Large uterine leiomyomata and risk of cesarean delivery

The influence of uterine fibroids on adverse outcomes in pregnant women: a meta-analysis

OBJECTIVE

The objective of the meta-analysis was to determine the influence of uterine fibroids on adverse outcomes, with specific emphasis on multiple or large (≥ 5 cm in diameter) fibroids.

MATERIALS AND METHODS

We searched PubMed, Embase, Web of Science, ClinicalTrials.gov, China National Knowledge Infrastructure (CNKI), and SinoMed databases for eligible studies that investigated the influence of uterine fibroids on adverse outcomes in pregnancy. The pooled risk ratio (RR) of the variables was estimated with fixed effect or random effect models.

RESULTS

Twenty-four studies with 237 509 participants were included. The pooled results showed that fibroids elevated the risk of adverse outcomes, including preterm birth, cesarean delivery, placenta previa, miscarriage, preterm premature rupture of membranes (PPROM), placental abruption, postpartum hemorrhage (PPH), fetal distress, malposition, intrauterine fetal death, low birth weight, breech presentation, and preeclampsia. However, after adjusting for the potential factors, negative effects were only seen for preterm birth, cesarean delivery, placenta previa, placental abruption, PPH, intrauterine fetal death, breech presentation, and preeclampsia. Subgroup analysis showed an association between larger fibroids and significantly elevated risks of breech presentation, PPH, and placenta previa in comparison with small fibroids. Multiple fibroids did not increase the risk of breech presentation, placental abruption, cesarean delivery, PPH, placenta previa, PPROM, preterm birth, and intrauterine growth restriction. Meta-regression analyses indicated that maternal age only affected the relationship between uterine fibroids and preterm birth, and BMI influenced the relationship between uterine fibroids and intrauterine fetal death. Other potential confounding factors had no impact on malposition, fetal distress, PPROM, miscarriage, placenta previa, placental abruption, and PPH.

CONCLUSION

The presence of uterine fibroids poses increased risks of adverse pregnancy and obstetric outcomes. Fibroid size influenced the risk of breech presentation, PPH, and placenta previa, while fibroid numbers had no impact on the risk of these outcomes.

Huge Fibroid in Pregnancy: A Case Presentation

Uterine fibroid, widely known as leiomyoma, is one of the most common benign tumours of the female reproductive system. It is not uncommon for pregnancies to be complicated by uterine fibroids. Most commonly, the first line of large uterine fibroids management in pregnancy is conservative, with myomectomy counselling after delivery if necessary. In this paper, we present a case of a very high-risk pregnancy, that was managed by delivery via caesarean section at 34 weeks of gestation, which was performed for a patient, with an 18 centimetres (cm) fibroid, first diagnosed during pregnancy. Interventional radiology involvement was critical in this case for minimizing the final blood loss and surgical complications. Bilateral internal iliac artery balloons were used. Maternal and foetal risks, the timing of delivery, and the options for the management of fibroids in pregnancy will be discussed.

A Case of an Obstructed Delivery by a Large, Lower Uterine Segment Fibroid Interlocked with a Fetal Mentum

Uterine leiomyomata are associated with many pregnancy complications and will likely become increasingly common as the average age of childbearing increases. We describe a case of an obstructed delivery by a large fibroid. A 37-year-old G2P1001 with a 10-cm anterior, lower uterine segment fibroid presented for labor induction. Labor was complicated by arrest of descent due to suspected obstruction of the fetal body by the fibroid after descent of the fetal head, and delivery during cesarean section was complicated by apparent interlocking of the fetal mentum with the fibroid. Large, anterior lower uterine segment fibroids have the potential to obstruct delivery of the fetal head or of the fetal body, and these patients should be counseled regarding the potential for complications via both vaginal and cesarean deliveries.

Fibroids-related complications in pregnancy: a twelve-year long experience at a maternal-fetal medicine referral center

BACKGROUND

Uterine fibroids are the most frequent female benign tumor, which can cause complications during pregnancy, mainly pain. Differential diagnosis may be challenging and a standardized management approach is lacking. We aim to propose an algorithm for the differential diagnosis of pain during pregnancy and for management of fibroid-related pain.

METHODS

A retrospective cohort study of all pregnant women admitted to our center for complications related to fibroids between 2008 and 2019. Data regarding clinical examination, laboratory results, imaging parameters, as well as perinatal outcomes, were collected and assessed (Fisher's Exact Test).

RESULTS

Twenty-four pregnant patients were admitted for fibroid-related complications. Six patients were admitted more than one times, for a total of 34 admissions. The main cause of hospital admission was pain (N.=33, 94.1%), which was successfully managed with acetaminophen and/or ketoprofen in 91.2%. In two cases, conservative management failed and a surgical approach was undertaken. Most women (N.=20, 90.9%) delivered at term, with a cesarean delivery and post-partum hemorrhage rate of 22.7%. All newborns had normal APGAR score, umbilical artery pH and birth weight.

CONCLUSIONS

Pain is the most common complication of fibroids during pregnancy. Accurate differential diagnosis and adequate management are pivotal to ensure good perinatal 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.

Leiomyomata, neonatal anthropometry, and pregnancy outcomes in singleton pregnancies

PURPOSE

To investigate the relationship of fibroids in pregnancy, preterm birth, and neonatal anthropometry.

METHODS

Pregnant women (n = 2578) in the National Institute of Child Health and Human Development Fetal Growth Studies-Singletons cohort had up to six ultrasounds across pregnancy. Sonographers recorded fibroid number and volume of the three largest fibroids. Trained personnel measured neonatal anthropometry. Linear and logistic regression compared neonatal anthropometry and pregnancy outcomes among pregnancies with versus without fibroids. Causal mediation analysis evaluated preterm birth as a mediator.

RESULTS

Average birthweight did not differ by fibroid status. However, compared with pregnancies without fibroids, neonates from pregnancies with single fibroids had 0.3- (95% confidence interval [CI], 0.0, 0.5) cm larger head circumferences; those with multiple fibroids had 0.3- (95% CI, 0.0, 0.6) cm larger arm circumferences; and those with small fibroid volume had 0.7- (95% CI, 0.3, 1.2) cm larger head, 0.4- (95% CI, 0.0, 0.8) cm larger arm, and 0.7- (95% CI, 0.1, 1.3) cm larger thigh circumferences. Presence versus absence of fibroids was associated with 1.73-2.65 times higher odds of preterm birth. Differences in preterm birth did not explain fibroid-anthropometry results.

CONCLUSIONS

We found no evidence that fibroids negatively impacted fetal growth; instead, fibroids were associated with increased head, arm, and thigh circumferences.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT00912132.

Uterine Fibroids and Pregnancy: A Review of the Challenges from a Romanian Tertiary Level Institution

Background and Objectives. Uterine fibroids are relatively common in reproductive-age women and are directly linked to pregnancy. There are many debates about performing a myomectomy at the same time as a caesarian section (CS) in such cases due to the risk of a hemorrhage. Our study aims to investigate fibroid features and their evolution in pregnancy, complications of a myomectomy during CS and maternal and fetal obstetric outcomes of pregnancies with fibroids. Materials and methods. We realize a prospective study that includes 57 patients with fibroids in pregnancy diagnosed in January 2017–June 2019. We analyze the number, the location and the growth of fibroids during pregnancy and the maternal and fetal outcome. We appreciate the bleeding in patients with a myomectomy and without a myomectomy during CS, using hemoglobin values before and after birth. Results. Most of the patients present single fibroids that are 30–160 mm in size, located on the anterior uterine wall. Vaginal delivery is used in 7% of women, whereas 85.96% deliver by CS. In addition, 68% of fibroids are diagnosed in the first trimester. In most cases, the fibroid has maximum growth in the second trimester of pregnancy. The myomectomy rate for fibroids during CS is 24.48. Hemoglobin values showed no statistically significant difference between the two groups with and without myomectomy. The operating time is double for the group with a myomectomy associated with a CS. The results of the obstetric outcomes are abortion in 7% of all patients, whereas premature delivery and births at term are 9.43% and 90.57%, respectively. Conclusions. The decision of performing a myomectomy during pregnancy can be a challenge and must be performed for selected cases. This procedure may have several benefits, such as avoiding another operation to remove fibroids.

The Impact of Uterine Fibroids on Fertility: How the Uncertainty Widens the Gap in Reproductive Outcomes in Black Women

Uterine fibroids (UFs) are the most common pelvic tumor in women. While the decreased quality of life and significant morbidity has been implicated with UFs, several important questions regarding the effect of UFs on reproductive outcomes remain unanswered. Furthermore, there is a disproportionate impact of UFs in Black women, in whom these tumors are known to be more common and more severe. The racial difference in UF burden is heightened during prime reproductive years, during which Black women undergo surgical intervention at an astoundingly increased rate compared to other races. Despite this, Black women are underrepresented in UF and treatment outcome research, and thus the uncertainty of the impact of UFs and UF treatment on fertility and pregnancy outcomes in this population is less defined. The purpose of this review article is to discuss recent findings in the literature regarding the impact of uterine UFs on reproductive outcomes with a primary focus on the implications for Black women. Additionally, we briefly discuss the importance of increased UF research funding and investigation and propose actionable items to help increase the representation of Black women in UF research.

World Federation for Ultrasound in Medicine Review Paper: Incidental Findings during Obstetrical Ultrasound

Although the prevalence of incidental findings revealed during an obstetric ultrasound examination is low, the findings may include adnexal and cervical masses, uterine or urinary congenital malformations, free fluid in the pouch of Douglas or tortuous vessels (varices). Adnexal masses are the most common finding and vary in imaging characteristics. They are mainly unilateral, cystic masses with a low risk of malignancy that are treated conservatively. The International Ovarian Tumor Analysis scoring models may be helpful in differentiating benign from malignant masses. For those masses >5 cm, follow-up is recommended, and resection could be considered to avoid risk of torsion, rupture and hemorrhage, which may compromise pregnancy outcome. Uterine masses such as fibroids are commonly diagnosed early in the first trimester and should be followed up during pregnancy to evaluate any changes. Transabdominal and transvaginal ultrasound is the first-line test for the diagnosis of such incidentalomas; however, magnetic resonance ultrasound may have a useful role in excluding malignancy potential. As a result of their low frequency and the lack of good evidence, there are no specific guidelines on the management of incidentalomas detected at obstetric scans. Their management should follow the related general guidelines for ovarian, cervical and uterine masses, with individualized management depending on the pregnancy status.

Uterine fibroids and risk of preterm birth by clinical subtypes: a prospective cohort study

Background

Fibroids are present in approximately one in ten pregnancies and are inconsistently linked with preterm birth. We sought to determine the association between fibroids and preterm birth in a prospective cohort with standardized research ultrasounds for characterizing fibroids in early pregnancy while accounting for the clinical paths that precede preterm birth.

Methods

Participants who were pregnant or planning a pregnancy were recruited from communities in three states between 2000 and 2012. Members of this prospective cohort had a research ultrasound in the first trimester to establish pregnancy dating and to record detailed information about the presence, size, number, and location of fibroids. Baseline information from time of enrollment and a detailed first trimester interview contributed key information about candidate confounders. Birth outcomes, including clinical classification of type of preterm birth (preterm labor, preterm premature rupture of membranes, and medically indicated preterm birth) were cross-validated from participant report, labor and delivery records, and birth certificate data.

Results

Among 4,622 women with singleton pregnancies, 475 had at least one fibroid (10.3%) and 352 pregnancies resulted in preterm birth (7.6%). Prevalence of fibroids was similar for women with preterm and term births (10.2% vs. 10.3%). Fibroids were not associated with increased risk of preterm birth after taking into account confounding (risk ratio adjusted for race/ethnicity and maternal age, 0.88; 95% confidence interval, 0.62–1.24) nor any clinical subtype of preterm birth. No fibroid characteristic or combination of characteristics was associated with risk.

Conclusions

If fibroids increase risk of preterm birth, the effect is substantially smaller than previous estimates. Given lack of effect in a large population of women from the general population, rather than higher risk academic tertiary populations previously most studied, we encourage a reconsideration of the clinical impression that presence of fibroids is a major risk factor for preterm birth.

Central Placenta Previa With Coexisting Central Cervical Fibroid in Pregnancy: An Obstetrician's Nightmare

Pregnancy with central placenta praevia and a coexistent cervical fibroid is infrequently encountered in clinical practice. A patient with this unusual combination is a nightmare for any clinician, especially if she presents with obstetric emergencies. In this scenario, there is a high chance of catastrophic obstetric hemorrhage during the peripartum period leading to a fatal outcome. We report a case of a 27-year-old lady at term pregnancy, who was brought to emergency in labor pain with antepartum hemorrhage. Subsequently, she was diagnosed to have central placenta praevia along with a large central cervical fibroid. An emergency cesarean section was performed to deliver the child. Intraoperatively, she had a major postpartum hemorrhage which was successfully managed with intrauterine balloon tamponade, hemostatic sutures, and uterine artery ligation. We could avoid cesarean hysterectomy by precise anticipation, meticulous planning, and step-wise protocol-driven management.

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.

The differences in characteristics of uterine leiomyomas and the diverse adverse pregnancy outcomes

Although previous studies have shown a relationship between uterine leiomyoma and pregnancy outcomes, this relationship is not yet completely understood. Many review articles have addressed this effect, but to date, none has classified this relationship according to the characteristics of the leiomyoma (i.e., type, size, number, and location). This review was conducted to evaluate and classify the relationship between leiomyoma characteristics and the effects of a leiomyoma on pregnancy and prenatal outcomes to facilitate decision-making in preconception and prenatal counselling. We examined articles published in English regarding any leiomyoma characteristics with obstetric outcomes during pregnancy using a collection of subject headings and key terms: 'leiomyomata,' 'myoma,' 'leiomyoma,' 'fibroid,' and 'pregnancy.' Many studies regarding the influence of leiomyoma characteristics on outcomes of pregnancy were identified, and the common conclusion was that the outcomes were dependent on leiomyoma characteristics. Most studies focussed on leiomyoma size, followed by type, location, and number of lesions. Different leiomyoma characteristics are related to diverse pregnancy outcomes. Therefore, it may be possible to predict the extent of the effects of these tumours on pregnancy outcomes by identifying all leiomyoma characteristics.

Use of point-of-care ultrasound to diagnose spontaneous rupture of fibroid in pregnancy

Background: Complications of fibroids in pregnancy are well known, including postpartum hemorrhage, labor dystocia, and cesarean delivery. Outside of pregnancy and labor, the rare occurrence of spontaneous fibroid rupture has been documented. Case: The current case report involves a woman who presented with acute abdominal pain in the third trimester of pregnancy and was found to have spontaneous rupture of a fibroid before the onset of labor. Her initial presentation, diagnosis through use of point-of-care ultrasound, acute surgical management, and postoperative course are described. Conclusion: When assessing acute abdominal pain in a pregnant patient, fibroid rupture should be considered despite the absence of prior uterine surgery. Bedside point-of-care ultrasonography is a useful tool for assessment of abdominal pain in the third trimester of pregnancy.

Predictive factors for secondary postpartum hemorrhage: a case-control study in Japan

BACKGROUND

Secondary postpartum hemorrhage (PPH) is defined as excessive vaginal blood loss occurring between 24 h and 6-12 weeks after birth. The incidence of secondary PPH varies from 0.2% to 3.0%, and the peak incidence ranges from 1 to 2 weeks postpartum. There is no clinical evidence regarding the cause of secondary PPH. Therefore, this study aimed to determine the predictive factors for secondary PPH in an Asian population.

METHODS

A case-control study was performed. The clinical data of 25 secondary PPH patients who had been admitted to our hospital between June 2012 and January 2019 were obtained for this study. Control patients (n = 100) were selected from pregnant women who delivered at the hospital during the same period; they were matched to secondary PPH patients using propensity score matching to adjust for maternal age at delivery, parity, and the use of assisted reproductive technology (ART). A multiple logistic regression analysis was used to determine the predictive factors for secondary PPH.

RESULTS

The median maternal age was 34 years (range, 24-42 years); 85 (68.0%) women were nulliparous, 31 (24.8%) used ART, and 116 (92.8%) had term deliveries. Immediate PPH (adjusted odds ratio [OR], 2.84; 95% confidence interval [CI], 1.04-7.75) and manual removal of the placenta (adjusted OR, 6.14; 95% CI, 1.21-31.1) were associated with secondary PPH.

CONCLUSION

Increasing the awareness of the predictive factors for secondary PPH could play an important role in the recognition and treatment of postpartum morbidity.

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.

Difficult caesarean section: A literature review

BACKGROUND

Caesarean section (CS) is usually perceived as a simple and safe alternative to natural birth, but in some instances can be technically difficult with consequent health hazards for both the mother and the fetus. We have proposed an evidence-based literature review of the most common difficult CS scenarios, with the aim to provide useful information about their management, possible prevention and resolution of complications.

METHODS

We identified articles through a reserch in PubMed, Scopus, Web of Science and Ovid MEDLINE for studies published between 1979 and 2019. We included the best available evidence, such as RCTs, non-randomised controlled clinical trials, case-control studies, cohort studies, and case series. About sixty articles were included in this review, four hundred and thirty-six were excluded after reviewing the title or abstract or because they weren't in English.

FINDINGS

The possible causes of "difficult" caesarean sections were divided into four categories: difficult access to the lower uterine segment; complicated fetal extraction, laceration or organ damage and abnormal placentation.

CONCLUSIONS

Knowing in advance the potential technical difficulties and resulting risks allows the surgeon to plan appropriate strategies.

Myoma praevia and pregnancy

The association of myoma and pregnancy is becoming more frequent due to the increasing age of first pregnancy. It may affect the outcome of fertility, pregnancy, labor and peripartum course. A 37 years old patient was referred to our unit for discovering uterine leiomyoma at 37 weeks of pregnancy. Ultrasound screening showed a praevia isthmic leiomyoma measuring 16cm. A caesarean delivery was scheduled and a large interstitial isthmic uterine myoma measuring 25cm was found. Hysterectomy was corporeal. The post-operative and puerperium course was normal.

Association between time from cessation of oxytocin infusion for labor to delivery and intraoperative severe blood loss during cesarean section: a retrospective cohort study

Aim: Prolonged oxytocin infusion during labor results in receptor desensitization and increases the risk of obstetric hemorrhage. We aimed to examine the association between recovery time (RT) and intraoperative severe blood loss in women who underwent a cesarean section after oxytocin pretreatment.Methods: We retrospectively assessed 103 Japanese women who underwent cesarean section after oxytocin pretreatment. RT (time from cessation of oxytocin infusion during labor to delivery) and intraoperative severe blood loss (active bleeding exceeding 1000 mL) were measured. Confounding factors were controlled, and RT cut-off value associated with severe blood loss and association between RT and intraoperative severe blood loss were assessed.Results: The mean maternal age was 34 years, and 100 (97.1%) women delivered at term. Mean RT was 121.6 min. The overall incidence of intraoperative severe blood loss was 22.3% (23/103). The cut-off point to predict intraoperative severe blood loss was 96 min (sensitivity, 65.2%; specificity, 81.3%). On multivariate analysis, an RT of ≤96 min [adjusted odds ratio (OR), 11.9; 95% confidence interval (CI), 3.32-42.7] and macrosomia (adjusted OR, 3.91; 95% CI, 1.10-13.8) were associated with intraoperative severe blood loss.Conclusions: Consideration of RT is helpful in the management of women undergoing cesarean section after oxytocin pretreatment.

Spontaneous expulsion of a huge cervical leiomyoma from the vagina after cesarean: A case report with literature review

RATIONALE

As more and more women delay their child bearing age, the prevalence of uterine fibroids during pregnancy is likely to increase.

PATIENT CONCERNS & LESSONS

We report a Chinese Tibetan case with spontaneous expulsion of a huge cervical myoma after cesarean. Decreased blood supply of the myoma and the uterine contraction may contribute to the spontaneous expulsion. Vaginal-myomectomy is recommended as the initial treatment.

Association between birth weight and massive haemorrhage in pregnancy with a low-lying placenta: a 9-year single-centre retrospective cohort study in Japan

A low-lying placenta is a well-known cause of a massive intrapartum haemorrhage. We aimed to evaluate whether neonatal birth weight deviation from the nationwide average could predict a massive haemorrhage during a delivery in the women with a low-lying placenta. This study included 40 women. The main outcomes were a massive haemorrhage and a neonatal birth weight deviation. We used a receiver operating characteristic curve analysis to determine the optimal birth weight deviation cut-off for predicting a massive haemorrhage. A multiple logistic regression model was used to identify the variables significantly associated with a massive haemorrhage. The best cut-off for predicting a massive haemorrhage was a birth weight deviation of +0.51 standard deviations (SDs) from the nationwide average. A birth weight deviation of ≥ +0.51 SDs was significantly associated with an increased massive haemorrhage risk. Impact statement What is already known on this subject? A low-lying placenta is a well-known cause of a massive intrapartum haemorrhage. Therefore, when managing pregnancies with a low-lying placenta, the possibility of severe perinatal bleeding should be considered, and it is desirable to determine reliable predictors of a haemorrhage. However, few studies have reported the predictive factors of a massive haemorrhage in patients with a low-lying placenta. What do the results of this study add? We demonstrated that a birth weight deviation from the nationwide average was significantly associated with a massive intrapartum haemorrhage in patients with a low-lying placenta. To our knowledge, this is the first study to clarify the association between a neonatal birth weight and a massive intrapartum haemorrhage incidence and to determine the optimal birth weight deviation cut-off for predicting a massive haemorrhage in patients with a low-lying placenta. What are the implications of these findings for clinical practice and/or further research? An accurate risk stratification using the foetal weight as a marker for a predicting massive intrapartum haemorrhage may help in the management of patients with a low-lying placenta. Studies with a larger sample size are required to confirm our findings.

An intramural uterine fibroid became submucosal in the puerperium - proposed probable mechanism: a case report

Background

Vaginal prolapse of a large uterine fibroid is a rare phenomenon in a woman who delivered vaginally recently, given that this fibroid might have obstructed labor. The author presents a case report of a vaginally prolapsed large pedunculated submucosal uterine myoma in a woman with a recent uncomplicated vaginal delivery.

Case presentation

A 25-year-old black African woman had four intramural uterine fibroids of diameters 62 to 94 mm diagnosed in April 2013 with standard ultrasound scan. She got pregnant in July 2014. An ultrasound scan done on 31 August 2014 at 10 weeks’ gestation identified four intramural uterine fibroids, with sizes varying from 70 to 150 mm. Her pregnancy was well followed up, without any complications. She had an uneventful vaginal delivery on 10 April 2015. During uterine exploration, indicated for retention of parts of fetal membranes, no pedunculated submucosal fibroid was found. On 15 May 2015, she consulted for difficult micturition and partial urinary retention that occurred 2 days ago. A vaginally prolapsed 10 cm uterine fibroid was diagnosed. Forty-eight hours after administration of intravenously administered broad spectrum antibiotics, the myoma was successfully twisted off by means of vaginal route under general anesthesia, which relieved her symptoms.

Conclusions

To the best of our knowledge, this is the first case of vaginally prolapsed large submucosal uterine fibroid in a woman who delivered vaginally recently. The author recommends that women with known large low situated uterine fibroid should be well observed during the postpartum period to diagnose a vaginally prolapsed uterine fibroid early, so as to prevent fibroid superinfection and obstructive complications.

Does Uterine Fibroid Adversely Affect Obstetric Outcome of Pregnancy?

Background

Fibroid is the most common benign tumor of the uterus and if associated with pregnancy may adversely affect the outcome of pregnancy. Objective of the present study was to assess the obstetric outcome (maternal and fetal) in pregnancy with fibroid.

Methods

A prospective observational study was performed over a period from May 2015 to August 2017 at Obstetrics and Gynecology Department in Zagazig University Hospitals, Egypt. 64 pregnant patients with >2 cm fibroid were taken in the study. Routine fundamental investigations were done for all. They were followed during antenatal period clinically and scanned by ultrasonogram which was done at booking visit and during subsequent visits to assess the change in the size of the fibroid and other obstetric complications. Maternal age, parity, size of fibroid, complications during pregnancy, and mode of delivery were noted.

Results

64 pregnant patients with uterine fibroids were recruited; 47 of them completed the study to the end. The average age was 31.80 ± 3.27 years, body mass index (BMI) [calculated as weight in kilograms divided by the square of height in meters] was 24.67 ± 2.46, primigravida was 23.4%, multigravida was 76.6%, duration of menstrual cycle/day was 29.68 ± 3.10, and duration of menstrual period/day was 6.46 ± 1.12. The percentage of spontaneous conception was 59.57% and 40.43% for using assisted reproductive technology. The results of obstetric outcome were spontaneous abortion in 2%, premature delivery in 27.7%, and delivery at 37–41 weeks of pregnancy in 70.2%. The mode of delivery was vaginal delivery in 15% and cesarean sections in 85%. Also, 34% had threatened miscarriage, 21% had preterm labor, 2% had antepartum bleeding in the form of placenta previa, 4% had abdominal pain needing admission, one of them underwent laparotomy and was diagnosed as red degeneration, 2 (4%) had postpartum hemorrhage, and only one needed blood transfusion. Cesarean sections were done in 85%. Neonatal outcome was acceptable with no perinatal mortality. There were no significant differences between patients with single or multiple fibroids as regards the obstetric outcome or type of fibroid either intramural or subserosal. The obstetric outcomes were not significantly affected by the number, size, or type of fibroids.

Conclusions

Even most of fibroids in pregnancy are asymptomatic but may be associated with some complications affecting the course of pregnancy and labor. So, pregnancy has to be cautiously screened in the antenatal period, through regular follow-up, to detect any adverse obstetric complications and so improve the outcome.

Outcome of Cesarean Myomectomy: Is it a Safe Procedure?

Objective

Myomectomy performed during cesarean section is still controversial because of the potential for associated complications, especially with large myomas. Many obstetricians avoid performing cesarean myomectomy procedures because of the risk of uncontrollable hemorrhage. However, the prevalence of pregnant women with myomas is increasing, leading to an increase in the likelihood that physicians will encounter this issue. The aim of this study was to compare outcomes and complications of patients who either had or did not have cesarean myomectomy.

Method

A total of 361 patients were evaluated in this retrospective study. Patients who had cesarean section with myomectomy and patients had cesarean section without myomectomy were compared with regard to demographics, drop in hemoglobin levels, complications, blood transfusion rates and duration of operation. These parameters were also compared when the diameter of the myoma was larger than 5 cm. Values of p < 0.01 and p < 0.05 were considered statistically significant.

Results

While maternal age and gravidity were similar in both groups (p > 0.05), the mean myoma diameter was smaller and the duration of operation was longer in the group who underwent cesarean myomectomy (p < 0.05). The reduction in hemoglobin level, rate of complications, and number of transfusions were similar in both groups (p > 0.05).

Conclusion

This study shows that myomectomy during cesarean section does not increase complications or transfusion rates and appears to be a safe procedure.

The uterine leiomyoma and placenta previa: a meta-analysis

Background: Some epidemiological studies have reported that uterine leiomyoma may increase the risk of placenta previa. To date, the meta-analysis has not been carried out for assessing the relationship between uterine leiomyoma and placenta previa. This meta-analysis was carried out to estimate the association between uterine leiomyoma and the risk of placenta previa. Methods: A systematic search was conducted out in major databases PubMed, Web of Science, and Scopus from the earliest possible year to June 2017. The heterogeneity across studies was explored by Q-test and I² statistic. The publication bias was assessed by Begg's and Egger's tests. The results were showed using odds ratio (OR) estimate with its 95% confidence intervals (CI) using a random-effects model. Results: The literature search included 1218 articles until to June 2017 with 255,886 women. Based on OR estimates obtained from case-control and cohort studies, there was significant association between uterine leiomyoma and placenta previa in studies adjusted (2.21; 95%CI: 1.48, 2.94). Conclusions: We showed based on reports in observational studies that uterine leiomyoma is a risk factor for placenta previa in studies adjusted.

Adverse obstetric outcomes in pregnant women with uterine fibroids in China: A multicenter survey involving 112,403 deliveries

Objective

To estimate the association between uterine fibroids and adverse obstetric outcomes.

Methods

This was a retrospective cross-sectional study of 112,403 deliveries from 14 provinces and 39 different hospitals in 2011 in mainland China. We compared pregnancy outcomes in women with and without uterine fibroids who underwent detailed second trimester obstetric ultrasonography during 18 to 22 weeks. Obstetric outcomes include cesarean delivery, breech presentation, preterm delivery, placenta previa, placental abruption, premature rupture of membranes and neonatal birthweight. Univariate analyses and multivariate logistic regression analyses were performed.

Results

Of 112,403 women who underwent routine obstetric survey, 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 (Adjusted odds radio [AOR] 1.8, 95% confidence interval [CI] 1.7–2.0), breech presentation (AOR 1.3, 95% CI 1.2–1.5) and postpartum hemorrhage (AOR 1.2, 95% CI 1.1–1.4). 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]).

Conclusion

Pregnant women with uterine fibroids are at increased risk for cesarean delivery, breech presentation and postpartum hemorrhage. And different characteristics of uterine fibroids affect obstetric outcomes through different ways. Such detailed information may be useful in risk-stratifying pregnant women with fibroids.

Rate of intrapartum cesarean section and related factors in older nulliparous women at term

AIM

The aim of this study was to determine the effect of maternal age on emergency cesarean section (CS) during labor, and to identify the independent risk factors for emergency CS.

METHODS

This was a retrospective cohort study using data from 2009 to 2014 from a tertiary perinatal care center in Japan. Inclusion criteria were maternal age ≥ 35 years, nulliparous singleton pregnancy at term and a cephalic presentation without indication of elective CS at onset of labor. The primary outcome was rate of emergency CS, while independent risk factors were elucidated using multivariate logistic regression analysis.

RESULTS

Of 953 women, 199 (20.9%) delivered by emergency CS. Rates of emergency CS were 18.3% (129/706) in women aged 35-39 years and 28.3% (70/247) in those aged ≥ 40 years (P < 0.01). Adjusted odds ratios (95% confidence intervals) of independent risk factors were 1.50 (1.03-2.18) for maternal age ≥ 40 years, 1.51 (1.06-2.17) for body mass index ≥ 25 kg/m² , 2.22 (1.24-3.98) for hypertensive disorder during pregnancy, 3.43 (1.31-8.95) for large-for-date fetus and 4.64 (3.23-6.69) for induction of labor.

CONCLUSIONS

The rate of intrapartum emergency CS in older nulliparous women at term was approximately 21%. Induction of labor should be recognized as a significant factor for emergency CS.

Myoma and myomectomy: Poor evidence concern in pregnancy

AIM

Summarize the results of the many, but often underpowered, studies on pregnancy complicated by myoma or myomectomy.

METHODS

Survey of the electronic PubMed database for the last two decades was conducted. We selected reviews, meta-analyses, case series, case reports, clinical studies only with statistical analysis, and guidelines from scientific societies.

RESULTS

Delaying childbearing leads to an increased incidence of pregnancy complicated by fibroids or previous myomectomy. Approximately 10-30% of pregnant women with myomas develop complications during gestation, at delivery and in puerperium. Submucosal, retroplacental, large and multiple myomas have a greater risk of complications. Cervical myomas, although rare, need careful management. The location and size of the fibroids should be assessed from the first trimester. Despite the increased risk of cesarean section, fibroids are not a contraindication to labor, unless they obstruct the birth canal or other obstetric conditions coexist. Myomectomy during pregnancy, in selected cases, is feasible and safe. Myomectomy cannot be considered a prophylactic measure prior to conception, but has to be individualized. Uterine rupture after myomectomy generally occurs in the third trimester or during labor and some associated risk factors have been identified. There is no consensus on the optimal interval between myomectomy and conception.

CONCLUSIONS

Pregnancy in patients with fibroids or previous myomectomy should be considered as high risk, requiring a maternal-fetal medicine specialist. To date available literature is inconsistent on evidence-based management. Further research is needed for definitive recommendations.

Ayurvedic Management of Recurrent Abortions due to Uterine Fibroid

Uterine fibroids are present in 30-70% of women of reproductive age. Uterine fibroids distort the uterine cavity. Therefore there is consensus of a negative impact on both the clinical pregnancy and delivery rates.[2] In addition, studies have also reported an increased risk of spontaneous miscarriage with submucosal fibroids. In biomedicine, myomectomy is considered the treatment of choice and Assisted Reproductive Technology is advised to overcome infertility. In Hārita Saṃhitā treatment is given for recurrent abortion (Garbhasrāvī). In this study, considering pitta doṣa and altered uterine receptivity (kṣetra duṣṭi) as causative factors, purgation (virecana karma) was done, enema (yoga basti) was given after post purgation protocol (saṃsarjana karma). After body purification (śodhana), garbhasthāpaka drugs were given to the patient for one month. Patient conceived in the second month with this treatment. In Antenatal Care, haematinics and calcium supplements and month wise Ayurvedic medication (Māsānumāsika kaṣāya) were given for nine months. Elective caesarean section ắs done after GA 38 weeks (USG) followed by inj. Wymesone 8 mg. The procedure uneventful. Thus proving Ayurvedic management of recurrent abortion due to uterine fibroid. It is cost effective and improves and normalises uterine receptive environment.

The effect of uterine leiomyoma on the risk of malpresentation and cesarean: a meta-analysis

BACKGROUND

some epidemiological studies have found that uterine leiomyoma can increase the risk of cesarean and malpresentation at term. To date, the meta-analysis has not been conducted for assessing the relationship between uterine leiomyoma and cesarean/malpresentation. This meta-analysis was conducted to estimate the association between uterine leiomyoma and the risk of cesarean/malpresentation.

METHODS

A literature search was conducted out in major databases PubMed, Web of Science, and Scopus up to September 2016. The heterogeneity across studies was conducted by Q-test and I² statistic. The publication bias was assessed by Begg's and Egger's tests. The results were shown using odds ratio (OR) estimate with 95% confidence intervals (CI) conducting a random-effect model.

RESULTS

The literature search included 1244 articles until September 2016 with 232,177 participants. Based on OR estimates obtained from case-control and cohort studies, there was significant association between uterine leiomyoma and cesarean (2.60; 95% CI: 2.02, 3.18) and between leiomyoma and malpresentation at term (2.65; 95% CI: 1.60, 3.70).

CONCLUSIONS

We showed based on reports in observational studies that uterine leiomyoma increased the risk of cesarean and malpresentation at term.

Relation between Birth Weight and Intraoperative Hemorrhage during Cesarean Section in Pregnancy with Placenta Previa

Background

Placenta previa, one of the most severe obstetric complications, carries an increased risk of intraoperative massive hemorrhage. Several risk factors for intraoperative hemorrhage have been identified to date. However, the correlation between birth weight and intraoperative hemorrhage has not been investigated. Here we estimate the correlation between birth weight and the occurrence of intraoperative massive hemorrhage in placenta previa.

Materials and Methods

We included all 256 singleton pregnancies delivered via cesarean section at our hospital because of placenta previa between 2003 and 2015. We calculated not only measured birth weights but also standard deviation values according to the Japanese standard growth curve to adjust for differences in gestational age. We assessed the correlation between birth weight and the occurrence of intraoperative massive hemorrhage (>1500 mL blood loss). Receiver operating characteristic curves were constructed to determine the cutoff value of intraoperative massive hemorrhage.

Results

Of 256 pregnant women with placenta previa, 96 (38%) developed intraoperative massive hemorrhage. Receiver-operating characteristic curves revealed that the area under the curve of the combination variables between the standard deviation of birth weight and intraoperative massive hemorrhage was 0.71. The cutoff value with a sensitivity of 81.3% and specificity of 55.6% was −0.33 standard deviation. The multivariate analysis revealed that a standard deviation of >−0.33 (odds ratio, 5.88; 95% confidence interval, 3.04–12.00), need for hemostatic procedures (odds ratio, 3.31; 95% confidence interval, 1.79–6.25), and placental adhesion (odds ratio, 12.68; 95% confidence interval, 2.85–92.13) were independent risk of intraoperative massive hemorrhage.

Conclusion

In patients with placenta previa, a birth weight >−0.33 standard deviation was a significant risk indicator of massive hemorrhage during cesarean section. Based on this result, further studies are required to investigate whether fetal weight estimated by ultrasonography can predict hemorrhage during cesarean section in patients with placental previa.

Are Women With Uterine Fibroids at Increased Risk for Adverse Pregnancy Outcome?

Uterine fibroids (leiomyomas) are common in reproductive age women. Most women with fibroids have uneventful pregnancies. The most common complication is painful degeneration. Are fibroids associated with adverse pregnancy outcomes? If so, can we predict which fibroids are most likely to cause complications? And is there anything that can be done to prevent these complications, such as performing a myomectomy before pregnancy? Here we review the published literature looking at the impact of uterine fibroids on adverse pregnancy events, such as miscarriage, preterm labor, placental abruption, fetal growth restriction, and fetal malpresentation. A series of clinical recommendations for the management of pregnancy in women with uterine fibroids are included.

[Management of uterine myomas during pregnancy]

OBJECTIVE

To assess the impact of myomas on pregnancy and discuss the role of myomectomy during cesarean section.

METHODS

Databases PubMed, Medline and Cochrane were searched until 30 June 2015.

RESULTS

The most commonly reported obstetric complications relative to fibroids are: increased rate of spontaneous miscarriage in women with submucosal or intramural fibroids, pain, placentation disorders and malpresentation. A higher cesarean section rate is found among pregnant women with fibroids. The most common postpartum complication is postpartum haemorrhage. For years, risk of haemorrhage led caregivers not to practice myomectomy during cesarean section. Current data are rather reassuring. No study shows significant hemorrhage differences between myomectomy during cesarean section and cesarean section alone or myomectomy alone. The long-term morbidity of myomectomy during cesarean section is not enough studied but does not appear higher than expected for fertility and complications during pregnancy. Therefore, myomectomy during cesarean section is not currently recommended by learned societies.

CONCLUSION

Women with fibroids is a common obstetric situation. Complications are rare. Myomectomy during cesarean section seems to be not associated with higher short-term maternal morbidity. But studies with a longer-term follow-up of patients are necessary.

The safety of cesarean myomectomy in women with large myomas

Objective

To evaluate the safety of cesarean myomectomy in large myomas sized >5 cm.

Methods

One hundred sixty-five pregnant women with myomas who delivered via cesarean section were identified. Ninety-six women had cesarean section without myomectomy, and 65 women underwent cesarean myomectomy. We compared the maternal characteristics, neonatal weight, myoma types, and operative outcomes between two groups. We further analyzed cesarean myomectomy group according to myoma size. The large myoma was defined as myoma >5 cm in size. The maternal characteristics, neonatal weight, and myoma types were compared between two groups. We also compared the operative outcomes such as preoperative and postoperative hemoglobin, operative time, and hospitalized days between two groups.

Results

There were no significant differences in the maternal characteristics, myoma types, neonatal weight and operative outcomes between cesarean section without myomectomy and cesarean myomectomy. The subgroup analysis according to myoma size (>5 cm or not) in cesarean myomectomy group revealed that there were no significant differences in the mean hemoglobin change (1.2 vs. 1.3 mg/dL, P=0.6), operative time (90.5 vs. 93.1 minutes, P=0.46), and the length of hospital stay (4.7 vs. 5.2 days, P=0.15) between two groups. The comparison of maternal characteristics, neonatal weight, and myoma types between two groups also showed no statistical significance.

Conclusion

Cesarean myomectomy in patients with large myomas is a safe and effective procedure.

Sonographic assessment of pregnancy co-existing with uterine leiomyoma in Owerri, Nigeria

BACKGROUND

Uterine myomas co-existing with pregnancy could cause obstetric complications.

OBJECTIVES

To assess sonographically the frequency of occurrence and effect of uterine myomas co-existing with pregnancy.

METHODS

A longitudinal study was conducted during a period of 23 months. A convenience sample of 816 consecutive consenting pregnant women who met the inclusion criteria was evaluated during routine prenatal ultrasound scan. The women were referred for prenatal sonography. One hundred of the subjects who had myoma co-existing with pregnancy and another 100 subjects without myoma were selected for follow-up. These groups were followed up till delivery and obstetric complications and outcomes were documented. Any changes in size and growth rate of myoma were documented.

RESULTS

Subjects with myoma co-existing with pregnancy were 12.3%. This was commoner with increasing maternal age. An increase was observed in myoma mean size from 60mm to 63mm from the 1(st) scan sequence to the 2(nd) scan sequence and a reduction from 63mm to 59mm in the 3(rd) scan sequence. Myoma growth rate was 0.667mm per week. Myomas in pregnancy especially large ones caused more complications during delivery when compared to pregnancies without myomas.

CONCLUSION

Routine sonography is important in pregnancy management of uterine myomas co-existing with pregnancy.

The health disparities of uterine fibroid tumors for African American women: a public health issue

Uterine fibroid tumors (leiomyomas) are the most common benign pelvic tumors in women and are the major indication for hysterectomy. Fibroid tumors are more common and more severe among African American women. Although this disease disproportionately affects the African American population, we understand little about what causes the disparity. Fibroid tumors should be considered a public health issue, given the magnitude of the problem and the costs of health care for this disease. In this review, we examine the burden of disease from fibroid tumors in the African American population and review the natural history, diagnosis, and treatment of uterine fibroid tumors, with emphasis on how these can differ, depending on race. We also focus on the socioeconomic burden caused by the disease and describe the anticipated influence of new health care reforms and funding mechanisms for fibroid tumor research.

Uterine leiomyomata and cesarean birth risk: a prospective cohort with standardized imaging

PURPOSE

To determine if women with leiomyomata detected using uniform ultrasound methods are at increased risk of cesarean birth, without regard to indication.

METHODS

Women were enrolled in Right from the Start (2000-2010), a prospective pregnancy cohort. Leiomyomata were counted, categorized, and measured during first trimester ultrasounds. Women provided information about demographics and reproductive history during first trimester interviews. Route of delivery was extracted from medical records or vital records, if the former were unavailable. Generalized estimating equations were used to calculate risk ratios (RR) and 95% confidence intervals (CIs) for the risk of cesarean birth by leiomyoma presence and characteristics.

RESULTS

Among 2635 women, the prevalences of leiomyomata and cesarean birth were 11.2% and 29.8%, respectively. Women with leiomyomata, compared with those without, had a 27% increase in cesarean risk (RR, 1.27; CI, 1.17-1.37). The association was weaker following adjustment for maternal body mass index and age (adjusted risk ratio [ARR], 1.11; CI, 1.02-1.20). The adjusted risk was elevated for women with a single leiomyoma 3 cm or more in diameter (ARR, 1.22; CI, 1.14-1.32) and women with the largest total leiomyoma volumes (ARR, 1.59; CI, 1.44-1.76).

CONCLUSIONS

Women with leiomyomata were at increased risk for cesarean birth particularly, those with larger tumor volumes.

The impact and management of fibroids for fertility: an evidence-based approach

Fibroids affect 35% to 77% of reproductive-age women. When selecting a treatment plan for symptomatic fibroids, the fibroid location, size, and number must be considered. Myomectomy remains the preferred method for women with fibroid-related infertility who wish to have children or maintain fertility. Currently available medical therapies reduce symptoms in the short term but may involve side effects when used long term. Initial fertility studies are encouraging but trials are needed. Recent medical advances have led to minimally invasive approaches for women with fibroid disease, but there is a strong demand for additional treatment options.

Leiomyoma: genetics, assisted reproduction, pregnancy and therapeutic advances

PURPOSE

Uterine leiomyomas are common, benign, reproductive tract tumors affecting a majority of reproductive aged women. They are associated with gynecologic morbidity and detrimentally affect reproductive potential. The etiology of leiomyomas is poorly understood and their diagnosis prior to treatment with Assisted Reproductive Technologies (ART) represents a management dilemma. The purpose of this paper is to review known genetic and molecular contributions to the etiologies of leiomyomas, describe their impact on ART outcomes and reproductive potential, and review alternative therapies and future directions in management.

METHODS

A critical review of the literature pertaining to genetic component of uterine leiomyomas, their impact on ART and pregnancy and leiomyoma therapeutics was performed.

RESULTS

Uterine leiomyomas are characterized by complex molecular mechanisms. Their location and size determines their potential detriment to ART and reproductive function and novel therapeutic modalities are being developed.

CONCLUSION

The high prevalence of uterine leiomyomas and their potential detrimental influence on ART and reproductive function warrants continued well-designed studies to ascertain their etiology, optimal treatment and novel less morbid therapies.

Neonatal outcomes in women with sonographically identified uterine leiomyomata

OBJECTIVE

We sought to compare perinatal outcomes between women with and without leiomyomata.

STUDY DESIGN

This is a retrospective cohort study comparing neonatal outcomes in women with and without uterine leiomyomata discovered at routine second trimester obstetric ultrasonography, all of whom delivered at a single institution. Potential confounders such as maternal age, parity, race, ethnicity, medical insurance, previous uterine surgery, fetal presentation, length of labor, mode of delivery, presence of placenta previa, placental abruption, chorioamnionitis, and epidural use were controlled for using multivariable logistic regression.

RESULTS

From 1993 to 2003, 15,104 women underwent routine second trimester prenatal ultrasonography, with 401 (2.7%) women identified with at least one leiomyoma. By univariate and multivariable analyses, the presence of leiomyomata was associated with statistically significant increased risks for preterm delivery at <34 weeks [adjusted odds ratio (AOR) 1.7, 95% confidence interval (CI) 1.1-2.6], <32 weeks (AOR 1.9, 95% CI 1.2-3.2), and <28 weeks (AOR 2.0, 95% CI 1.1-3.8). An association with increased risk for intrauterine fetal demise (IUFD) was also demonstrated (AOR 2.7, 95% CI 1.0-6.9). When IUFD was examined before and after 32 weeks' gestation, the finding only persisted at earlier gestational ages (<32 weeks: AOR 4.2, 95% CI 1.2-14.7 vs. >32 weeks: AOR 0.82, 95% CI 0.1-6.2).

CONCLUSION

Regardless of maternal age, ethnicity, and parity, pregnant women with leiomyomata are at increased risk for preterm birth and IUFD. This did not translate to lower birth weight outcomes among term patients, suggesting that LBW is more likely due to preterm birth than growth restriction. These results may be useful for preconception and prenatal counseling of women with leiomyomata.

At times, myomectomy is mandatory to effect delivery

BACKGROUND

Excision of a leiomyoma has never been a choice during caesarean section.

METHOD

Myomectomy of a massive fibroid was necessitated prior to delivering the baby.

RESULTS

Delivery of a healthy was effected by Classical caesarean section.

CONCLUSION

Leiomyoma in pregnancy is not an unknown entity and is a cause of concern for being a source of excruciating pain, at times, during the ongoing gestation.Although performed rarely, it is sometimes necessary to remove a large myoma to effect delivery of the baby during Cesarean section as is depicted in the case being presented hereunder.

[Leiomyoma during pregnancy: which complications?]

OBJECTIVE

We have observed the association between uterine leiomyomas and complications during pregnancy, delivery and post-partum among our patients over the last 10 years.

PATIENTS AND METHODS

We realized a retrospective case-control study comparing pregnancy and delivery outcomes in women with and without leiomyomas. In order to strengthen our observations, we conducted both univariate and multivariate analyses, and carefully respected 3 matching criteria between the two groups: age, parity and date of delivery.

RESULTS

Over a ten-year period, 117 (0.38%) women with at least one leiomyoma would give birth - among the 30,805 births registered in our unit. By multivariate analysis, the presence of leiomyomas was significantly associated with women's age over 35 (adjusted odds ratio [AOR] 2.48, 95% confidence interval (CI) [1.31-4.67]), smoking (AOR=4.3, [1.82-10.13]), cystitis (AOR = 6.55, [2.12-20.16]), hydramnios (AOR = 5.12, [1.57-16.65]), threatened preterm labor (AOR = 3.99, [1.66-9.56]), first trimester bleeding (AOR = 3.92, [1.62-13.26]), anaemia during pregnancy (AOR = 2.97, [1.30-6.78]), labor dystocia (AOR = 11.79, [2.80-49.56]), retained placenta (AOR = 4.25, [1.49-12.11] and neonatal pediatric intensive care (AOR = 4.44, [1.19-16.60]). Regarding cesarean delivery, the multivariate analysis found that women with several leiomyomas underwent 8.48 times more cesarean sections than women with a single leiomyoma (p = 0.001).

DISCUSSION AND CONCLUSION

Our study shows how specific features are to be kept in mind regarding obstetric outcomes for women with leiomyomas. These results emphasise the need for good perinatal care and raise the question of the treatment of those leiomyomas before pregnancy with the development of non-invasive procedures.