CASE REPORT

UTERINE FIBROID IN PREGNANCY

Supervised by:

dr. Hesty Duhita Permata, Sp.OG

Presented by:

Novita Dewi
2013730078

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

MUHAMMADIYAH JAKARTA FACULTY OF MEDICINE
RSUD SYAMSUDIN SH SUKABUMI
 CHAPTER I
INTRODUCTION

Uterine fibroids are benign growths that develops from muscle tissue of the uterus. They
are also called leiomyomas or myomas. The size, shape, and location or fibroids can vary
greatly. They may be present inside the uterus, on its outer surface or within its wall, or attached
to it by a stem-like structure.
Uterine fibroids are a very common finding in women of reproductive age. The majority
of fibroids do not change their size size during pregnancy, but one-third may may grow in the
first trimester. Although the data are conflicting and most women with fibroids have uneventful
pragnancies, the weight of evidence in the literature suggests that uterine fibroids are associated
with and increased rate of spontaneous miscarriage, preterm labor, plasenta abruption,
malpresentation, labor dystocia, cesarean delivery, and post partum hemorrage.
Based on World Health research Organisatioan (WHO) the cause of maternal mortality
due to uterine myoma in the year 2010 as many as 22 cases (1.95%) and year 2011 as many as
21 cases (2.04%) on all treated obstetric patients. Mioma uteri more commonly found in black
women compared with white women. In Indonesia, the incidence of uterine myoma is found
from 2.39 to 11.7% in all gynecologically treated patients. The number of incidents of this
disease in Indonesia ranks second after cervical cancer. Rarely, myoma is found in women aged
20 years, at most at the age of 35-45 years (approximately 25%).
Myoma are classified base on their location and direction of growth (subserosal myoma,
pedunculated myoma, parasitic myoma, intramural myoma, and submucous myoma). At times,
a subserous myoma becomes parasitic and derives its blood supply through the highly
vascularized omentum.
Treatment in pregnancy is treatment of symptomatic myomas consist of analgesia and
observation. Surgery is rarely necessary during pregnancy. The modality that we can use to
treat this disase is drug therapy (Nonsteroidal Anti-Inflamatory Drugs, Hormonal Therapy,
Androgens, GnRH Agonist, Antiprogestins and GnRH Antagonis), Uterine Artery
Embolization (UAE), and surgical management (Hysterectomy and Myomectomy).

2
 CHAPTER II
CASE REPORT

2.1. Patients Identity

Name : Mrs. A
Date of birth / Age : May, 3-1983 / 34 years-old
Nationality : Indonesian
Address : Kp. Cibuntu Sukaraja
Marital status : Married
Occupation : Housewife
Religion : Moslem
Date of admission : September 8, 2017
Date of examination : September 11, 2017

Husband Identity
Name : Mr. Solehudin
Age : 47 years-old
Nationality : Indonesian
Address : Kp. Cibuntu Sukaraja
Occupation : Driver
Religion : Moslem

2.2. History Taking

Chief Complaint
The patient is pregnant at term with high blood presure and intrauterine mass.

History of Present Illness

Patient G1P0A0 was referred by the midwife because of her high blood pressure
and the patient did physical and ultrasonography examination.
The patient had not felt any uterine contraction, abdominal pain, or bleeding
from her vagina. History of fluid coming out from birth canal was denied. She did not
have any history of curettage or surgery on her uterus.
During this pregnancy, patient did not feel the presence of any abnormal mass
or pain in the abdomen. She also had a 7-15 days menstrual cycle, but she always feel
dysmenorrhea during each menstruation period. She also had a history of irregular
bowel habits for the past nine months.

History of Past Illnesses

History of chronic hypertension : denied
History of trauma : denied
History of diabetes mellitus : denied
History of asthma : denied
History of allergy : denied

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 History of surgery : denied

Familial History
History of hypertension : denied
History of asthma : denied
History of diabetes mellitus : denied
History of allergy : denied

Menstruation History
Menarche :14 years old
Menstrual cycle : regularly, 28 days of cycle, 7 to 10 days
duration, with dysmenorrhea
Amount of menstrual blood : 3-4 normal pads / day ( 60 cc )
LMP : January 15- 2017

Contraception History
She doesnt took any contraception since first married.

Antenatal Care
Patient has a routine antenatal care once a month to Puskesmas Sukaraja during this
pregnancy. The patient already got her third TT injection and SF supplement during this
pregnancy.

Marital History
Married twice, she has been married for two years.

Obstetric History
Gestational Labor Birth
No Date Age Sex ASI
Age History Weight
1. 2017 This 32-33
Pregnancy weeks

2.3. Physical Examination

General condition : mildly ill appearance
Consciousness : compos mentis
Blood pressure : 170/90 mmHg
Heart rate : 95 bpm
Respiratory rate : 22x/minute
Temperature : 36,5C
Weight before pregnancy : 66 kg
Weight after pregnancy : 72 kg
Height : 156 cm
BMI : 27,12 kg/m2 (overweight)

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General Examination
Eyes : anemic conjunctiva -/-, icteric sclera -/-, edema palpebra -/-
Mouth : wet oral mucosa membrane
Neck : thyroid enlargement (-), trachea is in the middle
Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in breathing
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, ronchi -/-, wheezing -/-
Mammae : hyperpigmentation of areola +/+
Nipple retraction -/-
Breast milk -/-
Abdomen
Inspection : convex, striae gravidarum +, linea nigra +
Auscultation : bowel sound +, 7 times/minute
Extremities : warm, edema -/-/-/-, CRT < 2 seconds

Obestetric Examination
Inspection : convex
Palpation :
Leopold Manuver
Leopold 1 : soft and not fully rounded part was palpated
Leopold 2 : wide and flat part is at the maternal right lower side
Leopold 3 : hard and round part was palpated
Leopold 4 : convergen as the lowest part of fetus
Fetal heart rate : 133x/minute
Fundal height : 27 cm
HIS :-

Gynecologic Examination
Abdomen
Inpection : convex, linea nigra (+), striae gravidarum (+)
Auscultation : bowel sounds (+), 8x/minute
Palpation : feel difficult to palpate, tenderness (-)
Percussion : not done

Genital
Inspection of vulvae : normal
Inspeculo : not done
Vaginal Toucher :

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 - Vaginal vulvae : within normal limit
- Portio : thick and soft, no dilatation, no pain during palpation
- Adnexa and parametrium : within normal limit

2.4 Laboratory (September - 8 - 2017)

Types Results Units Normal Value

Hematology
Hemoglobin 8.9 g/dL 12 16
Hematocrit 28 % 37-47
Leucocytes 6.300 /uL 4000 10000
Platelets 300 Thousands/uL 150000-450000
Eritrocyte 4.0 Millions/ uL 3.8-5.2
BT 2.00 Minutes 1-3
CT 7.30 Minutes 5-15
Imuniserology
HIV qualitative Non reactive Non reactive

Macroscopic Urine
Color Yellow Yellow
Clarity Clear Clear
pH 6.0 4.6-8.0
Specific weight 1.020 1.005-1.03
Leukocyte Negative Cells/uL Negative
Nitrite Negative Negative
Protein Positive (++) Mg/dL Negative
Glucose Negative Mg/dL Negative
Keton Negative Mg/dL Negative
Urobilinogen Normal Mg/dL <1
Bilirubin Negative Negative
Eritrocyte Negative Cells/uL Negative

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 Microscopic Urine
Leukocyte 1-3 /LPB <6
Eritrocyte 2-4 /LPB <3
Epithel Pos (+) /LPK 1-15
Cylinder Negative /LPB Negative
Crystal Negative /LPB Negative
Bacteria Negative /LPK Negative
Others Negative Negative

2.5. USG examination (August 22nd 2017)

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USG result

- Fetal Weight : 29 weeks pragnancy

- Plasenta in anterior
- Normal amniotic fluid
- There is a solid mass in the fundus uterine with size 9 cm
- There is a hyperekoic dominant complex mass with firm borders

Fibroid
Plasenta

Pragnancy

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2.6. CTG examination

Baseline : 120-130 bpm

Variability : moderate
Acceleration : (+)
Deceleration : (-)
His : (-)
Interpretation : reaktif

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2.7. Working Diagnosis
Mrs. A, G1P0A0, 34 years old, 32-33 weeks of gestation with severe preeclamsia and fibroid
uterine.

2.8. Management
Conservative care
Loading dose 4 gr MgSo4 in 100 cc RL
Maintanance dose 10 gr MgSO4 in 500 c RL
Dopamet 3 x 500 mg po
Nifedipine 3 x 10 mg po

2.9. Follow Up

Date Subjective Objective Assessment Planning

08/09 Patient said General condition : G1P0A0 observation of
/2017 that not felt any mildly ill gravida 33-34 major complaints
12.00 uterine Level of consciousness: weeks with and vital signs
contraction, CM PEB and observation of the
abdominal pain, Vital Sign : myoma fetal heartbeat and
or bleeding Blood Pressure : 170/90 uterine his
from her mmHg Dexamethasone 2x5
vagina. Fetal Heart Rate : 90x/minute mg IM
movement is Respiratory Rate : 21x/ Dopamet 3x500 mg
still felt. minute IVFD RL 20 dpm
Dizziness, pain Body Temperature :
epigastrium, 36,1C
blurred vision, Abdomen :
vomit and Leopold 1 : soft and
nausea was not fully rounded part
denied.
was palpated
Leopold 2 : wide and
flat part is at the
maternal right lower
side
Leopold 3 : hard and
round part was palpated

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 Leopold 4 : convergen
as the lowest part of
fetus
Fundal height : 27 cm

09/08 Patient feel General condition : G1P0A0 observation of

/2017 dizzy mildly ill gravida 33-34 major complaints
Level of consciousness: weeks with and vital signs
CM PEB and observation of the
Vital Sign : myoma fetal heartbeat and
Blood Pressure : 130/90 uterine his
mmHg Dexamethasone 2x5
Heart Rate : 82x/minute mg IM
Respiratory Rate : 20x/ Dopamet 3x500 mg
minute IVFD RL 20 dpm
Body Temperature :
36,5C
Abdomen :
Leopold 1 : soft and
not fully rounded part
was palpated
Leopold 2 : wide and
flat part is at the
maternal right lower
side
Leopold 3 : hard and
round part was palpated
Leopold 4 : convergen
as the lowest part of
fetus
Fundal height : 27 cm

10/08 Patient feel General condition : G1P0A0 observation of

/2017 dizzy mildly ill gravida 33-34 major complaints
Level of consciousness: weeks with and vital signs
CM PEB and observation of the
Vital Sign : myoma fetal heartbeat and
uterine his

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 Blood Pressure : 120/90 Dexamethasone 2x5
mmHg mg IM
Heart Rate : 80x/minute Dopamet 3x500 mg
Respiratory Rate : 20x/ IVFD RL 20 dpm
minute
Body Temperature :
36,5C
Abdomen :
Leopold 1 : soft and
not fully rounded part
was palpated
Leopold 2 : wide and
flat part is at the
maternal right lower
side
Leopold 3 : hard and
round part was palpated
Leopold 4 : convergen
as the lowest part of
fetus
Fundal height : 27 cm

2.7. Prognosis
Quo ad vitam : bonam
Quo ad functionam : bonam
Quo ad sanationam : bonam

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 CHAPTER III
CASE ANALYSIS

3.1. Problems

1. How to Diagnose uterine fibroid in pragnancy ?

Theory Case
History Taking History Taking
1. Menstrual abnormalities, including 1. Patient complained about menstrual
menorrhagia. cycle 7 to 10 days duration, with
2. Pelvic pain and pressure dysmenorrhea.
3. Abdominal pain 2. Patient doesnt complain about
4. Urinary tract obstruction pelvic pain and pressure
5. Constipation 3. Patient doesnt complain about
6. Smoking abdominal pain
7. Family history of uterine fibroid tumors 4. There was no history of urinary track
8. Nulliparity obtraction
9. Obesity 5. Patient complain about of irregular
10. Prolonged use of oral contraceptives bowel habits for the past nine
months.
6. Patient doesnt smoking
7. There was no history of family with
fibroid uterine
8. This time is first pregnancy
9. Patient doesnt took any
contraception since first married

Theory
Physical Examination
1. Abdominal Exemination :
- There is a mass palpated with soft
consistecy, firm border, irregular
contour, and mostly multiple.
Case
Physical Examination
1. Abdominal Exemination :
- There was no mass palpated in
the abdomen

Digital Exemination Digital Exemination

The sonographic appearance of mioma vary The Sonographic appearances there is a

from hypo- to hyperechoic depending on the solid mass in the fundus uterine with size 9
ratio of smooth muscle to connective tissue and cm.
whether there is degeneration. Calcification and

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 cystic degeneration create the most
sonographycally distinctive.

2. What is the effect of pregnancy on uterine fibroids ?

The stimulatory effect on pregnancy on the growth of uterine fibroid is sometimes quite
impressive. The tumors diffrently in individual women, accurate prediction of their growth
is not possible.
During first trimester, fibroid of all size either remained unchanged or increase in size
a possible early response to increased estrogen. During the second trimester, smaller fibroid
usually remained unchaged or increased in size, whereas those larger than 6 cm became
smaller probably form initiation of estrogen receptor downregulation. Regadless on initial
fibroid size, during the third trimester, fibroid usually remained unchaged or decreased,
reflecting estrogen receptor downregulation.

Increases in size due to increased vascularity, edema, and hypertrophy and

hyperplasia of the fibromuscular tissues.
Changes in positition
Changes in shape becomme flattened
Degenerative changes, especially red regeneration
Torsion of pedunculated subserous fibroid

3. What is the effect of uterine fibroids on pregnancy ?

The two factors most important on determining morbidity in pregnancy are leiomyoma
size and location. The proximity of myoma to the placental implantation site is also a factor.
Specifically abortion, preterm labour, placental abruption and post partum hemorrhage all are
increased if the placenta is adjacent or implanted over a leiomyoma. Common causes for
spontaneous abortion are disturbances in blood flow, alterations in blood supply to the
endometrium, uterine irritability, rapid growth or degeneration of leiomyoma. Poor placentation
and mechanical obstruction to fetal growth account for pregnancy loss (abortion, preterm
delivery, still birth) and IUGR.

First and Second Trimester

Miscarriage
- The size of the fibroid does not affect the rate of miscarriage but multiple fibroid
may increase the miscariage rate compared with the single fibroid only.
- The location of fibroid, early miscarriage is more common in women with
fibroid located in the uterine corpus than in the lower uterine segmen.

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 Bleeding
- The location of fibroid determines the risk of bleeding
- More common if the plasenta implants close to the fibroid compared with
pregnancy in which there is no contact between the plasenta and fibroid.

Third Trimester
Plasental Abruption
- One possible mechanism of placental abruption may be diminished blood flow
to the fibroid and the adjacent tissues which results in partial ischemia and
decidual necrosis in the placental tissues overlaying the leiomyoma.
Plasenta Previa

Labor

Mother Fetus
Malpresentation IUGR
Labor distosia Preterm Labor and prematurity
Non-engagement of the presenting
part
Uterine inertia
Cervical or board ligament fibroid
Fibroid not pulled up above the
presenting part during labor
Obstructed labor
Cesarean delivery

Postpartum
Postpartum hemorrhage
- Fibroids may distort the uterine architecture and interfere with myometrial
contractions leading to uterine atony and postpartum hemorrhage. This same
mechanism may also explain why women with fibroids are at increased risk of
puerperal hysterectomy
- Incidence of postpartum hemorrhage is high and is due to decrease of force of
uterine contractions because of fibroids in myometrium or because of disruption
of the coordinated spread of contractile wave, there by leading to dysfunctional
labour.
Retained placenta,
- was more common in women with fibroids, but only if the fibroid was located
in the lower uterine segment.
Subinvolution

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 4. What is the management in this case ?

During Pregnancy
Patient with uterine fibroid during pregnancy is usually managed conservatively by bed
rest, hydration, and analgesics. Usual antenatal care is followed. Prostaglandin synthase
inhibitors (eg, nonsteroidal anti-inflammatory drugs) should be used with caution, especially
prolonged use (> 48 hours) in the third trimester where it has been associated with both fetal
and neonatal adverse effects, including premature closure of the fetal ductus arteriosus,
pulmonary hypertension, necrotizing enterocolitis, intracranial hemorrhage, or
oligohydramnios.
Place of myomectomy:
Myomectomy is generally contraindicated in pregnancy. During intrapartum period
elective myomectomy is strongly discouraged due to increased risk of hemorrhage, unless the
presence of fibroid making adequate closure of the uterine incision impossible. Caesarean
hysterectomy may be considered if there are multiple fibroids and the women has completed
her family but is associated with increased morbidity and reserved for emergency situations
only.
- Myomectomy for a case with intramural myoma during pregnancy or during cesarean
delivery cause profuse hemorrhage. Few case of successful surgery have been
currently reported though.
- Myomectomy at the time of cesarean delivery should only be performed if unavoidable
to facilitate safe delivery of the fetus or closure of the hysterotomy. Pedunculated
subserosal fibroids can also be safely removed at the time of cesarean delivery without
increasing the risk of hemorrhage.

In this case, the management for this patient is conservative care. Patients get treatment for
her blood high pressure and hydration. Because patient is not have a sign of pain or something
harm so this patient only get blood high pressure and hydration treatment. And the patient is
recommended for control a week after going home.

During Delivery

Fibroid situated above the pressenting part usually result in uneventful vaginal delivery.
Fibroid situated below the presenting part-spontaneous vaginal delivery may occur. If it
fails, cesarean section is to be done.
Many studies show that having uterine fibroids increase your odds of having a cesarean section.
That could be because the fibroids can keep the uterus from contracting and they can also block
your birth canal, slowing down the progress of your labor. Women who have fibroids are six
times more likely than other women to need a C-section.

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 CHAPTER IV
CONCLUSION

1. This Patient Mrs. A, G1P0A0, 34 years old, 32-33 weeks of gestation with severe preeclamsia
and fibroid uterine. Patient was referred by the midwife because of her high blood pressure.
During this pregnancy, patient did not feel the presence of any abnormal mass or pain in the
abdomen. She also had a 7-15 days menstrual cycle, but she always feel dysmenorrhea during
each menstruation period. She also had a history of irregular bowel habits for the past nine
months. In abdominal examination there was no mass palpated in the abdomen.
In obstetrical examination there is single fetus intrauterine with head presentation, with fundal
height 27 cm. Ultrasonography examination result plasenta is in anterior, normal amniotic fluid,
there is a hyperekoic dominant complex mass with firm borders and a solid mass in the fundus
uterine with size 9 cm.
2. During first trimester, fibroid of all size either remained unchanged or increase in size a possible
early response to increased estrogen. During the second trimester, smaller fibroid usually
remained unchaged or increased in size, whereas those larger than 6 cm became smaller
probably form initiation of estrogen receptor downregulation. Regadless on initial fibroid size,
during the third trimester, fibroid usually remained unchaged or decreased, reflecting estrogen
receptor downregulation.
3. The two factors most important on determining morbidity in pregnancy are fibroid size and
location. The proximity of myoma to the placental implantation site is also a factor. Specifically
abortion, preterm labour, placental abruption and post partum hemorrhage all are increased if
the placenta is adjacent or implanted over a fibroid. Common causes for spontaneous abortion
are disturbances in blood flow, alterations in blood supply to the endometrium, uterine
irritability, rapid growth or degeneration of leiomyoma. Poor placentation and mechanical
obstruction to fetal growth account for pregnancy loss (abortion, preterm delivery, still birth)
and IUGR.
4. In this case the management for this patient is conservative care. Patients get treatment for her
blood high pressure and hydration. Because patient is not have a sign of pain or something harm
so this patient only get blood high pressure and hydration treatment. And the patient is
recommended for control a week after going home.

17
 REFERENCES

1. Annachiara Basso, Mariana Rita Catalano, Giuseppe Loverro, Serena Nocera, et al.
Uterine Fibroid Torsion during Pregnancy: A Case of Laparotomic Myomectomy at 18
Weeks Gestation with Systematic Review of the Literature.

2. Hee Joong Lee, MD, PhD, Errol R Norwitz, MD, PhD, and Julia Shaw, MD, MBA.
Contemporary Management of Fibroids in Pregnancy. Int J Fertil Steril. 2016 Jan-
Mar; 9(4): 424435.
3. SOGC Clinical Practice Guideline. The Management of Uterine Leiomyomas. J Obstet
Gynaecol Can 2015;37(2):157178

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