1. Uterine Leiomyomata in Pregnancy Ruth Stefanski, PGY-1 January 12, 2010 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  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  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.  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  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: …..  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?  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  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  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  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. Complications during Pregnancy  Pregnancy loss  Preterm labor and birth  Placental abruption  Placenta previa  Pain  Pregnancy loss  Preterm labor and birth  Placental abruption  Placenta previa  Pain  PPH  Dysfunctional labor  Malpresentation  Malposition  Cesarean delivery

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 (?)  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 (?)  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  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  Varying evidence  Decreased force of contractions  Asymmetric wave of contractile force across uterus

19. Malpresentation, Malposition  Consistent evidence  Distorted shape of uterine cavity  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  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  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 1.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 1.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 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 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 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  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  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.  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.