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2001-04-12-14 Uterine myoma and pregnancy © Quintero www.thefetus.net/


Uterine myoma and pregnancy

Juan Carlos Quintero M. MD, Philippe Jeanty MD, PhD

Cali Colombia and Nashville, TN

Synonyms and definition:

Fibroid = Old term for uterine leiomyoma

Fibroleiomyoma = A leiomyoma containing non-neoplastic collagenous fibrous tissue, which may make the tumor hard. Fibroleiomyoma usually arises in the myometrium.

Leiomyoma = A benign neoplasm derived from smooth (nonstriated) muscle

Myoma = A benign neoplasm of muscular tissue.

Etymology:

Greek:

leios = smooth

muV = (myo) mouse or muscle

oma = tumor

Latin:

Fibra = fiber

Introduction: Fibroids are the most common benign tumor encountered in gynecologic practice. Present in more than 20% of women older than 35 years. More frequent in African American women. Consist in smooth muscle and connective tissue. Usually develop in the myometrium of the upper contractile fundal and corporeal portion of the uterus: (intramural, subserosus, submucosus, pedunculated), in the adnexa (intraligamentary), in the cervix (3 %)[1].

Etiology: Unknown. Estrogen-dependent, usually regress after menopause. During pregnancy the growth of fibroids is fastest during the first trimester[2].

Clinical presentation:

  • Multiple (usually) or solitary (2 – 5%).
  • Asymptomatic or symptomatic (palpable tumor, low abdominal pain, bleeding, infertility, torsion, ureteral obstruction, malignant changes to leyomiosarcoma in 0.2 %).
  • In pregnancy implicated in:
    • Abortion,
    • Threatened abortion (20 %)[3].
    • Preterm delivery,
    • Threatened preterm delivery,
    • Abruption placentae,
    • Increase cesarean section[4],
    • Intrauterine growth retardation,
    • Fetal malpresentation,
    • Premature rupture of the membranes,
    • Dystocia,
    • Retained placentae,
    • Postpartum hemorrhage (more than 500 cc).
  • The majority of complications during pregnancy depend
    • On the relative location of the fibroid to the placenta
    • On a location in the lower uterine segment,
    • Volume (bigger than 200 cc),
    • Echogenic structure [5] [6].
  • Others rare complications related with fibroids includes:
    • Intravenous leiomyomatosis with cardiac involvement[7].
    • Potential malignant changes during or after pregnancy[8].
    • Ureteral obstruction,
    • Sepsis,
    • Torsion may cause fever of unknown origin [9].

Sonographic findings: Mildly to moderately echogenic intrauterine mass(es) that cause nodular distortion of the uterine outline or myometrium. Degeneration may occur changing the appearance of the fibroid (carneus, hyaline, cystic, hemorrhagic) or calcification. May be located in the adnexa (intraligamentary) or pediculated.

 

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Implications for targeted examinations: Extended the ultrasound examination to differentiate uterine contraction from fibroid. In giant fundal fibroids recommend transvaginal ultrasound for better fetal anomaly diagnosis. Color Doppler may be used to asses flow within the fibroid and a physiological decrease in impedance in the uteroplacental circulation in pregnancy associated with fibroids, while the velocity of the radial arteries showed a significant increase between 10th and 14th week of gestation[10].

Differential diagnosis: Other solids masses (ovarian solid tumors, dermoid tumor), lymphoma, lymphangiomyoma[11].

Management: Conservative and ultrasound follow-up. Myomectomy during pregnancy is reserved to painful patients, suspicious of torsion, differential diagnosis or excessive growth of the mass.

References:


[1] Sonography in Obstetric and Gynecology (McGraw-Hill) 2001, Fleischer A, Manning F, Jeanty P, Romero R, Uterine Leiomyomata .Chap. 37 :961-965.

[2] Rosati P. The volumetric changes of uterine myomas in pregnancy.Radiol Med (torino) 1995 sep: 90 (3): 269-271).

[3] Piazze Garnica J, Gallo G, Marzano PF, Vozzi G, Mazzocco M, Ancachi MM, Rolfini G. Clinical and ultrasonographic implications of the uterine leiomyomatosis in pregnancy.Clin Exp Obst Gynecol 1995; 22 (4): 293-297).

[4] Vergani P, Ghidini A, Strbelt N, Roncaglia N, Locatelli A, Lapinski RH, Mangioni C. Do uterine Leiomyma influence pregnancy outcome ? Am J Perinatol 1994 sep; 11 (5) :356-8.)

[5] Exacoustos C, Rosati P. Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obste Gynecol 1993 Jul; 82 (5):881-882.

[6] Phelan JP. Myomas and pregnancy. Obstet Gynecol Clin North Am 1995 Dec; 22(4):801-805.)

[7] Marom D, Pitlik S, Sagie A, Ovadia Y, Bishara J.Am J Obstet Gyncol 1998 Mar; 178 (3) : 620-621.

[8] O`Connell MP, Jenkins DM, Curtain AW, Hughes PA, Doyle J. Benign cervical leyomioma leading to disseminated fatal malignancy. Gynecol Oncol 1996Jul;62(1):119-122.

[9] Ludwing M, Baumann P, Wolter-Kolbert F, Bauer O, FelberbaumR, Gembruch U, Diedrich K. Pregnancy and extreme myomatous uterus, conservative management. Zentralb Gynakol 1996; 118(9): 523-529.)

[10] Kurjak A, Kupesic-Urek S,Predanic M, Salihagic A. Transvaginal colos Doppler assesment of uteroplacental circulation in normal and abnormal early pregnancy. Early Hum Dev 1992 Jun-Jul;29(1-3):385-9.)

[11] Martin JP, PailleP, Caveriviere P, Galaup JL, Fournie A, Gouzi JL. Giant uterine leiomyoma and pregnancy. Clinical, radiologic, unusual histopathologyc aspects.Gynecol Obstet Biol Reprod (Paris) 1990; 19(3): 315-320.