Uterine Leiomyomata in Pregnancy

1. Uterine Leiomyomata in Pregnancy Ruth Stefanski, PGY-1 January 12, 2010

2. 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

3. 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 UTI’s, on suppression therapy • 3. GBS bacteruria • 4. Anemia, on Iron supplements

4. Case, Continued • OB Hx: 2008 TOP at 8wks • GYN Hx: 13/regular/3-5. No STI’s. 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.

5. 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

6. 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: Pt’s 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: …..

7. 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?

8. 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

10. Clinical Manifestations • Abnormal uterine bleeding • Menorrhagia • submucosal • NOT intermenstrual bleeding • Pelvic pressure and pain

11. 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

12. Pregnancy loss Preterm labor and birth Placental abruption Placenta previa Pain PPH Dysfunctional labor Malpresentation Malposition Cesarean delivery Complications during Pregnancy

13. 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 (?)

14. Placental Abruption • Conflicting evidence • Submucosal, retroplacental • Abnormal placental perfusion: decreased blood flow to endometrium overlying fibroid  placental ischemia, decidual necrosis abruption (?)

15. 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)

16. Pain • Reduced perfusion with rapid growth of fibroid • Ischemia, necrosis, release of prostaglandins

17. Postpartum Hemorrhage • Greater risk: retroplacental or cesarean delivery • Decreased force and coordination of contractions  uterine atony • Be prepared: PPH precautions

18. Dysfunctional Labor • Varying evidence • Decreased force of contractions • Asymmetric wave of contractile force across uterus

19. Malpresentation, Malposition • Consistent evidence • Distorted shape of uterine cavity

20. Cesarean Delivery • Consistent evidence • Location in lower uterine segment • Due to higher risk of malpresentation, dysfunctional labor, abruption

21. 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

22. Management during pregnancy, labor & delivery • 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.