroids alone and closely monitor your pregnancy.
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Is There A Non
Yes. Its called Uterine Fibroid Embolization. Embolization shrinks fibroids instead of cutting them out. It is a minimally invasive, non-surgical procedure. It works by blocking the blood supply to each fibroid, ending its ability to thrive and grow. Embolization doesnt involve cutting or cause any scarring. And embolization is extremely precise. It addresses only fibroids, leaving all other tissue healthy and whole. As the fibroids shrink, so do the fertility problems they create.
Can You Have A Normal Delivery After Removing Fibroids
It depends on the depth and size of the fibroids. If the fibroid was superficial , and the removal was done via a hysteroscopic procedure, you can still have a normal delivery. However, if a deep intramural fibroid was removed with a deep incision, you may need to discuss with your obstetrician-gynaecologist if you could still have a natural delivery.
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Do Fibroids Grow In Size During Pregnancy
It is common for fibroids to grow as the pregnant uterus grows. Size of fibroids may be affected by change in estrogen and progesterone levels, uterine blood flow, and, possibly, human chorionic gonadotropin levels. This however does not happen in every case. In some women, fibroids stay stable at a very similar size throughout the pregnancy and others even experience reduction in size of the fibroid.
Can You Leave Fibroids Alone
It depends on the clinical scenario. Some small fibroids can cause big problems while some big fibroids are hardly harmful. Regular screenings with your gynaecologist are encouraged for early detection, monitoring, and management of fibroids. Treatment will be based on the anticipation and clinical assessment of the patient.
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Are There Medications To Treat Fibroids
GnRHa injections induce a temporary menopause state and have been used to shrink fibroids before surgery. The effect is not long lasting and the fibroids quickly revert to its original size upon cessation of the treatment.
Ulipristal, a selective progestogen receptor modulator, has been shown to be effective in fibroid shrinkage and holds the promise for a longer term treatment. It can be repeated up to 4 courses over 18 months and the effects can potentially last longer.
Drug Exposure In Pregnant Women With Uterine Fibroids
The management of pregnant women with uterine fibroids antenatally is usually not different from those without uterine fibroids. However when complications arise they are managed accordingly. A common complaint they have is fibroid pain as a result of red degeneration, and this is usually managed conservatively by bed rest, hydration and analgesic use. Non steroidal anti-inflammatory drugs should be used with caution, especially in the third trimester because of the potential for fetal and neonatal adverse effects, including premature closure of fetal ductus arteriosus, pulmonary hypertension, necrotizing enterocolitis, intracranial hemorrhage and oligohydramnios . Additional pain management, especially opioid use, and on few occasions epidural analgesia and surgical management antenatally , may be employed when pain is intense .
The use of antenatal corticosteroids and tocolytics for management of preterm labor in pregnant women with uterine fibroids was earlier highlighted in this chapter.
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What Are Uterine Fibroids
Uterine fibroids are knotty masses of muscle and fibrous tissue that grow in and around the wall of the uterus. Fibroids are nearly always benign tumors and are very common. In fact, they affect up to 20 percent of women of child-bearing age and up to 80 percent of women by age 50.
Fibroids often go unnoticed, sometimes only getting picked up during a pelvic exam or prenatal ultrasound. But in some cases they can cause symptoms. These may include:
- Heavy, long or painful periods
- A full, heavy feeling in the lower abdomen
- Abdominal bloating
- Lower back pain
- Constipation
During pregnancy, the most common symptoms of fibroids are pain, vaginal bleeding and pelvic pressure, particularly in the second and third trimester.
Experts dont know for sure what causes fibroids, though hormones and genetics are thought to play a role. They also seem to be more common in Black women. Other risk factors may include obesity, early menstruation onset and a diet thats higher in red meat and lower in green vegetables.
Is It Harder To Get Pregnant With Fibroids
Having fibroids does not necessarily eliminate a womans chance of getting pregnant. Many women have, in fact, fallen pregnant and delivered healthy babies even with fibroids.
As explained in the main text, depending on the location and size of the fibroids, some can interfere with transport and retrieval of sperm and egg due to anatomical distortion of cervix, uterine cavity, tubal ostia and ovary. They can also interfere with fertilisation and/or the successful implantation of the embryo.
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Is Fibroid Degeneration A Good Thing
Though fibroid degeneration does decrease the size of fibroids, this is only temporarya degenerated fibroid is likely to expand and degenerate again. Though many people with fibroids dont experience symptoms on a daily basis, when fibroid degeneration starts, it can be uncomfortable and disruptive.
Large Fibroids And Becoming Pregnant
Fibroids are a noncancerous tumor found on or near the uterus. Fibroids can range in size, from about the size of a watermelon seed to the size of a grapefruit. According to the U.S. Department of Health and Human Services, 20 to 80 percent of women will develop fibroids by the time they are 50.
Many women with fibroids conceive without a problem and go on to have healthy, normal pregnancies. However, when fibroids are large, they can interfere with fertility. When fertility is affected, fibroids can be treated in our Lubbock clinic. Some women may benefit from fibroid removal, a procedure called a myomectomy. Often, this is enough to improve fertility when fibroids are the issue.
Whether or not a myomectomy is performed, most women who have fibroids will have normal pregnancies, but sometimes fibroids can lead to complications.
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Identifying Fibroids During Pregnancy
test has the highest resolution of the imaging modalities available but is rarely used in pregnant women with fibroids. There are no proven risks to pregnant women or unborn babies from MRI exams. Over the last 30 years, thousands of pregnant women have had MRI exams, and no known harmful effects to the baby have been found. MRIs role is one of problem-solving for cases that ultrasound does not provide an answer.
Transabdominal and transvaginal ultrasound is the most common imaging tool used in pregnant patients with or without fibroids. Because fibroids are harder to detect during pregnancy, experts agree that the actual number of cases is under-reported.
Fibroids In Pregnancy: Management And Outcomes
Djavid I Alleemudder MRCS MRCOG MRCS
Consultant in Obstetrics and Gynaecology with a special interest in Fertility, Ipswich Hospital, Ipswich, Suffolk, IP4 5PD UK
Djavid I Alleemudder MRCS MRCOG MRCS
Consultant in Obstetrics and Gynaecology with a special interest in Fertility, Ipswich Hospital, Ipswich, Suffolk, IP4 5PD UK
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How Do Fibroids Affect Fertility
Although fibroids can affect fertility, a lot of women have no trouble getting pregnant with fibroids. In fact, for most, conceiving naturally is possible and usually does not require treatment.
However, there are some cases when getting pregnant with uterine fibroids is difficult.
The ways in which fibroids can cause infertility include:
Mechanical/anatomical factors
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Fibroids can grow towards the cervix diminishing or blocking the entry of sperms into the uterus
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They can grow towards the fallopian tubes, impairing or blocking the passage of the egg.
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Submucosal fibroids that grow inside the uterine cavity can work as a foreign body and reduce the space for implantation of the embryo and development of the fetus.
Functional/physiological factors
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Fibroids can change the endometrial receptivity to embryo implantation by changing the hormonal milieu, blood flow and hence endometrial development. This was shown in studies using assisted reproductive fertility where the removal of fibroids increased the success rate after IVF treatment.
There are many causes of infertility and they are not always obvious. Infertility patients may have to undergo other investigations to rule out other factors before attributing their difficulty to fall pregnant to fibroids.
How Are Fibroids Treated Before Pregnancy To Improve Fertility
Treating uterine fibroids before pregnancy may improve your fertility risk. The most common treatments for fibroids that preserve fertility include:
- Myomectomy. This surgical procedure is used to remove fibroids. It may increase the need for cesarean delivery, and youll likely need to wait about three months following the procedure before attempting to conceive.
- Hormonal birth control pills. While youre on the pill, you wont be able to become pregnant. But this contraceptive can help ease symptoms of the condition, such as heavy bleeding and painful periods.
- Intrauterine device . Like the birth control pill, an IUD will prevent pregnancy as long as youre using it. However, it can help eliminate some of symptoms while preserving fertility.
- Gonadotropin-releasing hormone agonists. This type of medication blocks the production of the hormones that lead to ovulation and menstruation, so you wont be able to become pregnant while taking this medication. It can help shrink fibroids.
- Myolysis. This procedure uses an electric current, laser, or radio-frequency energy beam to shrink the blood vessels that feed the fibroids.
Other treatments are available for women with fibroids who may want to have children in the future. Each treatment carries its own risk and complications, so talk with your doctor about your options.
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Treatment Options For Uterine Fibroids
There are several uterine fibroid treatment options:
- Uterine fibroid embolization uses tiny particles about the size of sugar crystals that are injected into the blood vessels that lead to the uterus. The particles block the flow of blood to the fibroid, causing it to shrink and die. This minimally invasive procedure can be performed by an interventional radiologist on an outpatient basis. It doesnt require open surgery and offers relief of symptoms with fewer risks, less pain, and a faster recovery compared to surgical procedures.
- Magnetic resonance imaging-guided ultrasound surgery uses ultrasound waves to destroy fibroids. Waves are directed at the fibroids through the skin with the help of magnetic resonance imaging.
- Endometrial ablation destroys the lining of the uterus. This procedure is best for small fibroids that are less than 3 centimeters in diameter.
- Hysterectomy is the surgical removal of the uterus. Because this surgery removes the fibroids along with the uterus, there is no chance of becoming pregnant after undergoing a hysterectomy.
- Myomectomy is another surgical option to remove all types of fibroids. There are three approaches to performing a myomectomy: hysteroscopy, laparotomy, and laparoscopy.
Talk to your healthcare provider about the various uterine fibroid treatment options so that you fully understand the risks associated with surgery, as well as the benefits of a minimally invasive alternative treatment such as uterine fibroid embolization.
Treating Fibroids Before Pregnancy
Uterine fibroids are most common during the reproductive years, so it comes as no surprise to us that many of our patients are concerned about preserving fertility. Some avoid treatment altogether because theyve been told a hysterectomy, the complete surgical removal of the uterus, is their only option. We want you to know that this isnt true.
At USA Fibroid Centers, our experts offer an effective, non-surgical treatment that can preserve your uterus and retain your fertility. Uterine Fibroid Embolization is a minimally invasive, outpatient procedure that involves less risk and a significantly shorter recovery time than fibroid surgery.
If you suffer from symptomatic fibroids and have not been able to conceive, we suggest inquiring whether you are a good candidate for UFE. Even if you do not want to undergo uterine fibroid treatment during pregnancy, conceiving may become easier if you treat your fibroids prior to conception.
Treating fibroids before pregnancy is the safer, better alternative. Monitor any symptoms of uterine fibroids you may experience and seek medical advice as soon as possible. If you wait to seek treatment for fibroids until after you discover that youre pregnant, your treatment options will be limited until the baby is born. Due to the risk for the baby, doctors will generally only prescribe bed rest, mild pain relievers, and hydration to deal with the symptoms.
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