Uterine fibroids in pregnancy
During pregnancy, due to hormonal effects and increased pelvic blood supply, fibroids grow rapidly in a short period of time and can become red and degenerative during pregnancy or puerperium. Fibroids often have adverse effects on pregnancy, such as miscarriage in early pregnancy; abnormal fetal position in late pregnancy, increasing the rate of surgical delivery and also causing placenta praevia; obstruction of the birth canal in late pregnancy, prolonging labor and increasing the chance of surgery; affecting uterine contraction after delivery, causing postpartum hemorrhage and late postpartum hemorrhage, etc.
Symptoms of uterine fibroids combined with pregnancy
Compression symptoms: myoma increases and can compress the adjacent organs, resulting in various symptoms, especially in the lower part of the uterine body and cervical myoma. Compression of the bladder may cause frequent urination, difficulty in urination or urinary retention; compression of the rectum may cause difficulty in defecation; in rare cases, compression of the ureter by broad ligament fibroids may cause hydronephrosis, and compression of the internal and external iliac veins and nerves may cause edema or neuropathic pain in the lower limbs.
Lower abdominal pain: There can be two conditions.
1, subplasmalemma can be twisted, mostly in the middle of pregnancy, the symptoms of acute twisting are sudden severe pain on one side of the uterus, abdominal wall sensitivity, accompanied by gastrointestinal symptoms (such as nausea, vomiting, etc.), and the painful area can be palpable masses;
2, pregnancy due to high levels of estrogen and progesterone, causing uterine smooth muscle tumor cell hypertrophy edema, especially before the fourth month of pregnancy is more obvious, can appear relative blood supply deficiency, causing the most common and most clinically important myoma red degeneration. The incidence of red metaplasia in uterine fibroids during pregnancy has been reported to be 5%-8%. It occurs mostly in late pregnancy and puerperium, and the pregnant woman complains of pain and refusal to press on a particular part of the uterus, accompanied by fever.
Vaginal bleeding: The incidence of miscarriage is 2 to 3 times higher in patients with fibroids than in pregnant women without fibroids. Submucosal fibroids prevent the fertilization of the egg or cause early miscarriage, while larger interstitial fibroids combined with pregnancy also cause miscarriage due to mechanical obstruction or uterine malformation. In the case of miscarriage, the presence of fibroids, lack of contraction of the uterine muscles and deformation of the uterine cavity often lead to incomplete miscarriage and excessive blood loss.
Examination of pregnancy combined with fibroids
1. Primary examination: ultrasound examination reveals both myoma and fetal sonograms. The uterus may be irregularly enlarged in shape, and hypoechoic areas are visible within the uterus, with boundaries between the uterine wall. Color Doppler ultrasound shows abundant ring or semi-ring flow around the tumor, and more abundant or punctate flow signal within the tumor, with a reduced mean resistance index (Rl) (uterine artery RI of 0.88±0.04 in normal women of childbearing age).
2. Secondary examination: When the source of solid parametrial mass cannot be determined by ultrasound or other examinations and needs to be differentiated from ovarian tumor or other pelvic masses, laparoscopy is feasible to directly observe the size, morphology, tumor growth site and nature of the uterus.
Diagnosis of uterine fibroids combined with pregnancy
Treatment summary: Combined pregnancy with uterine fibroids is almost always relieved by bed rest and administration of antibiotics. Intervention of fibroids early in pregnancy tends to lead to miscarriage and can be waited until mid-pregnancy. Myomectomy may be considered in mid-pregnancy. Small fibroids are not managed. Conservative treatment is preferred for clinical management, including psychological reassurance, bed rest, and appropriate antibiotic application. The cesarean delivery with myomectomy should be performed with attention to all matters.
Detailed treatment of uterine fibroids combined with pregnancy.
1.Treatment principles
It depends on factors such as gestational week, fibroid size and clinical manifestations. The strategy of conservative or “peaceful coexistence” is often adopted for uterine fibroids in pregnancy. If the fibroids are red and degenerative, bed rest and antibiotics can almost always relieve them, whether during pregnancy or puerperium. Myoma removal should be considered for subplasmalemma torsion, large fibroids (diameter >250px), and those with peritoneal irritation.
2.Specific treatment methods
(1) Early pregnancy combined with uterine fibroids: intervention of fibroids in early pregnancy may easily lead to miscarriage, and can wait until mid-pregnancy; if the fibroids are large, it is estimated that there are more chances of complications in continuing pregnancy, and the patient abandons the pregnancy, abortion can be performed first, and then myomectomy can be performed within a short period of time; or myomectomy can be performed at the same time of abortion.
(2) Mid-pregnancy combined with fibroids: asymptomatic patients can have regular prenatal checkups and most of them do not need special treatment; fibroids >150px in diameter may continue to grow as the uterus grows, and large fibroids are prone to red degeneration and stimulate uterine contractions or have symptoms of peritoneal irritation, so give conservative treatment such as antibiotics and suppression of contractions, and wait for the fetus to mature and deliver before reviewing the fibroids, which may shrink and then Then we can decide the treatment method.
(3) Combined uterine fibroids in late pregnancy: Small fibroids are not treated and can be delivered by cesarean section at full term without any symptoms. At present, it is considered safe to perform myomectomy during cesarean section, but the indications should be strictly controlled and individualized.
It is generally considered to be indicated in the following cases.
(i) submucosal myoma;
②Uterine fibroids with a tipped or mostly protruding subplasma;
(3) interstitial fibroids located near the incision or easy to perform uterine repair after myomectomy.
4, red degeneration of uterine fibroids treatment: clinical treatment preferred conservative treatment, including psychological comfort, bed rest, appropriate antibiotic application, such as regular contractions can be given contraction inhibitors. If conservative treatment is ineffective or the pain is too severe to be relieved, myomectomy is feasible. With strict indications and careful case selection for those for whom conservative treatment is ineffective, myomectomy during pregnancy is feasible when necessary and does not increase the rate of abortion. The procedure should preferably be performed before the 5th month of pregnancy.
5.Delivery period and postpartum complications management: Regarding delivery, it depends on the size and location of the fibroid and whether it obstructs the fetal descent, etc. Most of them do not affect vaginal delivery. If the fibroids are large, located in the pelvic cavity, or affect the contraction of the uterus, resulting in abnormal labor and stalled labor, cesarean section should be considered to reduce complications such as retained placenta, bleeding and infection. Myoma removal during cesarean delivery is safe and feasible and usually does not increase bleeding, but if combined with serious complications, the operation should be shortened as much as possible and performed under the premise of ensuring maternal safety.
Uterine fibroids can affect the contractility of the uterus and result in stalled labor and postpartum hemorrhage. The treatment during labor includes paying attention to the height of the previa and fetal orientation, monitoring the progress of labor, timely detection of obstructed labor and correction of obstructed labor. Postpartum management includes strengthening the application of uterine contraction drugs and the observation of uterine contraction and vaginal bleeding, and the treatment of postpartum bleeding in pregnancy with uterine fibroids focuses on interruption and prevention. The treatment of interstitial fibroids and submucosal fibroids affects the uterine rejuvenation and has the potential to lead to infection and late postpartum hemorrhage during the puerperium. The treatment includes the application of antibiotics in addition to strengthening contractions.
Care of uterine fibroids combined with pregnancy
After the diagnosis of uterine fibroids is confirmed, regular checkups should be conducted at the hospital. If the fibroid increases slowly or has not increased in size, it can be reviewed once every six months; if it increases significantly, surgery should be considered to avoid severe bleeding or compression of abdominal organs.
Avoid getting pregnant again. Women with fibroids have poor uterine recovery after abortion, which often causes prolonged bleeding or chronic genital inflammation.
For asymptomatic women, regular prenatal checkups are required to closely observe the development of fibroids until >37 weeks of gestation, when a decision on the mode of delivery is made based on the growth site of fibroids, the fetus and the pregnant woman.