Jaideep M Palwade¹, Charushila S Borole^2*

¹Associate Professor, Department of OBGY, Vedantaa Institute of Medical Sciences, Palghar, Maharashtra, INDIA.

²Assistant Professor, Department of OBGY, Ulhas Patil Medical College & Hospital, Bhusawal Road, Jalgaon, Maharashtra, INDIA.

Email: palwadejaideep@gmail.com

RESULTS

76 pregnant women with fibroid during pregnancy were studied. Majority of patients were from 26 -30 years age group (44.74 %) followed by 31-35 years age group (27.63 %). Majority of patients were gravida 2-3 (43.42 %).

Table 1: Demographic variables

We noted that majority of patients had subserous fibroids (68.42 %). located at fundus region (73.68 %), had 2-3 fibroids on USG examination (47.37 %).

Table 2: Features of uterine fibroids

In present study, majority of cases were reached up to term (89.48 %), 3 cases aborted (3.95 %), 2 cases delivered between 21-32 weeks (2.63 %) while 3 cases delivered between 33-37 weeks (3.95 %). Caesarean section (71.05 %) was most common Mode of Delivery followed by vaginal delivery (19.74 %). Hysterotomy was required in 3 cases (3.95%) while 1 case underwent suction and evacuation. PROM with poor Bishop score (20.37%), Placenta previa (18.52%), Uterine inertia (18.52%) and Fetal distress (16.67%) were common indications for caesarean section.

Table 3: Obstetric outcome

60.53 % patients were asymptomatic throughout pregnancy, other common complications noted were threatened preterm labour (15.79 %), blood transfusion (14.47 %), postpartum hemorrhage (9.21 %), antepartum bleeding (7.89 %), threatened miscarriage (5.26 %).

Table 4: Complication during pregnancy (n=50

Low APGAR Score at 5 min (10.53 %), Required resuscitation (10.53 %), Required NICU admission (17.11 %), Low birth weight (5.26 %) were common complications noted. Fetal outcome was abortion (3.95 %), fresh stillborn (1.32 %) and neonatal death (1.32 %).

Table 5: Fetal Outcome

DISCUSSION

The incidence of uterine fibroids in pregnancy would likely increase globally due to delay in childbearing which is more prevalent now due to different factors. The two most important factors which determines morbidity in pregnancy are leiomyoma size and its location.¹⁰ The proximity of myomas to the placental site is also a factor, especially abortion, preterm labor, placental abruption and post-partum hemorrhage; all are increased if the placenta is adjacent to or implanted over a leiomyoma. On the other hand, tumor in the cervix or lower uterine segment may obstruct labor. Malpresentations, especially breech presentations are reported to be high and the size and location of leiomyoma might predict the magnitude of the risk.^11,12 The absence of multilayer closure in cases of deep intramural leiomyoma or to the injudicious use of electrosurgical energy during myomectomy has been reported to be a possible cause of uterine rupture during pregnancy.^13,14 Pullemalla SS¹⁵ studied 40 patients of 21 to 45 years with pregnancy with fibroid, 15 patients had threatened miscarriage, 12 had preterm labor, 2 had antepartum bleeding, 3 had abdominal pain needing admission, 2 had laparotomy due to pain, 1 had a postpartum hemorrhage and only one patient needed a blood transfusion. Spontaneous abortion was observed in 2 patients, premature delivery in 15, delivery at 37-41 weeks in 37, vaginal delivery in 5 patients and cesarean section in 44 patients. In a prospective study by Dasgupta A et al.,¹⁶ 15 patients with large fibroids (>5cm) complicating pregnancies, all underwent caesarean deliveries. 53% women were at 34 yrs of age, 87% women had a history of infertility. 46 % delivered prematurely. 13.33 % with the largest fibroids measuring up to 16 and 24 cm respectively needed prophylactic bilateral internal iliac artery ligation and myomectomy to deliver the baby but avoided caesarean hysterectomies. 60% women had fetal malpresentations. 60% had postpartum hemorrhage and 87 % needed blood transfusions. Posteriorly located cervical fibroids bled more than anterior cervical fibroids. Puerperal pyrexia was noted in 50% of the women with retained uterus. In study by Afzal A et al., with 85 patients, mean age of patients was 32.56 ± 4.3 years, primigravida was 27.05%, multigravida was 72.94%. Spontaneous conception was seen in 75.29 % and 24.70% used assisted reproductive treatment for conception. Spontaneous abortion was seen in 11.76%, premature delivery in 18.7%, and full term delivery in 81.3% Caesarean section was performed in 74.67 %of cases and normal vaginal delivery in 25.33 %. 12.9% had threatened miscarriage, 18.7 % had preterm labour, 5.3 % had antepartum bleeding due to placenta previa, 11(14.67%) had postpartum haemorrhage. Intramural location and multiple fibroids were associated with increased risk of caesarian section as compared to sub serosal fibroids and single fibroids. In a multicenter study by Zhao R et al.¹⁸, 112,403 women were studied, 3,012 (2.68%) women were identified with at least 1 fibroid. By univariate and multivariate analyses, the presence of uterine fibroids was significantly associated with cesarean delivery, breech presentation and postpartum hemorrhage. The size of uterine fibroids and location in uterus had important effect on the mode of delivery. The rates of PPH were significantly higher with increasing size of the uterine fibroid (P<0.001). And the location of fibroid (intramural, submucosal or subserosal) also have a statistically significant impact on the risk of PPH (5.6% [subserosal] vs 4.7% [submucosal] vs 8.6% [intramural]). Ciavattini A et al.,⁵ studied the impact of sonographically identified multiple or large (5 cm in diameter) fibroids on obstetric outcomes. The study was performed on 219 women with uterine fibroids. It was reported that compared to women with no fibroids, women with multiple fibroids (n = 34) had a significantly higher rate of preterm birth, cesarean section and breech presentation. Women with large fibroids (n = 48) had a higher rate of preterm birth and PPROM. Their study indicates that multiple rather than large fibroids are associated with a significantly increased risk of preterm birth and cesarean delivery while large fibroids are associated with a higher risk of PPROM. The treatment of fibroids in pregnancy is usually conservative. Myomectomy during pregnancy is controversial. The surgical management of uterine leiomyoma during pregnancy may be performed successfully in carefully selected patients, which seems to imp [rove pregnancy outcome.

CONCLUSION

Although most fibroids remain asymptomatic throughout the course of pregnancy, still pregnancies with fibroids are high risk pregnancies, associated with complications during antepartum, intrapartum, and postpartum period, also associated with increased incidence of cesarean delivery and PPH.

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