Uterine Leiomyomas

Also known as myomas and erroneously called fibroids, uterine leiomyomas are benign
smooth muscle tumors commonly found during pregnancy. Rice and colleagues (1989)
reported that 1.4 percent of more than 6700 pregnancies were complicated by myomas.
Sheiner and co-workers (2004) cited an incidence of 0.65 percent in nearly 106,000
pregnancies. Katz and associates (1989) reported that 1 in 500 of all pregnant women were
admitted for a complication related to a leiomyoma.
Myomas may be located immediately beneath the endometrial or decidual surface of the
uterine cavity (submucous), immediately beneath the uterine serosa (subserous), or may be
confined within the myometrium (intramural). As an intramural myoma grows, it may
develop a significant subserous component, a submucous component, or both. Submucous
and subserous myomas may be pedunculated and may undergo torsion with necrosis. At
times, a subserous myoma may become parasitic, and much or all of its blood is supplied
through the highly vascularized omentum.
Myomas during pregnancy or the puerperium occasionally undergo red or carneous
degeneration that is caused by hemorrhagic infarction. The symptoms and signs are focal
pain, with tenderness on palpation, and sometimes low-grade fever. Moderate leukocytosis is
common. On occasion, the parietal peritoneum overlying the infarcted myoma becomes
inflamed, and a peritoneal friction rub develops. Myoma degeneration may be difficult to
differentiate from appendicitis, placental abruption, ureteral stone, or pyelonephritis, but
imaging techniques discussed subsequently will likely prove helpful (Kawakami and
associates, 1994).
Treatment of symptomatic myomas consists of analgesia and observation. Most often, signs
and symptoms abate within a few days, but inflammation may stimulate labor. Surgical
management will be discussed (see Myomectomy).
Infertility and Treatment
In spite of the relatively high prevalence of myomas in young women, it is not clear whether
they diminish fertility, other than by possibly causing early miscarriage (Stewart, 2001). In a
review of 11 studies, Pritts (2001) concluded that only submucous myomas had a significant
negative impact on fertility. He also reported that hysteroscopic myomectomy improved
infertility and early miscarriage rates in women with submucous tumors. Intramural
myomectomy is especially hazardous for subsequent pregnancy. Thus, when myoma
resection from the abdominal approach results in a defect into or immediately adjacent to the
endometrial cavity, uterine rupture may occur remote from labor and sometimes even early in
pregnancy (Golan and associates, 1990a). In these instances, cesarean delivery is
recommended before active labor begins.
Arterial embolization of uterine myomas has been used to treat symptomatic leiomyoma in
nonpregnant women. Many procedures are performed for uterine bleeding in perimenopausal
women (Walker and Pelage, 2002). Their effect on the outcomes of subsequent pregnancies is
unclear. Ravina and colleagues (2000) reported generally good outcomes. However, Goldberg
and associates (2002) reviewed 50 published cases and cited increased risks for preterm birth,
malpresentation, cesarean delivery, and postpartum hemorrhage. Because of the paucity of

data, the American College of Obstetricians and Gynecologists (2004) considers embolization
for leiomyoma investigational.
Effects of Pregnancy on Myomas
The stimulatory effects of pregnancy on the growth of uterine myomas may be impressive. It
originally made sense to assume that growth was stimulated via estrogen and progesterone
receptors. It now seems apparent, however, that normal rapid uterine expansion during
pregnancy results from a complex mechanism mediated not only by estrogen and
progesterone but also by growth factors that include platelet-derived growth factor, epidermal
growth factor, endothelin-1 (subtype ETA), and insulin-like growth factor 1 (Honor, 2000;
Ichimura, 1998; Rein, 1995, and all their associates). Angiogenic growth factors, basic
fibroblast growth factor, and at least one gene (HMGIC) are also involved (Stewart, 2001).
Estrogen receptors are reduced in normal myometrium during the secretory phase of the
menstrual cycle and during pregnancy (Benassayag and colleagues, 1999). In myomas,
estrogen receptors are present throughout the menstrual cycle, but they are suppressed during
pregnancy. Progesterone receptors are present in both myometrium and myomas throughout
the menstrual cycle and pregnancy. Thus, myoma growth in early pregnancy is stimulated by
similar hormonal and growth factors that cause normal uterine growth.
Paradoxically, myomas respond differently in individual women, and thus, accurate
prediction of their growth is not possible. For example, in the study shown in Table 404,
only half of myomas changed significantly in size during pregnancy. During the first
trimester, myomas of all sizes either remained unchanged or increased in sizea possible
early response to increased estrogen. During the second trimester, smaller myomas (2 to 6
cm) usually remained unchanged or increased in size, whereas larger myomas became
smallerprobably from initiation of estrogen receptor downregulation. Regardless of initial
myoma size, during the third trimester, myomas usually remained unchanged or decreased,
reflecting estrogen receptor downregulation.

Table 404. Ultrasonically Measured Changes in Myomas during Pregnancy

Small Myomas (26 cm) (n = 111)

Large Myomas (612 cm) (n = 51)

Trimester No Change Increase

No. (%)
No. (%)

Decrease
No. (%)

No Change Increase
No. (%)
No. (%)

Decrease
No. (%)

First

7 (58)

5 (42)

1 (20)

4 (80)

Second

42 (55)

23 (30)

11 (15)

11 (38)

4 (14)

14 (48)

Third

14 (61)

1 (4)

8 (35)

5 (29)

2 (12)

10 (59)

Modified from Lev-Toaff and co-workers (1987).

Effects of Myomas on Pregnancy

These common tumors are associated with a number of obstetrical complications, including
excessive preterm labor, placental abruption, fetal malpresentation, obstructed labor, cesarean
delivery, and postpartum hemorrhage (Davis, 1990; Hasan, 1990; Katz, 1989; Lev-Toaff,
1987; Rice, 1989; Sheiner, 2004; Winer-Muram, 1984, and all their colleagues). In a review
of pregnancy outcomes in 2065 women with leiomyoma, Coronado and co-workers (2000)
reported that placental abruption and breech presentation increased fourfold, first-trimester
bleeding and dysfunctional labor increased twofold, and cesarean delivery increased sixfold.
In a case-control study, Salvador and associates (2002) reported an eightfold second-trimester
abortion risk. They also concluded that genetic amniocentesis did not increase the risk of
midpregnancy loss in women with myomas.
The two factors most important in determining morbidity are myoma size and location.
Proximity to the placental implantation site is important (Table 405). Specifically, abortion,
placental abruption, preterm labor, and postpartum hemorrhage all are increased if the
placenta is adjacent to or implanted over a myoma. Tumors in the cervix or lower uterine
segment are particularly troublesome, because they may obstruct labor (Fig. 4012). Large
tumors distort anatomy and push the ureters laterally. A case of complete inferior vena caval
obstruction by a large myoma at 17 weeks was described by Greene and colleagues (2002).
Hemorrhage is more likely at cesarean delivery, and hysterectomy can be technically difficult
(Fig. 4013). In some cases, myomas that are contiguous with the birth canal may be carried
upward as the uterus enlarges. In many cases, the route of delivery can be decided before the
onset of labor.

Table 405. Pregnancy Complications and Relationships of the Myoma to the Placenta

Myoma (Percent)
Investigators

Complication

No Contact with
Placenta No. (%)

Contact with
Placenta No. (%)

Winer-Muram et al
(1984)

Bleeding and pain

5/54 (9)

8/35 (23)

Abortion

1/54 (2)

9/35 (26)

Preterm labor

5/35 (14)

4/35 (11)

Preterm labor

19/79 (24)

1/14 (7)

Abruption

2/79 (3)

8/14 (57)

27/133 (20)

35/49 (71)

Major complications

Postpartum
hemorrhage
Rice et al (1989)

Total

Figure 4012.

Major complications

Two uterine myomas (*), one posterior and one anterior, are seen in this 13-week pregnancy.
Arrows point to fetal head and body. (B = bladder.) (Courtesy of Dr. R. Santos.)

Figure 4013.

Cesarean hysterectomy specimen from the case shown in Figure 4012. The upper mass is
the body of the uterus which was just emptied by cesarean delivery. The lower mass is a
huge myoma arising low in the uterus. The infant weighed 3250 g, and the uterus with the
myoma weighed 2900 g.

Management of Myomas during Pregnancy

After the diagnosis is confirmed, expectant management is recommended.
Imaging of Myomas
Ultrasound is indispensable to correctly identify myomas and to follow their growth during
pregnancy (see Fig. 4012). There are limitations to sonography in evaluating myomas and
other pelvic masses (Exacoustos and Rosati, 1993; Kier and co-workers, 1990; Strobelt and
associates, 1994). Specifically, myomas have been confused with ovarian massesboth
benign and malignantas well as with molar pregnancy, ectopic pregnancy, missed abortion,
bowel abnormalities, and even the fetal head. In some cases the use of color Doppler may be
beneficial (Kessler and colleagues, 1993; Locci and associates, 1993).
MRI serves as an adjunct to ultrasound (Hricak and associates, 1992; Karasick and
colleagues, 1992; Kier and co-workers, 1990). Comparisons with ultrasonic imaging have
been made in the same women, and MRI was found to be superior (Weinreb and associates,
1990; Zawin and colleagues, 1990). MRI techniques have been described which markedly
improve the reliability of identifying uterine myomas (Mayer and Shipilov, 1995; Schwartz
and associates, 1998; Torashima and colleagues, 1998).
Myomectomy
Resection of myomas during pregnancy is generally contraindicated. We agree with most
other authorities that surgery should be limited to tumors with a discrete pedicle that can be
clamped and easily ligated (Burton and associates, 1989). Resection of intramural myomas
during pregnancy, or at the time of delivery, may stimulate profuse bleeding. In some cases,
unrelenting pain from infarction and degeneration prompts surgical treatment. De Carolis and
colleagues (2001) and Celik and associates (2002) have described good outcomes following
myomectomy in a total of 23 women. Most of the women were between 14 and 20 weeks,

and in almost 50 percent of cases, the surgery was performed because of pain. In some of
these cases, an intramural myoma was in contact with the implantation site. Except for one
loss immediately following surgery at 19 weeks, most women had cesarean delivery at term.
These investigators, as well as Mollica and associates (1996), emphasize that such
management is for highly selected cases. Jo and co-workers (2001) described antepartum
removal of a 940-g degenerating fundal myoma that caused fetal postural deformity and
oligohydramnios at 25 weeks. Postoperatively amnionic fluid volume normalized, and a
normal infant was delivered by cesarean at term.
Infection of Myomas Postpartum
Although puerperal pelvic infections and myomas are both fairly common, myomas rarely
become infected (Genta and colleagues, 2001). Myomas may become infected postpartum
when there is pelvic infection or septic abortion (Figure 4014). They are especially likely to
do so if the myoma is located immediately adjacent to the placental implantation site, or if an
instrument, such as a sound or curette, perforates the myoma.
Suspect myoma uteri
Anamnesis :

Bimanual exam

Menstruation disorder
Mass in lower abdominal

Pregnant test, USG

Myoma uteri in pregnancy 29-30 w + PPROM + IUGR

Estimate fetal weight : 1000 gr
Condition of mom and fetal good, no inpartu

Concervative treatment (28-34 weeks) if there is not other complication

-

Observe sign on inpartu

Sign and symptom of amnionitis
Antibiotic prophylaxis
Ultrasonoghraphy