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Management of uterine fibroids in pregnancy

Article  in  Current opinion in obstetrics & gynecology · October 2015

DOI: 10.1097/GCO.0000000000000220

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REVIEW

CURRENT
OPINION Management of uterine fibroids in pregnancy:
recent trends
Salvatore G. Vitale a, Francesco Padula b, and Ferdinando A. Gulino a

Purpose of review
The review analyzes how fibroids may influence pregnancy and how myomas may be modified by
pregnancy. The most important clinical aspect concerns the impact of myoma on pregnancy and the
possibility of a well tolerated surgical treatment for the mother and her fetus, preserving maternal
reproductive capacity.
Recent findings
Fibroids significantly increase in size during early pregnancy and then decrease in the third trimester.
Although most women with uterine fibroids have a regular pregnancy, data from the literature suggest that
they may have a higher risk of fertility problems and pregnancy complications.
Summary
Myomectomy can increase the rate of pregnancy in women with infertility, attempting to restore a normal
anatomy and reduce uterine contractility and local inflammation associated with the presence of fibroids,
improving the blood supply.
Current evidence does not suggest routine myomectomy during pregnancy or at the cesarean birth, as
fibroids-related complications are rare and may be overcome by the risks of surgery. However, in selected
cases, myomectomy is a feasible and safe technique and associated to a good outcome.
The diagnosis of myomas in pregnancy may require attention for the adequate management to preserve
maternal and fetal well-being.
Keywords
fibroid, myoma, myomectomy, outcome, pregnancy

INTRODUCTION fibromatosis in pregnancy may require attention

Fibroid, myoma, and leiomyoma are synonymous to
define the most common benign solid tumor of the
female genital tract, whose prevalence increases
with age, peaking in women in their 40s. The exact
incidence is difficult to calculate, as they may be
asymptomatic and diagnosed only incidentally.
However, up to 50% that are asymptomatic may
have significant social and economic impact, and
may affect women’s quality of life negatively [1 ].
&&
Clinical symptoms include menstrual abnormal-
ities, anemia, bladder dysfunction, pelvic pain,
and fertility problems.
Although most women with uterine fibroids
have a regular pregnancy, data from the literature
suggest that they are associated with a higher risk of
spontaneous miscarriage, preterm labor, placental
abruption, premature rupture of membranes, fetal
malpresentation, labor dystocia, cesarean delivery,
and postpartum hemorrhage and hysterectomy
&&
[1 ,2]. In this setting, the diagnosis of uterine
for the adequate management.
The review aims to focus on how fibroids may
influence pregnancy and how they are influenced
by pregnancy.
DOES PREGNANCY INFLUENCE
MYOMAS?
Myomas are benign monoclonal tumors arising
from the uterine smooth muscle tissue with variable
molecular features, so that each fibroid has its own
a
Department of General Surgery and Medical Surgical Specialties,
University of Catania, Catania and bAltamedica, Fetal-Maternal Medical
Centre, Department of Prenatal Diagnosis, Rome, Italy
Correspondence to Salvatore G. Vitale, MD, Via Santa Sofia 78, 95123
Catania, Italy. Tel: +39 3479354575; fax: +39 0953781326;
e-mail: vitalesalvatore@hotmail.com
Curr Opin Obstet Gynecol 2015, 27:432–437
DOI:10.1097/GCO.0000000000000220

www.co-obgyn.com Volume 27  Number 6  December 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Fibroids significantly increase in size during early
pregnancy and then decrease in the third trimester.
 Women with uterine myomas may have a higher risk of
fertility problems and pregnancy complications,
although most of them have normal pregnancy
outcome.
 Routine myomectomy during pregnancy or cesarean
birth, even a safe and feasible procedure, is not
suggested, but reserved to rare cases.
 Uterine rupture during pregnancy after myomectomy is
rare and should not systematically preclude a trial of
vaginal delivery; a waiting period of about 12 months
between myomectomy and subsequent pregnancy
would allow for optimal tissue repair of
the myometrium.
intrinsic growth rate independent from its size and
localization. In fact, within the same woman, they
might show different growth rates [3–5].
The precise etiopathology of uterine fibroids is
still unclear, although, as they are characterized by a
greater concentration of estrogen and progesterone
receptors than adjacent myometrium, the key role
of ovarian hormones is widely accepted. Indeed, the
increased frequency and severity of myomas
because of a large exposition to steroid hormones
(early menarche [6], pregnancy and perimenopause,
and overweight and obese women [7,8]) and the
reduced growth in menopause, clearly denote their
&&
estrogen dependence [3,9 ,10]. Conflicting data
exist about the role of oral contraceptives on the
growth of fibroids, maybe because of the different
content and types of hormones in each formulation
[3].
Genetic and epigenetic mechanisms reflecting
for example on a positive family history for myomas
and other predisposing risk factors, such as different
hormonal metabolism, or environmental factors,
&&
such as diet [11], are important too [12,13 ]. Cyto-
genetic anomalies are observed in about 40% of
uterine fibroids [14], including genes that are
involved in cellular and extracellular modulation
and proliferation [3,15].
Myomas are more frequent in African-American
women than white and Asian women, who show
differences in their circulating serum estrogens
&
[16 ,17–19].
Thus, although estimated around 1.6–10.7%
[20], the exact incidence of myomas in pregnancy
is not easily calculable, depending not only on all
the above-mentioned risk factors, but also on the
different gestational ages at the ultrasound scan.
1040-872X Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Management of uterine fibroids in pregnancy Vitale et al.
&&
Data from the literature [9 ] suggest that the
growth of fibroids during pregnancy is not directly
related to only increase of serum estrogen, as myo-
mas significantly increase during early pregnancy,
in particular doubling within 6–7 weeks’ gestation,
when estrogen and progesterone are still low. Then,
after a phase of deceleration in their growth in the
second half of pregnancy, they decrease in size in
the third trimester.
It seems rather that hypertrophy and hyperpla-
sia of myometrial cells is because of a series of
hormones, cytokines, and growth factors produced
by the fetoplacental unit through direct and indirect
mechanisms [11], whereas estrogen is considered
the primary growth promoter of myomas and pro-
gesterone should be involved in their maintenance
&&
and growth [21 ,22,23].
Finally, during pregnancy, myomas are some-
times complicated with secondary changes, such as
hemorrhage, necrosis, and degeneration that, histo-
logically, may represent a major diagnostic concern
towards the rare leiomyosarcoma [1 ].
&&
Ultrasonographic evaluation before and during
pregnancy is the best tool to determine not only the
size, but also the number, location, and ultrasound
features of myoma, its relationship with the area of
placental insertion, and its vascularization.
DOES MYOMA INFLUENCE PREGNANCY?
It is commonly believed that submucosal or intra-
mural myomas are the main cause of impaired
fertility and may limit uterine expansion during
pregnancy. Diffuse uterine myomatosis in preg-
nancy is a rare occurrence, with a prevalence of
0.1–3.9% [24], as it is rather associated with signifi-
cant infertility, low pregnancy and implantation
rates after in-vitro fertilization treatments [25],
&&
and miscarriage complications [21 ]. Uterine myo-
mas are considered to be the unique cause of infer-
tility in 1–3% of women, may contribute to
infertility in 5–10% [26], and are involved in 7%
of recurrent spontaneous abortions [27 ,28].
&&
Myomectomy can increase the rate of preg-
nancy in women with infertility [29] since the
surgery attempts to restore a normal anatomy,
reduce uterine contractility [30,31] and local inflam-
mation associated with the presence of fibroids
[32,33], improving the blood supply. However, even
the precise mechanisms are not still clear.
Myomectomy can be performed through
laparoscopic or laparotomic techniques [34–39].
Basically, skilled surgeons should prefer the less
invasive approach as it is associated to a reduced
hospitalization and less intra and postoperative
complications, including adhesions, bleeding, and
www.co-obgyn.com 433
Women’s health
pain. However, the two approaches do not show
significant difference in pregnancy rates (55.9%
with abdominal myomectomy vs. 53.6% with
laparoscopic myomectomy) or abortion rates (12
vs. 20%) in women with large myomas [40].
A laparotomic approach is preferred in cases of
large subserosal fibroids or multiple myomas (more
than five), and the pregnancy rate after laparotomic
myomectomy is around 54–78.9%, with a 12–22%
miscarriage rate [41].
However, only myomectomy of submucosal
myomas significantly increases the pregnancy rate
[42], in particular after hysteroscopic myomectomy,
that is associated to a low risk of uterine rupture
during pregnancy and vaginal delivery.
Recently, robot-assisted laparoscopic myomec-
tomy showed similar pregnancy outcome to
traditional laparoscopy, and it may be applied suc-
cessfully in myomas considered more difficult to
remove laparoscopically, ensuring the advantages
of a minimally invasive approach [43]. However,
this technique should be reserved only to selected
cases and performed by skilled surgeons, also con-
sidering the higher costs.
Regardless of the surgical approach, the recur-
rence rate of myoma is 15% and it is associated with
young age of treatment, preoperative number of
fibroids, uterine size, and childbirth after myomec-
&& &
tomy [1 ,44,45 ].
The rare uterine rupture during pregnancy
after myomectomy, estimated 0.2% in abdominal
approach and 0.26% in laparoscopy, could be
related to the absence of multilayer myometrial
closure, or to the excessive use of electrosurgical
&&
energy [27 ,39,46,47]. However, it should not sys-
tematically preclude a trial of vaginal delivery; a
waiting period of about 12 months between myo-
mectomy and subsequent pregnancy would allow
for optimal tissue repair of the myometrium [48,49].
However, in selected cases, it is possible to shorten
this interval, preferably also administering oral con-
&&
traceptives after myomectomy [1 ].
Pregnancy with myomas is at a higher risk for
obstetric complications than pregnancy without
&
myomas [50 ,51,52].
The rate of spontaneous miscarriage has been
investigated by several authors, accounting for
about two-fold increase [odds ratio (OR) 1.6; 95%
confidence interval (CI), 1.3–2.0] [53]. Even the
intrinsic risk for pregnancy loss in the first trimester
may overestimate the exact number of fibroids-
related fetal loss.
Submucosal and small myomas (<3 cm) increase
the risk of spontaneous miscarriage slightly, whereas
subserosal or intramural larger myomas do not
increase the risk of pregnancy loss [54].
434 www.co-obgyn.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
In the second trimester of pregnancy, uterine
myomas do not modify the rate of complications
after amniocentesis [55].
Myomas have been associated with an increased
risk for fetal malpresentation (OR 2.9; 95% CI,
2.6–3.2), cesarean birth (OR 3.7; 95% CI, 3.5–3.9),
preterm delivery (OR 1.5; 95% CI, 1.3–1.7) especially
for subserous and submucosal fibroids, premature
rupture of membranes, pelvic pain, placental abrupt-
ion, dysfunctional birth, dystocia, and postpartum
&&
hemorrhage [1 ,56–60].
Some of these complications are primarily
related to the location of the myoma (e.g., placental
abruption when a submucous leiomyoma is located
beneath a placental site), whereas others can be
related to its size (e.g., dystocia, dysfunctional birth)
&
[61 ]. Indirectly, fibroid location and size may fur-
ther increase the rate of cesarean birth, affecting
uterine vascular and contractile activity.
Most myomas in pregnancy are asymptomatic,
whereas the remaining have symptoms depending
&
on their number, size, and location [61 ].
Myomectomy in pregnant women is a very
uncommon practice, except for symptomatic
pedunculated fibroids, especially in the first half
of pregnancy.
However, some studies have described a good
outcome if myomectomy was performed in the first
and second trimester of pregnancy, particularly if
the myoma did not enter into the uterine cavity
&&
[3,20,27 ,62–70]. Major concerns relate to the
higher risks of uncontrollable bleeding, uterine
atony, hysterectomy [56], pregnancy injury and/or
pregnancy loss, formation of postsurgical uterus-
intestinal adhesions, and the possibility of recur-
rence with time.
However, myomectomy in pregnancy can be
considered as an option for selected cases. Urgent
myomectomy is related mainly to a torsion of a
pedunculated myoma or to rare cases of necrosis
and consequent inflammatory peritoneal reaction
[71].
In some cases [72,73], a pedunculated myoma
could lead to a complete axial torsion of all the
pregnant uterus, with subsequent massive abrupt-
ion and shock.
Spontaneous rupture of a degenerated fibroid
and bleeding are other uncommon conditions,
which need an urgent operation in pregnancy
[74,75].
Other indications for myomectomy in preg-
nancy are recurrent or severe pain, which have failed
to be treated by conservative management after the
first trimester, rapid growth of myoma, large fibroids
located in the lower uterine segment or if they
deform the placentation site, and large fibroid
Volume 27  Number 6  December 2015

causing compression phenomena with intestinal
obstruction or subobstruction.
Absolute contraindications to myomectomy are
uterine atony, intramural nodules growing and
expanding toward the uterine cavity, or displacing
large vessels.
Most of the studies in the literature report a
preference of the laparoscopic approach for the
treatment of fibroids in pregnancy.
The optimal technique for initial access is an
open technique and the site of entry is chosen
according to the fundal height [76]. The main
concern regarding Veress needle technique is
represented by the higher probability of damage to
the uterus or other intra-abdominal organs as fundal
height increases. It is recommended to place the
woman in the left lateral recumbed position. Pneu-
moperitoneum should not exceed 10–15 mmHg.
Monopolar energy should never be used and bipolar
energy should be applied only if strictly necessary.
Uterine mobilization is obviously limited and should
be avoided. Myoma morcellation should be very
careful [77].
Myomectomy during cesarean section is still
controversial, even though a well tolerated and
&
feasible procedure [20,61 ,78–83]. Routine myo-
mectomy should be abandoned, but it could be
considered only in selected patients with careful
consideration of different factors: uterine contrac-
tion, size, number, and location of myomas in com-
parison with large vessels and presence of placenta
accreta/increta. Routine myomectomy has to be
executed only if unavoidable to facilitate safe deliv-
ery of the fetus or closure of the uterine breach.
Pedunculated subserosal fibroids could also be safely
carried out at cesarean birth without increasing the
risk of hemorrhage. Particularly, the experience of
the surgeon and the presence of a tertiary center
have to be considered, because a correct myomec-
tomy during cesarean birth requires special tech-
nical care about incision orientation, recognition
and preparation of cleavage plain, hemostasis, and
sutures.
The advantage of cesarean myomectomy is that
it avoids the need for interval myomectomy and
decreases the risk of complications associated with
fibroids in successive pregnancies. Cesarean myo-
mectomy also increases the possibilities of vaginal
delivery in subsequent pregnancies when removed
from the lower uterine segment [84].
CONCLUSION
Although a majority of women with uterine myo-
mas will have normal pregnancy outcomes, data
from the literature suggest that they may have a
1040-872X Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Management of uterine fibroids in pregnancy Vitale et al.
higher risk of fertility problems and pregnancy com-
plications, when comparing women with and with-
out myoma. Current evidence does not suggest
routine myomectomy during pregnancy as well as
during cesarean birth, as these complications are
rare and may be overcome by the risks associated
with surgery. Minimally invasive myomectomy
should be reserved to selected cases, and it is associ-
ated to a good outcome.
In our opinion, further studies should focus on
primary prevention of fibroids, and on new medical
and surgically minimal invasive options, thus reduc-
ing the recurrence rate, and better preserving
maternal and fetal well-being.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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