Uterine fibroid size modifications during pregnancy and puerperium: evidence from the first systematic review of literature

Uterine Leiomyomas and Reproduction

There is a prevailing opinion by gynecologists, much of it based on expert opinion or anecdotal evidence, that myomas are detrimental to pregnancy. Newer data challenge much of this dogma, but incorrect assumptions remain. Although not impeccable, multiple data address the correlation between myomas and reproduction, and some emerging evidence addresses surgical removal of these myomas and subsequent outcomes. A thorough literature search was performed, and the amassed data were analyzed to answer some of our most important queries about the role that myomas play in pregnancy and delivery. Uterine leiomyomas ultimately decrease in size during late pregnancy and postpartum. Spontaneous abortion rates are similar in women with and without leiomyomas. The data addressing leiomyoma effects on preterm prelabor rupture of membranes, placental abruption, cesarean delivery, and postpartum hemorrhage rates are conflicting, but the best evidence does not show a significant correlation compared with women without myomas. Preterm delivery rates are elevated in women with leiomyomas. Myomectomy does not decrease preterm deliveries and may increase this risk. Women with myomectomies have increased elective cesarean delivery rates and more blood loss at delivery compared with women with leiomyomas in situ.

The Impact of a Huge Fibroid on Pregnancy: A Case Report

Uterine fibroids are benign smooth muscle tumors of the uterus, are relatively common in reproductive-age women, and are associated with increasing maternal age. This case study details a 37-year-old female patient who was incidentally diagnosed with a larger lower segment fibroid during her first pregnancy scan and responded well to treatment, delivered by a cesarian due to transverse lie and lower uterine segment fibroid completely obstructing the birth canal.

Interdisciplinary co-teaching as a sustainable model for health humanities pedagogy

Academics and students from marginalised identities encounter challenges and barriers at all levels of participation in the settler colonial university, in both practices of teaching and learning. While this observation holds true for courses in the health humanities, their unique interdisciplinary position and context creates space for challenging dominant norms in society and in academia. In this paper, we describe our experiences as two black and queer graduate students developing and co-teaching an online interdisciplinary course, 'Race and Medicine'. The idea for co-teaching originated as a means of ensuring continuity and sustainability in the course (AvB was expecting her first child and contending with the possibility of unplanned preterm birth) and emerged into what we suggest, in line with the transformative pedagogical theory of bell hooks, was a micro-scale transgressive learning community. We argue that our co-teaching partnership facilitated practices of revealing, mitigating and disrupting oppressive structures in the white heteropatriarchal academy, in addition to offering unique learning opportunities for students. The intersections of difference and similarity between our disciplinary, professional and social identities transformed and enhanced the types of conversations and learning activities we held with the class and were a feature of the course which was rated highly in evaluations. We conclude by suggesting co-teaching as a possible model of sustainable pedagogy for the health humanities, one that is especially valuable for racialised graduate students who are developing professional identities as instructors and exploring careers in the health humanities. In addition to facilitating interdisciplinary student learning, co-teaching and the subsequent formation of micro-scale transgressive learning communities challenges the dominant power structures of the academy by making space for teaching and learning in the contexts of solidarity, care and sustainability.

Successful pregnancy outcome after sonographic control and gasless laparoscopic removal of 810-gram fibroid during pregnancy: case report

The management of symptomatic uterine fibroids during pregnancy is a challenging situation. In some cases, surgical therapy can be required. Reports indicate that both laparotomy and laparoscopy are safe methods. However, laparoscopy is associated with less morbidity. This paper describes the case of a 31-year-old woman with a symptomatic uterine fibroid which was removed by gasless laparoscopy.

Preterm birth and uterine fibroid necrosis: The clinical presentation illustrated in a case series

OBJECTIVE

Uterine fibroids increase the risk of preterm birth. The current study highlights uterine fibroid necrosis as a possible cause of (extreme) preterm birth.

STUDY DESIGN

Retrospective cohort study in one Dutch academic hospital. Cases were selected from the 526 participants of the MyoFert study (Netherlands Trial Register, NL7990), which included patients who presented between 2004 and 2018 and were between the age of 18 and 45 years at the time of diagnosis of uterine fibroids. Of these participants, 414 women became pregnant. A retrospective chart review of the first pregnancies was performed. The main outcomes were (imminent) preterm birth and signs of fibroid necrosis on ultrasound. In women with signs of fibroid necrosis, the following data were collected systematically: fibroid characteristics, clinical presentation, pregnancy outcome, and postpartum period.

RESULTS

In total, 66 women had a preterm birth (16 %, 66/414), of which 25 pregnancies ended between 16 and <24 weeks (38 %, 25/66) and 41 pregnancies ended between 24 and <37 weeks of gestation (62 %, 41/66). Of all women with preterm birth and available ultrasound images, 15 % (7/48) had fibroid necrosis at the time of labour. These seven patients, supplemented with three patients with fibroid necrosis during their first pregnancy and at least one episode of imminent preterm birth, are described in more detail. In these ten patients, the fibroids increased substantially in size during the first and second trimester, leading to severe abdominal pain in all patients and hospital admission in seven patients. Ultrasound examination of the fibroids showed heterogenic changes and focal transonic areas in the fibroid, which are characteristics that indicate fibroid necrosis. In four patients, myomectomy was performed and necrosis was confirmed histologically.

CONCLUSION

Fibroid necrosis during pregnancy is likely associated with (imminent) preterm birth. Clinicians are advised to structurally evaluate the myometrium in pregnancy, specifically in women presenting with abdominal pain in the second trimester.

Clinical signs and diagnosis of fibroids from adolescence to menopause

The aim of this review was to provide an updated assessment of the present diagnostic tools and clinical symptoms and signs to evaluate uterine fibroids (UFs) on the basis of current guidelines, recent scientific evidence, and a PubMed and Google Scholar search for peer-reviewed original and review articles related to clinical signs and diagnosis of UFs. Approximately 50%-75% of UFs are considered nonclinically relevant. When present, the most common symptoms are abnormal uterine bleeding, pelvic pain and/or bulk symptoms, and reproductive failure. Transvaginal ultrasound is recommended as the initial diagnostic modality because of its accessibility and high sensitivity, although magnetic resonance imaging appears to be the most accurate diagnostic tool to date in certain cases. Other emerging techniques, such as saline infusion sonohysterography, elastography, and contrast-enhanced ultrasonography, may contribute to improving diagnostic accuracy in selected cases. Moreover, artificial intelligence has begun to demonstrate its ability as a complementary tool to improve the efficiency of UF diagnosis. Therefore, it is critical to standardize descriptions of transvaginal ultrasound images according to updated classifications and to individualize the use of the different complementary diagnostic tools available to achieve precise uterine mapping that can lead to targeted therapeutic approaches according to the clinical context of each patient.

Hemorrhaging Uterine Fibroid Leading to Emergent Early Term Cesarean Delivery: A Case Report

Background  The incidence of uterine leiomyomas, or fibroids, affecting pregnant individuals is estimated to be 10%, but there are no guidelines or recommendations for fetal or maternal surveillance in pregnancies affected by them. Risks associated with fibroids during pregnancy include potential for pain, preterm birth, fetal growth restriction, higher cesarean delivery rate, fetal malpresentation, placenta abruption, and postpartum hemorrhage. Case Presentation  This case describes a 26-year-old gravida 1 para 0 who presented at early term for severe abdominal pain and was found to have acute abdomen accompanied by a nonreassuring fetal heart rate tracing. With emergent cesarean delivery, it was found that the patient was hemorrhaging from a ruptured vessel of a pedunculated fibroid and myomectomy was subsequently performed. Conclusion  While rare, hemorrhage from a uterine fibroid should be considered a part of the differential diagnosis of abdominal pain in pregnant patients with fibroids, particularly when accompanied by concurrent indicators such as free fluid, hypotension/tachycardia, or concerning changes in fetal heart rate, especially in a patient without risk factors for uterine rupture.

The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties

Uterine leiomyomas (ULs) are non-cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a "paradoxical disease" where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification "subserosal, intramural and submucosal", facilitating a detailed examination of individual ULs impact on the female reproductive system. The "type 3 UL" is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique "hybrid" between a submucous and an intramural UL, that may exert a detrimental "double hit" mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.

Giant uterine tumor and miscarriage: how to proceed?

Expanding uterine masses can be the cause of pregnancy loss and add technical difficulties to uterus evacuation due to the intense anatomical distortion of the endocervical canal and uterine cavity. The literature is scarce in the peculiarities of the management of missed abortions in uterus with important distorted anatomies. We report a case of a primigravida patient who presented a rapid and expressive increase of abdominal volume due to a giant uterine mass, evolving to miscarriage. Ultrasound can be a useful tool, allowing visualization of the endocervical path and uterine cavity, helping to perform uterine evacuation in the presence of anatomical distortion without compromising the reproductive future. To the best of our knowledge, no such case has been previously reported.

Recurrence of Uterine Fibroids After Conservative Surgery or Radiological Procedures: a Narrative Review

The present narrative review aims to discuss the available data on the incidence and the risk factors of uterine fibroids (UFs) recurrence after different types of conservative surgical or radiologic procedures in women wishing to preserve their uterus. UFs are the most common benign tumors in women all over the world. Clinical presentation, including abnormal uterine bleeding (AUB), pelvic pain, bulky symptoms, and infertility affect patients' quality of life, and a large variety of conservative treatments are available especially for those with desire of pregnancy. Fertility sparing surgery, by either laparoscopy, hysteroscopy or laparotomy, or radiological interventions (uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound), are the most common therapeutic approaches. However, the genetic or acquired predisposition to UFs remain despite the treatments, and the recurrences are frequently described in a large percentage of patients. The most relevant risk factors for recurrence of UFs are young age at the first surgery, incomplete fibroid resection, the presence of multiple lesions, an enlarged uterus, and the coexistence with other pelvic diseases. The discussion on the possible medical strategy to reduce the recurrence is an open field of clinical investigation, in particular by using hormonal drugs.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper

BACKGROUND

Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology.

OBJECTIVES

This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas.

METHODS

This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023.

OUTCOME

Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management.

CONCLUSIONS AND OUTLOOK

The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

Spontaneous regression of a giant uterine leiomyoma after delivery: a case report and literature review

BACKGROUND

Uterine leiomyomas are hormone-dependent benign tumors and often begin to shrink after menopause due to the reduction in ovarian steroids. The influence of pregnancy on uterine leiomyomas size remains unclear. Here, we present a case of spontaneous regression of a giant uterine leiomyoma after delivery.

CASE PRESENTATION

A 40-year-old woman presented with multiple uterine leiomyomas, one of which is a giant uterine leiomyomas (approximately 8 cm in diameter) that gradually shrinked after delivery. At over two months postpartum, the large myometrial leiomyoma had transformed into a submucosal leiomyoma, and over 3 years postpartum, both the submucosal leiomyoma and multiple intramural leiomyomas completely regressed.

CONCLUSION

Spontaneous regression of a giant uterine leiomyom is rare after delivery. Considering uterine leiomyoma regression until over 3 year postpartum,we need to observe the regression of uterine fibroid for a longer time postpartum in the absence of fibroid related complications. In addition, it will provide new insights for treatment options of uterine leiomyomas in the future.

Pregnancy outcomes following ultrasound-guided high-intensity focused ultrasound in submucous leiomyomas: a retrospective study

OBJECTIVE

To investigate the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) on pregnancy in submucous leiomyomas.

MATERIALS AND METHODS

Between October 2015 and October 2021, a retrospective observational study was conducted at the Affiliated Hospital of North Sichuan Medical College, China, for 32 women with submucous leiomyomas who became pregnant after USgHIFU. Pregnancy outcomes, submucous leiomyomas characteristics, and USgHIFU parameters were analyzed.

RESULTS

A total of 17 (53.1%) deliveries were successfully achieved, with full-term delivery in 16 (94.1%) patients and preterm delivery in 1 (5.9%). After USgHIFU, the effective volume in the uterus cavity and the volume of submucous leiomyomas shrank in all 32 patients. The median time to achieve pregnancy after USgHIFU was 11.0 months. Before pregnancy, myoma type was downgraded in 13 (40.6%) patients, stable in 10 (31.3%) and upgraded in 9 (28.1%). The vaginal expulsion rate of submucous leiomyomas was 28.1%, with complete expulsion in 3 (9.4%) patients and partial expulsion in 6 (18.8%). After USgHIFU, the size of submucous leiomyomas did not increase in each trimester (all p > 0.05). The high complications rate during pregnancy (7/17, 41.2%) was associated with advanced maternal age, with only one (5.9%) premature rupture of membranes possibly associated with submucous leiomyomas. There were 6 (35.5%) vaginal delivery and 11 (64.7%) cesarean sections. All 17 newborns developed well, with a mean birth weight of 3482 g.

CONCLUSIONS

In patients with submucous leiomyomas, pregnancies and full-term deliveries can be successfully achieved following USgHIFU, with few related complications.

Impact of FIGO type 3 uterine fibroids on in vitro fertilization outcomes: A systematic review and meta-analysis

BACKGROUND

The effect of FIGO (the International Federation of Gynecology & Obstetrics) type 3 myomas on in vitro fertilization (IVF) is uncertain.

OBJECTIVES

To evaluate whether FIGO type 3 myomas affect IVF outcomes, through a systematic review and meta-analysis (CRD42022379700).

SEARCH STRATEGY

Electronic databases were searched until November 15, 2022.

SELECTION CRITERIA

Studies evaluating the effects of FIGO type 3 myomas on IVF outcome.

DATA COLLECTION AND ANALYSIS

Pooled results were expressed as odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity was assessed using Higgins I2 . Sources of heterogeneity were explored with sensitivity and subgroup analyses.

MAIN RESULTS

In total, 1020 patients were included: 324 with FIGO type 3 myomas and 696 controls (without myomas). A pooled data analysis showed a significantly lower live birth rate (OR 2.16, 95% CI 1.55-3.01, I2  = 0%, P < 0.00001), clinical pregnancy rate (OR 2.06, 95% CI 1.52-2.81, I2  = 0%, P < 0.00001), and implantation rate (OR 1.77, 95% CI 1.35-2.32, I2  = 0%, P < 0.00001) in women with untreated myomas compared with controls. The number and size of fibroids correlated with a worsening of IVF outcomes.

CONCLUSIONS

FIGO type 3 myomas are significantly associated with a lower implantation rate, cumulative pregnancy rate, and live birth rate. Furthermore, their deleterious effect on the outcome of IVF increases further with increasing size and number. Nevertheless, no firm conclusions could be drawn about the potential benefits of surgery for FIGO type 3 uterine fibroids on IVF outcomes.

Outcomes of Laparotomic Myomectomy during Pregnancy for Symptomatic Uterine Fibroids: A Prospective Cohort Study

Background: The incidence of pregnant women with uterine fibroids is increasing. As they are reactive to hormonal stimuli, in some cases, uterine fibroids tend to grow during pregnancy and potentially generate symptoms with different levels of severity, causing maternal-fetal complications. In very select cases, when other treatment strategies fail to manage symptoms and there is a substantial risk of adverse pregnancy outcomes, a surgical approach during pregnancy may be considered. Methods: From 2016 to 2021, the data from 28 pregnant women with symptomatic uterine fibroids who underwent laparotomic myomectomy during pregnancy were prospectively collected, and operative and maternal-fetal outcomes were analyzed (ClinicalTrial ID: NCT06009562). Results: The procedure was carried out between 14 and 16 weeks of pregnancy. Four (14.3%) patients had intraoperative complications (miscarriages) and nine (32.1%) had postoperative complications (threatened preterm birth). Overall, 24 (85.7%) women delivered at full term (mean: 38.2 gestational weeks), more than half (n = 13; 54.2%) by vaginal delivery, with normal fetal weights and 1 and 5 min Apgar scores. Conclusions: Laparotomic myomectomy during pregnancy can be considered in selected cases for uterine fibroids with severe symptoms when other treatment options have failed and there is high risk of adverse maternal-fetal outcomes.

Study Protocol of a Prospective, Monocentric, Single-Arm Study Investigating the Safety and Efficacy of Local Ablation of Symptomatic Uterine Fibroids with US-Guided High-Intensity Focused Ultrasound (HIFU)

Uterine fibroids are the most common benign tumors of the uterus. Approximately 20-50% of women with myomas experience a variety of symptoms such as vaginal bleeding, abdominal pain, pelvic pain and pressure, and urological problems, possibly interfering with fertility and pregnancy. Although surgery remains the standard treatment option for fibroids, non-invasive therapeutic options, such as high-intensity focused ultrasound (HIFU), have emerged over the last dec ade. During HIFU, ultrasound is focused on the target tissue causing coagulation necrosis. HIFU has, meanwhile, become an established method for treating uterine fibroids in many countries. Clinical data have shown that it effectively alleviates fibroid-related symptoms and reduces fibroid size with a very low rate of side effects. However, there is a lack of data on how this treatment affects laboratory parameters and structural features of uterine tissue. As our center is the only one in German-speaking countries where ultrasound-guided HIFU technology is currently established, the aim of this prospective, monocentric, single-arm trial is not only to evaluate the safety and efficacy of local US-guided HIFU in symptomatic uterine fibroid patients according to GCP standards but also to explore its effects on blood parameters and the structural integrity of uterine tissue using elastographic methods.

Pregnancy is associated with reduced progression of symptomatic adenomyosis: a retrospective pilot study

BACKGROUND

Adenomyosis is a common gynecological disease in women of reproductive age and causes various symptoms such as dysmenorrhea and heavy menstrual bleeding. However, the influence of pregnancy on the progression of adenomyosis remains unclear. The insight into whether the size of adenomyosis is increased, decreased, or unchanged during pregnancy is also undetermined. The current study aimed to evaluate the influence of pregnancy in patients with symptomatic adenomyosis.

METHODS

This study retrospectively enrolled patients diagnosed with adenomyosis by magnetic resonance imaging between 2015 and 2022 at The University of Tokyo Hospital. Uterine size changes were evaluated by two imaging examinations. In the pregnancy group, the patients did not receive any hormonal and surgical treatments, except cesarean section, but experienced pregnancy and delivery between the first and second imaging examinations. In the control group (nonpregnancy group), the patients experienced neither hormonal and surgical treatments nor pregnancy from at least 1 year before the first imaging to the second imaging. The enlargement rate of the uterine size per year (percentage) was calculated by the uterine volume changes (cm3) divided by the interval (years) between two imaging examinations. The enlargement rate of the uterine size per year was compared between the pregnancy group and the control group.

RESULTS

Thirteen and 11 patients with symptomatic adenomyosis were included in the pregnancy group and in the control group, respectively. The pregnancy group had a lower enlargement rate per year than the control group (mean ± SE: -7.4% ± 3.6% vs. 48.0% ± 18.5%, P < 0.001), indicating that the size of the uterus with adenomyosis did not change in the pregnancy group.

CONCLUSIONS

Pregnancy is associated with reduced progression of symptomatic adenomyosis.

Feasibility and Surgical Outcomes of Hysteroscopic Myomectomy of FIGO Type 3 Myoma: A Systematic Review

The latest classification from the Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) has reclassified type 3 myomas, changing their classification from intramural to submucosal. While hysteroscopic myomectomy is considered the gold standard treatment for patients experiencing symptoms from submucosal myomas, there are currently no specific guidelines available for managing type 3 myomas, and the optimal surgical approach remains uncertain. Methods: The search for suitable articles published in English was carried out using the following databases (PROSPERO ID CRD42023418602): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, Web of Science and search register. Only original studies reporting data on hysteroscopic myomectomy of type 3 myoma were considered eligible. The main outcomes investigated were the effectiveness and feasibility of hysteroscopic myomectomy and reproductive outcomes after surgical treatment. Results: Two hundred and sixty-one studies were screened and nineteen of these were read for eligibility. Three studies encompassing 56 patients in total were included. Among the overall population studied, three patients needed an additional procedure to completely remove the myoma and five cases of post-surgical synechiae were recorded. No complications were reported. Of 42 patients wishing for pregnancy, the cumulative live birth rates before and after the hysteroscopic myomectomy were 14.3% and 42.9%, respectively. Conclusions: Hysteroscopic myomectomy appears to be a safe and feasible approach. Nevertheless, data reported in the literature are extremely scarce and based on studies with few patients enrolled. New evidence is needed to assess the safety and effectiveness of hysteroscopic treatment for FIGO type 3 myomas.

Associations of Pregnancy Per- and Polyfluoroalkyl Substance Concentrations and Uterine Fibroid Changes across Pregnancy: NICHD Fetal Growth Studies - Singletons Cohort

BACKGROUND

Fibroids (hormonally responsive benign tumors) often undergo volume changes in pregnancy. Because per- and polyfluoroalkyl substances (PFAS) disrupt hormonal signaling, they might affect fibroid growth. We assessed associations between PFAS and fibroid changes in pregnancy.

METHODS

We analyzed seven PFAS, including perfluorohexanesulfonic acid (PFHxS), perfluorooctanesulfonic acid (PFOS), perfluorodecanoic acid (PFDA), and perfluoroundecanoic acid (PFUnDA), in plasma collected at 10-13 wk gestation from 2,621 women in the NICHD Fetal Growth Studies - Singletons cohort (2009-2013). Sonographers recorded fibroid number and volume of the three largest fibroids during up to six timed ultrasounds. Generalized linear models assessed associations of baseline log 2 - transformed PFAS and fibroid number, volume, and presence, and weighted quantile sum regression evaluated the PFAS mixture. Generalized linear mixed models with random intercepts assessed associations of PFAS and longitudinal fibroid number and total volume. Volume analyses were stratified by total volume at first visualization [equivalent to a fibroid < 1 cm (small), 1  to < 3 cm (medium), or ≥ 3 cm (large) in diameter].

RESULTS

Fibroid prevalence was 9.4% (n = 245 women). PFAS were not associated with changes in fibroid number, but were associated with volume trajectory, depending on baseline volume. Among women with small volume, PFAS were associated with fibroid growth: Each doubling in PFHxS and PFOS concentrations was associated with 3.6% [95% confidence interval (CI): 0.2, 7.0 and 5.2% (95% CI: - 0.4 , 11.1)] greater weekly fibroid growth, respectively. Among women with medium volume, PFAS were associated with shrinking: Doublings in PFOS, PFDA, and PFUnDA concentrations were associated with 1.9% (95% CI: 0.4, 3.3), 1.2% (95% CI: 0.1, 2.4), and 1.6% (95% CI: 0.4, 2.8) greater weekly fibroid volume reduction, respectively.

DISCUSSION

Certain PFAS were associated with fibroid growth among women with small fibroids and decreases among women with medium fibroids. PFAS were not associated with fibroid prevalence or number; therefore, PFAS may influence prevalent fibroids rather than initiating fibroid development. https://doi.org/10.1289/EHP11606.

Mimics of cancer in pregnancy

Pregnancy is a remarkable time of pronounced growth and development of the fetus. Benign pathologies outside of the uterus, including those containing hormonally responsive tissue which undergo physiologic changes and other incidentally identified lesions, may mimic malignancy on clinical evaluation and imaging. A detailed history and physical exam, ultrasound and non-contrast magnetic resonance imaging features and comparison with prior imaging if available may help to narrow the list of potential differential diagnoses. Follow-up imaging in the postpartum period is often vital to confirm benignity and, in some cases, sampling to confirm the diagnosis is necessary. This review will cover the clinical, pathological and multimodality imaging features of numerous potential mimickers of cancer in the setting of pregnancy organized by organ systems. The goal is to better equip abdominal radiologists to accurately identify benign disease and help guide further imaging or follow-up recommendations to avoid unnecessarily aggressive intervention and improve patient care.

Effects of physical exercise in people with epilepsy: A systematic review and meta-analysis

BACKGROUND

Studies suggest that physical exercise lead to improvements in the psychosocial dimension, associated comorbidities as well as to a higher quality of life (QoL) in people with epilepsy. However, there is a need to provide evidence-based guidelines for its prescription. Therefore, this review aimed to systematically evaluate and meta-analyze the available data on the potential effects of physical exercise training programs in people with epilepsy.

METHODS

Four electronic databases (MEDLINE/PubMed, PEDro, SPORTDiscuss and Scopus) were searched systematically from their inception until April 2022 for randomized controlled trials (RCTs), comparative studies and non-controlled studies that provided information regarding the effects of physical exercise training programs on people with epilepsy. The studies' methodological quality assessment was performed using the PEDro, the MINORS and the Quality Assessment Tool for Before-After Studies with No Control Group scales. For the meta-analysis, inverse variance or generic inverse variance was use to report mean difference or standardized mean difference for continuous data and their 95% confidence intervals (CI). Heterogeneity was assessed with the Chi-squared test and I² test.

RESULTS

After removing duplicated studies, 82 results were retrieved by the literature search and 14 were eligible for full text search. Finally, 14 studies with a methodological quality ranging from good to low quality met the inclusion criteria. Totally, 331 people with epilepsy were evaluated. Significant changes between preand post-intervention results in the exercise intervention groups were observed for QoL, fitness level, psycho-affective and neurocognitive outcomes. Findings from the meta-analysis indicated that moderate exercise led to a non-significant decrease (p = 0.08, Chi-squared test) in seizure frequency (SMD 0.33 95% CI 0.04; 0.70), while a significant effect of exercise was observed on QoL with a mean improvement of 4.72 percentage points (95% CI 0.58; 8.86, p = 0.03).

CONCLUSION

Improvements on QoL, fitness level, psycho-affective and neurocognitive outcomes can be achieved through exercise training in people with epilepsy. Altogether, the findings suggest that people with epilepsy can benefit from exercising.

Serum sestrin 2 levels in patients with uterine leiomyomas

Our aim was to evaluate SESN2 levels in patients with uterine leiomyomas by comparing serum SESN2 levels in myoma patients with the levels in healthy women to deepen our understanding of the pathophysiology of uterine leiomyomas. Patients 18-50 years of age who applied to the University of Health Sciences Turkey, Istanbul Kanuni Sultan Suleyman Training and Research Hospital between January and March 2021 and who were diagnosed with uterine leiomyoma were defined as the 'myoma group'. The control group included patients without any sign of leiomyomas in routine ultrasonography. The patients' demographic features, gynecological symptoms, myoma volume and classification were recorded. Serum SESN2 concentrations in venous blood samples were measured using a sandwich enzyme-linked immunosorbent assay (ELISA) kit.The study included 31 patients in the myoma group and 30 in the control group. The mean age/gravid/parity or BMI values did not differ significantly between the groups. The only gynecological symptom that showed a significant difference was menorrhagia. Serum SESN2 levels were significantly higher in the myoma group then the control groups (11.7 ± 2.5) (p < 0.001). In conclusion, although uterine leiomyoma is the most common benign tumour in women of reproductive age, there are no known markers for predicting the development of leiomyomas. Based on the results of the current study, SESN2 could be such a marker.IMPACT STATEMENTWhat is already known on this subject? Uterine leiomyoma is the most common type of benign tumour in women of reproductive age as well as the most common indication for a hysterectomy. Symptoms associated with uterine leiomyoma include abnormal bleeding, chronic pelvic pain, menorrhagia, dysmenorrhoea, dyspareunia and anaemia, which adversely affect the patient's quality of life. Sestrins are a family of metabolic regulator proteins that play a potential role in carcinogenesis.What the results of this study add? This is the first study evaluating the role of sestrin in the development of uterine leiomyomas. Significantly higher levels of sestrin 2 (SESN2) were detected in patients with leiomyomas.What are the implications of these findings for clinical practice and/or further research? Although uterine leiomyoma is the most common type of benign tumour in women of reproductive age, there are still many unknowns regarding its pathophysiology. Further, there are still no known markers for predicting the development of leiomyomas. Hence, primary prevention is not possible. Based on the results of the current study SESN2, could be such a marker. Further studies are needed to confirm the results of this study.

Natural history of fibroids in pregnancy: National Institute of Child Health and Human Development Fetal Growth Studies - Singletons cohort

OBJECTIVE

To describe the natural history of fibroids in pregnancy in a racially diverse cohort and explore whether fibroid changes were associated with participant characteristics.

DESIGN

Prospective cohort study.

SETTING

Twelve clinical sites.

PATIENT(S)

Pregnant women (n = 2774; 27% non-Hispanic White, 28% non-Hispanic Black, 29% Hispanic, 17% Asian/Pacific Islander) who had up to 6 obstetric ultrasounds in gestational weeks 10-41.

INTERVENTION(S)

Sonographers recorded fibroid number and volume of the 3 largest fibroids at each visit. Generalized linear mixed models estimated the trajectories of fibroid number and total volume (overall and stratified by total volume at first visualization: equivalent to a fibroid of <1 cm [small], 1 to <3 cm [medium], or ≥3 cm [large] in diameter). We tested the interactions between the trajectories and race/ethnicity, age (<26, 26-30, 31-34, and ≥35 years), body mass index (<25, 25-29.9, and ≥30 kg/m2), previous miscarriage, parity, and fetal sex, adjusted for total volume at first visualization.

MAIN OUTCOME MEASURE(S)

Average change in total fibroid volume during pregnancy.

RESULT(S)

Overall, 9.6% (266/2,774) of women had a visualized fibroid at any time during pregnancy, including 9% (67/745) of non-Hispanic White women, 14% (106/770) of non-Hispanic Black women, 6% (47/794) of Hispanic women, and 10% (46/465) of Asian or Pacific Islander women. The mean total fibroid volume decreased by 1.0% (95% confidence interval [CI], -1.9%, -0.2%) per week, with a variation in starting total volume. On average, the total volume increased by 2.0% (95% CI, -0.3%, 4.5%) per week among women with small volume; decreased by 0.5% (95% CI, -2.0%, 1.0%) per week among women with medium volume; and decreased by 2.2% (95% CI, -3.4%, -1.0%) per week among women with large volume at first visualization. The volume change also varied by race or ethnicity, parity, age, and miscarriage history. For example, non-Hispanic Black women's total fibroid volume decreased more than those of non-Hispanic White, Hispanic and Asian/Pacific Islander women (-2.6%, 0.1%, 0.5%, and 0.9% average change per week, respectively). The visualized fibroid number declined on an average by 1.2% per week (95% CI, -1.9%, -0.5%) without significant variation by demographic characteristics.

CONCLUSION(S)

The total fibroid volume declined on average throughout pregnancy. However, summarizing across all fibroids disguises substantial heterogeneity by starting total fibroid volume and maternal characteristics. The findings may be a useful reference for clinicians to anticipate how fibroids may change in obstetric patients.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00912132.

Uterine Fibroids Causing Preterm Birth: A New Pathophysiological Hypothesis on the Role of Fibroid Necrosis and Inflammation

According to recent studies and observations in clinical practice, uterine fibroids increase the risk of preterm birth. There are several theories on the pathogenesis of preterm birth in the presence of fibroids. One theory proclaims that fibroid necrosis leads to preterm birth, though pathophysiological mechanisms have not been described. Necrotic tissue secretes specific cytokines and proteins and we suggest these to be comparable to the inflammatory response leading to spontaneous preterm birth. We hypothesize that fibroid necrosis could induce preterm parturition through a similar inflammatory response. This new hypothesis generates novel perspectives for future research and the development of preventative strategies for preterm birth. Moreover, we emphasize the importance of the recognition of fibroids and especially fibroid necrosis by clinicians during pregnancy.

The Influence of Intraoperative Ultrasound Monitoring on the Risk of Recurrence and Reoperation in Patients with Hysteromyomectomy

In recent years, with the continuous development and application of minimally invasive methods in China, laparoscopic myomectomy has become the primary method for clinical treatment of uterine fibroids. There is also a high risk of recurrence and reoperation after endoscopic myomectomy. Intraoperative use of ultrasound for auxiliary examination can provide medical staff with spatial information and position information of fibroids and help medical staff to accurately locate the surgical incision. The aim is to investigate the effect of intraoperative ultrasound monitoring on the risk of postoperative recurrence and reoperation in patients undergoing myomectomy. This study retrospectively collected 80 patients who underwent laparoscopic myomectomy in the gynecology department of our hospital from January 2020 to January 2022. According to the different treatment methods, they were divided into a study group and a control group (both n = 40). The control group underwent preoperative ultrasonography and then underwent myomectomy, while the study group underwent both preoperative and intraoperative ultrasonography before undergoing hysterectomy. Myomectomy: all the enrolled patients were followed up by ultrasound after surgery and followed up for 1 year (recheck ultrasound every 3 months). The indicators, postoperative complications, postoperative average diameter of uterine fibroids, postoperative residual rate of uterine fibroids, postoperative recurrence, and reoperation were compared between the two groups. Intraoperative ultrasound monitoring has a significant effect on patients undergoing myomectomy, which can effectively reduce the residual rate of fibroids, completely remove small and deep fibroids, and reduce complications, postoperative recurrence, and reoperation risks. It has good clinical application value.

Review of uterine fibroids: imaging of typical and atypical features, variants, and mimics with emphasis on workup and FIGO classification

Uterine fibroids are the most common gynecologic neoplasm. Although non-degenerated fibroids are easily identifiable on imaging, degenerated fibroids, fibroid variants, and fibroids with unusual growth patterns can constitute a diagnostic dilemma. Identification of these abnormal morphologic features can alter the diagnosis of presumed uterine fibroids and hence change management plans. This article reviews the typical and atypical radiologic imaging features of uterine fibroids, with an emphasis on the pitfalls, mimics, and radiologically identifiable features that can alter clinical management plans.

Current approaches to overcome the side effects of GnRH analogs in the treatment of patients with uterine fibroids

Introduction: Uterine fibroids (UFs) are the most prevalent benign neoplastic threat originating from myometria of reproductive age women, with a profound financial load valued in hundreds of billions of dollars. Unfortunately, there is no curative treatment so far except surgery and available pharmacological treatments are restricted for short-term treatment options. Thus, there is a large unmet need in the UF space for noninvasive therapeutics.Areas covered: The authors reviewed the literature available for the utility of gonadotropin-releasing hormone (GnRH) analogs in women with UFs. We also focused on clinical studies exploring the therapeutic benefits of novel oral non-peptide GnRH antagonists that were recently approved by the U.S. Food and Drug Administration (FDA) in combination with estradiol/norethindrone acetate for the management of heavy menstrual bleeding associated with UFs in premenopausal women.Expert opinion: The results regarding the efficacy of new-generation oral GnRH-antagonists, such as elagolix, relugolix and linzagolix, are promising and offer potential prospect for the future therapy of UFs. However, these antagonists must be combined with hormonal add-back therapy to minimize the resultant hypoestrogenic side effects such as bone loss.

Change of uterine leiomyoma size during pregnancy and the influencing factors: A cohort study

OBJECTIVE

To evaluate the changes of uterine leiomyoma size during pregnancy and determine the factors influencing it.

METHODS

A prospective study was conducted from June 2016 to June 2018. Women with pregnancies complicated by leiomyoma were recruited. Ultrasound examinations were conducted to measure the size of leiomyoma during 6-7, 11-14, 22-24, 28-34 weeks of pregnancy and before delivery. The clinical characteristics and delivery details of the pregnant women were collected. Changes in leiomyoma size during different gestation periods and the influencing factors were analyzed.

RESULTS

Leiomyoma size commonly increased before 22-24 weeks of pregnancy and the fastest growth occurred before 11-14 weeks. From 22-24 weeks to the date of delivery, the size of leiomyoma remained unchanged. The initial size of the leiomyoma showed negative correlation with the changes in leiomyoma diameters during pregnancy. Pre-pregnancy body mass index, fetus number, leiomyoma location, and parity were positively correlated with the size changes in leiomyoma from 22-24 to 28-34 weeks of pregnancy.

CONCLUSION

Before 22-24 weeks of pregnancy, the size of the leiomyoma was gestation-dependent, which increases with gestational weeks. The fastest growth rate was before 11-14 weeks. The growth of leiomyoma is affected by multiple factors, and different factors can play different roles during different periods of the pregnancy.

5-aza-2'-deoxycitidine inhibits cell proliferation, extracellular matrix formation and Wnt/β-catenin pathway in human uterine leiomyomas

BACKGROUND

Uterine leiomyoma is a benign tumor with unclear pathogenesis and inaccurate treatment. This tumor exhibits altered DNA methylation related to disease progression. DNMT inhibitors as 5-aza-2'-deoxycytidine (5-aza-CdR), have been suggested to treat tumors in which DNA methylation is altered. We aimed to evaluate whether DNA methylation reversion with 5-aza-CdR reduces cell proliferation and extracellular matrix (ECM) formation in uterine leiomyoma cells to provide a potential treatment option.

METHODS

Prospective study using uterine leiomyoma and adjacent myometrium tissues and human uterine leiomyoma primary (HULP) cells (n = 16). In tissues, gene expression was analyzed by qRT-PCR and DNMT activity by ELISA. Effects of 5-aza-CdR treatment on HULP cells were assessed by CellTiter, western blot, and qRT-PCR.

RESULTS

DNMT1 gene expression was higher in uterine leiomyoma vs myometrium. Similarly, DNMT activity was greater in uterine leiomyoma and HULP cells (6.5 vs 3.8 OD/h/mg; 211.3 vs 63.7 OD/h/mg, respectively). After 5-aza-CdR treatment on HULP cells, cell viability was reduced, significantly so at 10 μM (85.3%). Treatment with 10 μM 5-aza-CdR on HULP cells significantly decreased expression of proliferation marker PCNA (FC = 0.695) and of ECM proteins (COLLAGEN I FC = 0.654; PAI-1, FC = 0.654; FIBRONECTIN FC = 0.733). 5-aza-CdR treatment also decreased expression of Wnt/β-catenin pathway final targets, including WISP1 protein expression (10 μM, FC = 0.699), c-MYC gene expression (2 μM, FC = 0.745 and 10 μM, FC = 0.728), and MMP7 gene expression (5 μM, FC = 0.520 and 10 μM, FC = 0.577).

CONCLUSIONS

5-aza-CdR treatment inhibits cell proliferation, ECM formation, and Wnt/β-catenin signaling pathway targets in HULP cells, suggesting that DNA methylation inhibition is a viable therapeutic target in uterine leiomyoma.

A prognostic index model for predicting long-term recurrence of uterine leiomyoma after myomectomy

INTRODUCTION

Uterine leiomyoma (UL) is a common benign pelvic tumor in women that has a high recurrence rate. Our aim is to propose a prognostic index (PI) model for predicting the long-term recurrence risk of uterine leiomyoma (UL).

METHODS

A total of 725 women who underwent myomectomy were enrolled in this retrospective multicenter study. Patients were contacted for follow-up. A PI model was proposed based on the multivariate Cox regression analysis in the model group. The predictive value of this model was tested in both internal and external validation group.

RESULTS

PI formula = 1.5(if 3-5 leiomyomas) or 2(if >5 leiomyomas)+1(if residue)+1(if not submucosal)+1(if combined endometriosis). The PI value was divided into low-risk, intermediate-risk, and high-risk group by cut-off values 1.25 and 3.75. In the model group, the high-risk group had a significantly 4.55 times greater recurrence risk of UL than that in the low-risk group [cumulative recurrence rate (CR): 82.1% vs 29.5%, HR = 4.55, 95% CI 2.821-7.339]; the intermediate-risk group had a significantly 2.81 times greater recurrence risk of UL than that in the low-risk group (CR: 62.3% vs 29.5%, HR = 2.81, 95% CI 2.035-3.878). The differences between any two risk groups were also significant (P< 0.05) in both internal and external validation groups.

CONCLUSION

The model was proved to be effective in predicting recurrence of UL after myomectomy.

A comparison of the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound ablation and laparoscopic myomectomy for uterine fibroids: a comparative study

Objective: To compare the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation and laparoscopic myomectomy (LM).Materials and methods: This study included 676 women with symptomatic uterine fibroids who wished to become pregnant underwent USgHIFU or LM at three hospitals in China from 1 May 2009 to 31 May 2018. The related information of pregnancy and delivery were followed up and analyzed using the chi-square test and two-sided Student t-test.Results: The median follow-up duration was 5 (1-8) years; 20 patients (2.9%) were lost to follow-up. 320 patients were treated with UsgHIFU, and 336 were treated with LM. Two hundred nineteen (68.4%) women became pregnant after USgHIFU ablation, and 224 (66.7%) became pregnant after LM. Four hundred forty-three patients had 501 pregnancies (natural pregnancies, 405; in vitro fertilisation-embryo transfer pregnancies, 38). Average times to pregnancy were 13.6 ± 9.5 months after USgHIFU and 18.9 ± 7.3 months after LM (p < 0.05). The rate of cesarean delivery was lower in the USgHIFU group (41.6%) than in the LM group (54.9%) (p < 0.05). Incidences of placenta increta, placenta previa, and postpartum hemorrhage were low after USgHIFU compared with after LM. Incidences of preterm birth, fetal distress, fetal growth restriction, and puerperal infection were higher after USgHIFU than after LM. There was a risk of uterine rupture after both procedures.Conclusions: Compared with LM, USgHIFU ablation can significantly shorten the time to pregnancy, although pregnancy rates of the two procedures are similar. Some risks in pregnancy and delivery after HIFU should be evaluated and monitored.

Uterine Fibroids and Pregnancy: How Do They Affect Each Other?

The present narrative review is aimed to rekindle discussion regarding whether and how uterine leiomyoma and pregnancy may impact each other. Although fibroids are hormone-dependent lesions, their growth during pregnancy seems to have a nonlinear trend. Besides placental estrogens and progesterone, an array of endocrine and paracrine factors affect fibroid blood supply, growth rate, and risk of degeneration along the gestational and puerperal periods. According to current evidence, the presence of leiomyomas might increase the risk of some adverse pregnancy outcomes. Although a causative relation between fibroids and spontaneous abortion is questionable, the presence of multiple submucosal lesions in certain populations, such as infertile women, may increase the risk of pregnancy loss. Slightly increased risks of placenta previa, placental abruption and fetal malpresentation may occur, mainly due to the mechanical influence of multiple and large fibroids. Cesarean section and preterm birth rates are also probably increased in the presence of fibroids. The risk associations are based on meta-analyses of cohort studies (level of evidence 2a), retrospective cohort studies (2b), case-control (3a), and cross-sectional studies (3b), but with a predominantly low risk of bias. For evaluating the growth pattern of leiomyomas and their real influence on obstetric outcomes, future studies should enroll women with fibroids diagnosed prior to pregnancy and follow them prospectively throughout the gestation and puerperium.

Oxytocin and Misoprostol With Diclofenac in the Preparation for Magnetic Resonance-Guided High-Intensity Ultrasound Treatment of Symptomatic Uterine Fibroids: A Prospective Cohort Study

Uterine fibroids (UFs) are very common benign tumors of the female reproductive tract. According to recent reports, magnetic resonance-guided high-intensity ultrasound (MR-HIFU) appears to be a well-tolerated and efficient treatment option for UFs. However, MR-HIFU still presents several limitations. The treatment is rarely associated with achieving complete non-perfused volume (NPV). Not all patients are qualified for a final procedure, and selected women obtain very good results in such treatment. The primary objective of this experimental study was to assess the effect of transvaginal misoprostol and intravenous oxytocin preparation on UF volume change, sonication time and NPV after MR-HIFU procedure in women of reproductive age with symptomatic UFs. Secondary outcomes included the effect on the peri-procedural effectiveness of misoprostol and oxytocin. This study enrolled 247 women with symptomatic UFs; based on gynecologic examinations and magnetic resonance imaging (MRI) scans, 128 women qualified for MR-HIFU without pharmacologic treatment, 57 women qualified for the misoprostol/diclofenac group and 62 women qualified for the oxytocin group. Pharmacologic pre-treatment improved NPV compared with non-pharmacologic treatment (average NPV: controls 61.9% ± 25.8%; oxytocin 76.8% ± 20.7%; misoprostol/diclofenac 85.2% ± 15.1%; average sonication time: controls 120 min ± 56.4%; oxytocin 111 min ± 45.4%; misoprostol/diclofenac 80 min ± 47.7%). Statistical analysis did not reveal significant intergroup differences in UF volume changes after 6 mo (controls: n = 40, 37.4% ± 27.5%; oxytocin n = 25, 45.8% ± 31%; misoprostol/diclofenac n = 19, 33.4% ± 23.2%). The misoprostol/diclofenac group, which achieved the highest NPV immediately after the MR-HIFU procedure, was characterized by the lowest UF volume change percentages 6 mo later. The administration of vasoconstrictor drugs (oxytocin and misoprostol/diclofenac) to support MR-HIFU in UF treatment is a new issue that may improve the total effectiveness of this method. Randomized controlled trials are necessary to estimate the real effect of vasoconstrictors on MR-HIFU.

Myomectomy during pregnancy: an obstetric overview and two case-series

INTRODUCTION

Uterine fibroids (UFs) are the most common benign disease affecting female reproductive system, occur in 20-40 % of women, and in 10 % of pregnancies. The aim of the investigation was to summarize evidences about the management and treatment of UFs and related complications in pregnancy.

MATERIALS AND METHODS

A literature review was performed using scientific databases, including all case report and case series, using a combination of key words relating to the problem exposed. Data about gestational age at diagnosis, maximum fibroids diameter, type of surgery and gestational age at surgery, delivery and perinatal outcome were collected. Two clinical cases were also included.

RESULTS

Sixty-six articles were selected and 199 patients were included. In 76 % of patients the gestational age at myomectomy was lower than 20 weeks, in 85 % laparotomic surgery was chosen, in 41 % of cases the maximum fibroid diameter was between 7-20 cm, in 41 % of pregnancies the route of delivery was cesarean section. The eight percent of cases was complicated by miscarriage or fetal demise or neonatal death.

CONCLUSIONS

Myomectomy is a feasible procedure in those pregnancies complicated by symptomatic fibroids, though surgery in pregnancy is associated with an increased risk of obstetric complications.

Pregnancy outcomes in women with large uterine fibroids

STUDY AIM

To evaluate the effects of the combination of Arabin pessary or cervical cerclage with vaginal micronised progesterone versus micronised progesterone or no medical management on the outcomes of pregnancies in women with large uterine fibroids.

MATERIALS AND METHODS

This was a retrospective, observational, controlled study in 120 women aged 18-45 years with large uterine (≥8 cm) fibroids diagnosed in the first trimester, who underwent treatment in the regional perinatal center of the Omsk Regional Clinical Hospital between 2015 and 2019. Women in Group A (n = 90) were divided into two subgroups. In Subgroup А₁ (n = 35), participants received the combination of a cervical procedure (Arabin pessary or cerclage) and micronised progesterone, and in Subgroup А₂ (n = 55) all participants additionally underwent myomectomy. In Group B (n = 18), only micronised progesterone was used. In Group C (n = 12), no medical therapy was administered during pregnancy.

RESULTS

Large uterine fibroids in pregnancy were associated with a threatened pregnancy loss in 46.4% of women and pain in almost 40% of women. Myomectomy in pregnancy was performed in 55 women. The combination of Arabin pessary or cervical cerclage with micronized progesterone reduced the rates of preterm delivery by 2.2-fold versus the progesterone-only group and by 11.2-fold versus no medical management group (χ² = 19.4; p = .0001).

CONCLUSION

The combination of Arabin pessary or cervical cerclage with micronized progesterone in our study helped achieve term deliveries in >90% of pregnant women with large fibroids.

Current Treatment Options for Cervical Leiomyomas: A Systematic Review of Literature

Background and objectives: Cervical leiomyomas are a rare benign disease. Although they are mainly treated surgically, currently, there is not a standardized treatment for cervical leiomyomas. This study aims to summarize current literature evidence about treatment options for cervical leiomyomas. Materials and methods: A systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, including observational prospective and retrospective studies, case series and case reports. We collected data regarding studies related to treatment options for cervical leiomyomas, evaluating the following aspects: study design, population, treatment type, rate of surgical complications, and fertility outcome. Results: According to literature research, 38 articles were included. Among 214 patients, the weighted average age was 39.4 years-old; 23 patients were pregnant. Most of the leiomyomas (78%) were extracervical; in 22% of cases (29 patients) were intracervical; 188 patients (88%) received surgical treatment, 6 (3%) received exclusive conservative management and 21 (10%) underwent interventional radiology treatment. One hundred twenty-seven patients (67.5%) underwent myomectomy, while 54 (28.7%) and 7 (3.7%) hysterectomy and trachelectomy, respectively. Cervical myomectomy was performed by open surgery in 21 out of 127 cases (16.5%), while in 92 (72.4%) and 6 (4.7%) patients the surgical approach was performed by traditional and robot-assisted laparoscopy, respectively. The total rate of surgical complications was 5.6%. Conclusion: Surgery is the primary therapeutic option for cervical leiomyomas with a low rate of surgical complications. Interventional radiology techniques have reported promising but still limited results.

Hysteroscopic management of endometrial polyps and submucous leiomyomas in women using a levonorgestrel-releasing intrauterine system

INTRODUCTION

This study was designed to evaluate the feasibility and effectiveness of hysteroscopy in the management of symptoms related to endometrial polyps and submucous leiomyomas in women using a levonorgestrel-releasing intrauterine system (LNG-IUS).

MATERIAL AND METHODS

Twenty-three LNG-IUS users presenting with endometrial polyps and/or submucous leiomyomas and irregular uterine bleeding were recruited for hysteroscopic examination and surgery. Intrauterine pathology was investigated and treated by hysteroscopic resection with the LNG-IUS in situ, and the effect of the procedure on symptoms was evaluated after three to six months.

RESULTS

Intrauterine pathology was successfully resected by hysteroscopy in 23 (100.0%) out of 23 cases. Following hysteroscopy, 18 (78.3%) women reported amenorrhea, one (4.3%) regular spotting, three (13.0%) irregular spotting and one (4.3%) patient resumed normal menstrual cycle. We conclude that 19 (82.6%) patients were postoperatively asymptomatic. All procedures were uncomplicated and 4 (17.4%) were carried out without general anesthesia as office procedures.

CONCLUSION

Endometrial polyps and submucous leiomyomas can develop in LNG-IUS users, and this can cause irregular uterine bleeding. Hysteroscopic resection of these pathologies is a feasible method in the clinical management of symptoms.

Enlarged uterine fibroid forming uterine diverticulum during pregnancy: a case report

BACKGROUND

Although uterine fibroids are a common gynecologic neoplasm, uterine diverticulum accompanied by a uterine fibroid is unique. In addition, pregnancy complicated with uterine diverticulum is extremely rare. We experienced a case of a uterine fibroid that was associated with a uterine diverticulum that enlarged during pregnancy and puerperium.

CASE PRESENTATION

A 25-year-old nulligravida woman had an abnormal uterine cavity surrounded by myomatous mass. After natural conception, the mass and pouch had enlarged during pregnancy. Six months after elective cesarean delivery, she underwent laparotomy because of abdominal pain caused by the myomatous mass and the fluid inside. The tumor was connected to the midline of the posterior wall of the normal uterus. The resected tumor was pathologically diagnosed as leiomyoma and diverticulum.

CONCLUSIONS

Pregnancy can stimulate uterine fibroids to form uterine diverticula. Resection of the diverticulum and fibroid is a useful option for symptomatic patients with desired future fertility.

Vilaprisan, a New Selective Progesterone Receptor Modulator in Uterine Fibroid Pharmacotherapy-Will it Really be a Breakthrough?

BACKGROUND

Vilaprisan (VPR) is a new orally available selective progesterone receptor modulator (SPRM), with anti-proliferative activity against uterine fibroids (UFs). It definitively causes suppression of ovulation and inhibition of proliferation of endometrial, myometrial and UF cells.

PURPOSE

This review aims to summarize current knowledge on VPR from all studies, including clinical trials, conducted to date and to contextualize the potential role of VPR in future medical regimens for the treatment of UFs.

METHODS

We performed a literature search in PubMed US National Library of Medicine and Google Scholar databases. Both databases were extensively searched for all original and review articles/book chapters as well as congress abstracts published in English until July 2019. The use of VPR for UF therapy was identified by using the keywords: "uterine fibroids" and "vilaprisan".

RESULTS

In phase I and II clinical trials, VPR was shown to be effective in ameliorating UF-related clinical symptoms, especially abnormal or excessive uterine bleeding and in shrinking UFs. The tolerability of VPR is roughly similar to that of ulipristal acetate (UPA) and it tends to be more favorable than that of GnRH-agonists.

CONCLUSION

Presently, all trials examining the utility of VPR for the treatment of UF are halted; likely, due to the recently reported cases of hepato-toxicity with UPA, in addition to non reassuring toxicology results from preclinical long-term testing on rodents, carried out in parallel with late stage testing on humans. An accurate summary of robust data related to the safety of VPR is urgently needed to draw definitive conclusions on the future clinical development of this drug for UF therapy.

Management of pregnancy in case of multiple and giant uterine fibroids

Uterine fibroids are common among women of reproductive age. During the pregnancy, the potential complications of fibroids, although rare, are of frequent clinical concern. Available studies describing management and obstetrical outcomes in pregnant women with giant fibroids are limited. We present the case of a 39-year-old pregnant woman with multiple and large uterine fibroids. During the pregnancy, there was adequate fetal development, without major maternal complications. Given the characteristics of the fibroids and breech position of the fetus, an elective caesarean section was decided, and postpartum hysterectomy planned. This challenging obstetrical case required a multidisciplinary approach.We considered crucial discussing five main issues: preconceptional counselling, tailored pregnancy surveillance, decision of time and route of delivery, decision to perform a peripartum hysterectomy and management of decreasing blood loss perioperatively. Given the limitation of the published reports, we believe that sharing our experience, along with a literature review, is beneficial for other clinicians.

The Effect of Small Size Uterine Fibroids on Pregnancy Outcomes in High-risk Pregnancies

OBJECTIVE

 To evaluate the obstetric outcomes of singleton high-risk pregnancies with a small size uterine fibroid.

METHODS

 This retrospective cohort study was conducted among 172 high-risk pregnant women who were followed-up by a single surgeon between 2016 and 2019. Pregnant women with preconceptionally diagnosed small size (< 5 cm) single uterine fibroids (n = 25) were compared with pregnant women without uterine fibroids (n = 147) in terms of obstetric outcomes.

RESULTS

 There was no statistically significant difference between the groups in terms of adverse pregnancy outcomes. The size of the fibroids was increased in 60% of the cases, and the growth percentage of the fibroids was 25% during pregnancy. Intrapartum and short-term complication was not observed in women who underwent cesarean myomectomy.

CONCLUSION

 Small size uterine fibroids seem to have no adverse effect on pregnancy outcomes even in high-risk pregnancies, and cesarean myomectomy may be safely performed in properly selected cases.

Uterine Isthmus Tourniquet during Abdominal Myomectomy: Support or Hazard? A Randomized Double-Blind Trial

BACKGROUND AND OBJECTIVES

A tourniquet has been suggested as a useful means of reducing massive hemorrhage during myomectomy. However, it is not clear whether the restricted perfusion affects the ovaries. In the present study, we examined the effect of a tourniquet on ovarian reserve and blood loss during myomectomy.

MATERIALS AND METHODS

In a randomized double-blind clinical trial, fertile nonobese patients scheduled for abdominal myomectomy at Rasool-e-Akram Hospital from February 2018 to June 2019 were randomized to a tourniquet (n = 46) or a non-tourniquet group (n = 35). Serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) were measured before and 3 months after surgery, blood loss was recorded during surgery, and serum levels of hemoglobin (Hb) were recorded before surgery, 6 h and 3 days after surgery. SPSS version 21 was used for statistical analysis.

RESULTS

Demographic, obstetric, and myoma characteristics were similar in the 2 groups (p > 0.05). The mean baseline values of AMH and FSH did not differ between groups (p > 0.05). After surgery, only FSH was higher in the control group (p = 0.043). Despite the time taken to fasten and open the tourniquet, the mean operating time was shorter in the tourniquet group (p < 0.001). Blood loss was higher in the control group (p = 0.005). The drop in Hb levels at 6 h after surgery was higher in the non-tourniquet group (p = 0.002). Blood loss was significantly associated with the duration of surgery (r = 0.523, p < 0.001).

CONCLUSION

The use of a tourniquet during abdominal myomectomy significantly reduced the mean volume of blood loss compared to the non-tourniquet group, while it did not prolong the duration of surgery, nor reduced the ovarian reserve. A tourniquet is a safe and efficient measure during abdominal myomectomy.

Iron Deficiency Anemia in Pregnancy: Novel Approaches for an Old Problem

Iron needs increase exponentially during pregnancy to meet the increased demands of the fetoplacental unit, to expand maternal erythrocyte mass, and to compensate for iron loss at delivery. In more than 80% of countries in the world, the prevalence of anemia in pregnancy is > 20% and could be considered a major public health problem. The global prevalence of anemia in pregnancy is estimated to be approximately 41.8%. Undiagnosed and untreated iron deficiency anemia (IDA) can have a great impact on maternal and fetal health. Indeed, chronic iron deficiency can affect the general wellbeing of the mother and leads to fatigue and reduced working capacity. Given the significant adverse impact on maternal-fetal outcomes, early recognition and treatment of this clinical condition is fundamental. Therefore, the laboratory assays are recommended from the first trimester to evaluate the iron status. Oral iron supplementation is the first line of treatment in cases of mild anemia. However, considering the numerous gastrointestinal side effects that often lead to poor compliance, other therapeutic strategies should be evaluated. This review aims to provide an overview of the current evidence about the management of IDA in pregnancy and available treatment options.

Uterine fibroids and preterm birth risk: A systematic review and meta-analysis

AIM

This study explored the association between the presence of uterine fibroids (UF), as determined by ultrasound, and preterm birth (PB) risk.

METHODS

Medline, Embase, Cochrane, Scopus and Web of Science databases. Studies reporting women with and without UF demonstrated by an ultrasound exam. The primary outcome was the risk of PB < 37 weeks of gestation in pregnancies with UF diagnosed by an obstetric ultrasound exam. Effects for dichotomous and continuous outcomes are, respectively, reported as risk ratios (RR) or mean differences and their 95% confidence intervals (CI).

RESULTS

Eighteen studies were included comprising 276 172 pregnancies to whom obstetric ultrasound assessment was performed for the presence/absence of UF. Women with UF were older (mean difference = 2.40 years, 95% CI 0.94-3.85) and were at higher risk of PB before 37 (RR = 1.43, 95% CI 1.27-1.60), 34 (RR = 1.79, 95% CI 1.32-2.42), 32 (RR = 1.94, 95% CI 1.33-2.85) and 28 (RR = 2.17, 95% CI 1.48-3.17) weeks as compared to those without UF (P < 0.01). In addition, women with UF were at higher risk of threatened preterm labor, preterm premature rupture of membranes, fetal malpresentation, placental abruption, lower gestational age and birthweight at delivery and a higher cesarean delivery rate.

CONCLUSION

Pregnant women with UF are at increased risk of PB and other adverse obstetric outcomes.

The role of magnetic resonance-guided focused ultrasound in fertility-sparing treatment of uterine fibroids-current perspectives

Uterine fibroids (UFs) are the most common benign tumours of the female reproductive system and the most frequent reason for hysterectomy worldwide. UFs are reported in 20%–70% of women of reproductive age depending on a study group. Although most women with UFs are asymptomatic, over 30% of them will present with different symptoms. Abnormal uterine bleeding, pain, pressure and infertility are the most common. Lesions that cause these kinds of symptoms may require medical intervention.

Trends in UF treatment change along with patient awareness and the introduction of new methods and techniques. Selecting an appropriate treatment option should be individualised and adjusted to the patient’s expectations as much as possible. This choice will mostly depend on the patient’s age, UF location, the size and number of lesions, severity of symptoms and, most importantly, the patient’s expectations concerning the preservation of fertility. Observations made for the past few years showed an increasing number of pre- and perimenopausal women who wish to preserve their uterus or decline surgery. In line with current trends and demands in medicine, great importance is attached to the development and upgrade of new minimally invasive or noninvasive procedures in UF therapy.

Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is not associated with severe destruction of the uterine cavity and walls. For this reason, this method may be considered as a kind of hope in fertility-sparing UF therapy and the data about its use in this indication raises future hope. In this review, we summarise the available data on the use of MR-HIFU as a fertility-sparing method in the treatment of UFs. We also indicate how it could evolve in the future.

According to the available data, MR-HIFU is a relatively safe noninvasive method which seems not to deteriorate fertility compared to the pre-treatment status. MR-HIFU may constitute an alternative solution and be chosen in patients who meet the qualification criteria and deny other methods, which also facilitates the use of other treatment options in case the procedure is ineffective. Further randomised studies are necessary to confirm the above information.

The Role of miRNA and Related Pathways in Pathophysiology of Uterine Fibroids-From Bench to Bedside

Uterine fibroids (UFs) are the most common benign tumors of the female genital tract. Their prevalence usually is estimated at 30-40%, but may reach up to 70-80% in predisposed groups of women. UFs may cause various clinical issues which might constitute the major reason of the overall deterioration of the quality of life. The mechanisms leading to UFs formation and growth still remain poorly understood. The transformation of smooth muscle cells of the uterus into abnormal, immortal cells, capable of clonal division, is thought to be a starting point of all pathways leading to UF formation. Micro-ribonucleic acids (miRNAs) are non-coding single-stranded RNAs about 22 nucleotides in length, that regulate gene expression. One of recent advances in this field is the comprehension of the role of miRNAs in tumorigenesis. Alterations in the levels of miRNAs are related to the formation and growth of several tumors which show a distinct miRNA signature. The aim of this review is to summarize the current data about the role of miRNAs in the pathophysiology of UFs. We also discuss future directions in the miRNA research area with an emphasis on novel diagnostic opportunities or patient-tailored therapies. In our opinion data concerning the regulation of miRNA and its gene targets in the UFs are still insufficient in comparison with gynecological malignancies. The potential translational use of miRNA and derived technologies in the clinical care is at the early phase and needs far more evidence. However, it is one of the main areas of interest for the future as the use of miRNAs in the diagnostics and treatment of UFs is a new and exciting opportunity.

The effect of ulipristal acetate on tumor necrosis factor α, insulin-like growth factor 1, and plasminogen activator inhibitor-1 serum levels in patients with symptomatic uterine fibroids

Introduction

Uterine fibroids (UFs) are benign tumors of the female reproductive system originating from the smooth muscle of the uterus. Currently, progesterone is known to play a key role in the differentiation of the myometrial tissue to form UFs and their abnormal growth. The mechanism of action of progesterone in UF tumorigenesis involves its effect on increasing the concentrations and dysregulation of selected growth factors.

Material and methods

A retrospective cohort study was performed to evaluate and compare tumor necrosis factor α (TNF-α), insulin-like growth factor 1 (IGF-1), plasminogen activator inhibitor-1 (PAI-1) serum concentrations in patients with UFs without prior hormonal treatment, patients with UFs treated with a 3-month standard ulipristal acetate (UPA - a type of selective progesterone receptor modulator) scheme (5 mg/day) and in control patients without UFs. A total of 120 patients were divided into 3 groups (controls, UFs with UPA treatment, UFs without UPA treatment).

Results

There were no significant differences in TNF-α serum concentrations between patients with UFs who underwent UPA treatment and patients who did not. Serum concentrations of IGF-1 and PAI-1 did not show significant intergroup differences.

Conclusions

No significant differences were found between TNF-α concentrations in the serum of patients with UFs treated with UPA, and patients without UPA treatment. In addition, our data analysis did not show significant differences in the concentrations of IGF-1 and PAI-1 between patients with UFs and the control group. Further studies on the dependence of specific symptoms on selected growth factors are mandatory.

Evaluation of Uterine Artery Embolization on Myoma Shrinkage: Results from a Large Cohort Analysis

Objective:

There are still contradictory opinions on the success rates of uterine artery embolization (UAE) for the treatment of myomas. In this scenario, our study aims to assess the effect of UAE on myoma shrinkage.

Materials and Methods:

The study included 337 women in reproductive age affected by a single symptomatic intramural myoma and declined surgery, undergoing UAE. The uterus and myoma diameters and volumes were determined on ultrasonographic scans before and 3, 6, and 12 months after the procedure.

Results:

The mean uterine volume before intervention was 226.46 ± 307.67 mm³, whereas myoma volume was 51.53 ± 65.53 mm³. Further myoma progression was registered in only four patients. In remaining women, uterus volume in average decreased for 149.99 ± 156.63 mm³, whereas myomas decreased for 36.57 ± 47.96 mm³. The mean volume reduction rate of the uterus was 49.54 ± 35.62 and for myoma was 57.58 ± 30.71. A significant decrease in both uterine and myoma volume was registered in every stage of the follow-up. The highest average decrease in uterine volume was in the first 3 months and myoma volume between 3 and 6 months following UAE. After 12 months follow-up, successful outcome (volume regression >50% respect to the baseline) was registered for uterus in 97.4% and for myoma in 67.9% of investigated patients.

Conclusion:

UAE was proven to allow a good success rate and can be considered as an effective alternative procedure for myoma treatment.

Isoliquiritigenin Suppresses E2-Induced Uterine Leiomyoma Growth through the Modulation of Cell Death Program and the Repression of ECM Accumulation

Uterine leiomyomas, also known as fibroids, are common and prevalent in women of reproductive age. In this study, the effect of Isoliquiritigenin (ISL), a licorice flavonoid, on the anti-proliferation of uterine leiomyoma was investigated. We found that the survival of uterine leiomyoma ELT3 cells and primary uterine smooth muscle (UtSMC) cells was reduced by treatment with ISL alone or with ISL plus estradiol (E2). Cell cycles were arrested through the reduction of G2/M- and S-phase populations in ELT3 and UtSMC cells, respectively. Furthermore, increased sub-G1 phase and nucleus condensation were observed in ELT3 cells but not in UtSMC cells. Co-treatment of ELT3 cells with E2 and ISL inhibited ERK1/2 activation, whereas p38 and c-Jun N-terminal kinase (JNK) activation was enhanced. Moreover, ISL-induced apoptosis and autophagy cell death in ELT3 cells were observed. Serum E2 and P4 levels were reduced in a E2-enhanced uterine myometrium hyperplasia mouse model by ISL treatment, which contributed to the downregulation of the expression of extracellular matrix (ECM) associated proteins and matrix metalloproteinase (MMPs). Taken together, these results showed that ISL exerted a higher effect on the inhibition of estrogen-induced uterine leiomyoma growth for both in vitro and in vivo ECM accumulation, demonstrating its potential as a new option for treatment of uterine leiomyoma.