Fibroids and Pregnancy

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Dr. V.P. Jyotsna

Dr. V.P. Jyotsna MBBS, MD (JIPMER) Consultant Obstetrician & Gynecologist and Laparoscopic surgeon 9M by Ankura Hospital, Nanakramguda, Hyderabad

Fibroids of the uterus or the womb are a common occurrence with nearly 40-60 percent of women above 35years age being diagnosed with these benign tumours. Younger women too are increasingly being diagnosed with fibroids making them a possible reason for complications during pregnancy. So, on the occasion of Fibroid awareness month let us take a look at how fibroids in the uterus can affect pregnancy.

What are fibroids?

Fibroids are localized nodules of muscle cells that form in the myometrium or muscle layer of the uterus. They can occur as a single tumor or in multiples in variable sizes and cause symptoms due to their location and size. The usual symptoms related to fibroid are heavy menstrual bleeding, painful periods and pressure effects like urinary disturbances, constipation etc.

How can fibroids be diagnosed?

Fibroids can be felt on clinical examination when they are large but when smaller than 5 cm, they are difficult to diagnose by clinical examination alone. Ultrasound scans can diagnose fibroids in most cases. In an extremely enlarged uterus with multiple fibroids, sometimes an MRI scan may be advised to understand the location and how the uterine cavity is distorted by them.

How do fibroids affect pregnancy?

12-25% of women who come for infertility treatments are found to have fibroids in the uterus, but it is not necessary that every woman has problems related to the fibroids. Depending on the size and locations, fibroids larger than 5cm and those which are close to the cavity of the uterus are the ones which cause most effect on pregnancy.

· Fibroids can affect fertility by causing problems with implantation of embryo leading to bleeding or even cause miscarriages in some.

· If the pregnancy continues with large fibroids in the uterus, the uterus may be a bit distorted and baby may come to lie in breech or transverse positions,. The fibroids may cause growth problems for the baby in some cases.

· There is double the risk of placenta previa or a low lying placenta.

· There is a higher risk for preterm labor and labor abnormalities, a nearly 4 times higher risk of cesarean delivery etc.

· If the placenta is attached over the surface of the fibroid there may be higher risk of premature separation of placenta causing bleeding (Abruption) and reduced blood supply to the baby inside. There is higher risk for excessive bleeding after delivery or postpartum hemorrhage.

If a woman who has fibroids conceives then the fibroids may show some changes under the influence of pregnancy hormones. Pain is the most common complaint in women with fibroids

· 60-78% of fibroids do not show any change in volume during pregnancy. The 22- 32% which show a change the maximun growth of size happens in the first 3 months. Small fibroids are just as likely to grow as large fibroids, but some studies show that smaller fibroids show more growth than very large fibroids.

· As they increase in size the fibroids especially the ones bigger than 6cm in diameter might undergo degeneration from within. The typical degeneration of fibroids in pregnancy is called “red degeneration” and it causes severe pain and feverishness. Usually nothing can be done about it except giving some pain relief medications until delivery. In very severe cases a myomectomy was done in the 4th or 5th month of pregnancy rarely.

· Fibroids attached to the uterus surface by a pedicle can twist on themselves causing severe pain and may need emergency surgery.

What about myomectomy?

Myomectomy is a surgery done to remove the fibroids alone without removing the entire uterus. It can be done by laparoscopy or by open surgery or even by hysteroscopy for fibroids which are protruding into the cavity of uterus.

Typically myomectomy is advised when

· There are large fibroids or if they are blocking the tubes or distorting the shape of the uterus and causing difficulty in conceiving.

· The woman has extremely heavy periods and the fibroids are the cause.

· The woman has suffered from previous miscarriages as a result of the fibroids.

· Very rarely myomectomy is advised during pregnancy or along with a cesarean section.

After a myomectomy usually a gap of 3-6 months is recommended before planning pregnancy to give time for the stitches on the uterus to heal. A majority of pregnancies after a myomectomy will be delivered by a cesarean because there is a risk of the uterus rupturing at the myomectomy site during labor.

To conclude many women are being diagnosed with fibroids today but not all fibroids cause problems. Women diagnosed with fibroids during pregnancy planning stage or after becoming pregnant need to discuss the possible complications with their gynecologist . Careful evaluation is required whether a surgery is required before planning pregnancy and with the use of minimally invasive surgical techniques surgery for removal of fibroids can be done safely with quick recovery times and good outcomes.