Myomas and Pregnancy: A Case Report and Review of the Literature

F. Ouakka ¹, J.Rahmouni ¹, K. Saoud ¹, N. Mamouni ¹, S. Errarhay ¹, C. Bouchikhi¹,
A. Banani¹, G. El Mounssefe ²

1. Obstetrics gynecology I Department of the CHU HASSAN II, Faculty of Medicine, Sidi Mohamed Ben Abdellah University, FES, Morocco.

2. Radiology Department of the CHU HASSAN II, Faculty of Medicine, Sidi Mohamed Ben Abdellah University, FES, Morocco.

Corresponding Author: MD Ouakka Fatiha, Obstetrics gynecology I Department of the CHU HASSAN II, Faculty of Medicine, Sidi Mohamed Ben Abdellah University, FES, Morocco.

Copy Right: © 2023 MD Ouakka Fatiha, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: March 21, 2023

Published Date: April 01, 2023

Abstract

Myoma is the most common benign pelvic tumor in women, with a prevalence in the general population of between 20 and 50% of women of reproductive age [1]. During pregnancy, the frequency of myomas is estimated to be between 3 and 13% [1]. Their discovery in this context is all the more frequent as the age of patients at the time of their first pregnancy increases and the average number of ultrasounds performed during pregnancy has increased over the last 20 years. Fibroids are a source of obstetrical complications in pregnant women in 10 to 40% of cases: they can have consequences on fertility or complicate the evolution of the pregnancy, delivery and post-partum. We report the case of a large uterine myoma discovered during pregnancy in a primiparous woman [2].

Key words: Myoma, pregnancy, necrobiosis, restricted growth, delivery, myomectomy, hysterectomy.

Introduction

Uterine fibroid is the most common benign tumour in women of childbearing age. The probability? of the association of fibroids with pregnancy is therefore high. This probability? is constantly increasing, linked on the one hand to the later onset of pregnancies, knowing that the incidence of myomas rises progressively with age, and on the other hand to the emergence of ultrasound which reveals fibroids that were previously asymptomatic during systematic ultrasound scans of pregnancy. In most cases, there is mutual tolerance. However, fibroids can affect fertility or complicate the course of pregnancy, delivery and postpartum.

Case Report

This is Mrs F.E, aged 40, married for 10 months before her admission, with no notable pathological history, primiparous, who came to our centre for the management of pain

Abdominal and pelvic pain of progressive onset and accentuation in a pregnancy of 18 weeks' gestation, with no other associated signs, notably no metrorrhagia and no fever. The parturient was not monitored and did not have a dating ultrasound, the examination on admission found a conscious patient who was hemodynamically and respiratorily stable, apyretic, the obstetrical examination found an increased uterine height in relation to the gestational age, a supple abdomen, in a parturient who was out of labour, with an intact water bag.

Obstetrical ultrasound showed a progressive monofetal pregnancy in cephalic presentation, homogeneous fundal placenta, biometrics at 18-19 AUG, with the presence of a voluminous solidocystic image probably continuing with the uterine fundus measuring 14*13 cm, evoking either a myoma in cystic degeneration or an abdominopelvic mass, The exploration was thus completed by an abdominopelvic MRI which revealed a voluminous mass at the uterine level, fundial under serous of heterogeneous signal delimiting liquid zones within it in hyposignal T1 hypersignal T2, and a portion in connection with haemorrhagic remodelling, this lesion pushes up the transverse colon and compresses the anterior abdominal wall, it measures 14*13*11cm, aspect suggestive of a voluminous fundial myoma in aseptic necrobiosis, moreover, the ovaries are of normal size, no effusion.

Our conduct was to continue the clinical, ultrasound and biological monitoring of the pregnancy in our centre, which was regular in order to watch for other complications of fibroids during pregnancy, in particular Intrauterine growth restriction, especially given the fundial location of the myoma, which can reduce maternal- fetal flow and restrict growth. The patient presented pelvic pain managed by analgesics, the fetal growth was normal with eutrophic biometrics, concerning the delivery route, the vaginal route was accepted as the myoma was not prævia, with spontaneous labour at 37SA, the evolution of the labour was harmonious with vaginal delivery of a female newborn weighing 3000g,  with good adaptation to the extra-uterine life. The immediate and late post-partum effects were simple, notably no haemorrhagic, infectious or thromboembolic complications. Moreover, the surgical management of the myoma is scheduled in our centre.

Discussion

Fibroids are the most common benign tumour in women. Its prevalence, still rather uncertain, depends on several factors, the advanced age of the patient, ethnic variations, nulliparity, family predisposition as well as overweight because there is a positively significant association between obesity? and fibroid growth, probably through hyperestrogenism. In addition, there are also protective factors with regard to the development of fibroids: multiparity, oral contraception, low weight, late age of first menstruation and smoking because it acts as an anti-estrogen[3].

The presence of one or more myomas during pregnancy and childbirth is an obstetric situation that obstetricians are and will be increasingly confronted with due to the increase in the age of parturients and the improved ultrasound screening. Obstetrical complications related to the presence of myomas are known and not very frequent. There is a consensus that there is no indication for myomectomy during pregnancy except in exceptional cases[4].

The relationship between fibroids and pregnancy is threefold, but in most cases the combination of fibroids and pregnancy does not lead to complications for either [5,6]:

• Fibroids can prevent conception and nidation and be a factor of infertility?, according to Poncelet et al, the mechanisms allowing to explain infertility?  in case of myomas are an obstruction of the tubal orifices, a significant modification of the uterine cavity? forcing a longer path to the spermatozoa, a modification of the endometrial vascularization or even an endometrial erosion. Myomas as the only cause of infertility? are found in only 1 to 2% of patients.
• Fibroids can complicate the course of pregnancy, childbirth and the postpartum period.
• Pregnancy can facilitate the progression of fibroids to complications.

Influence of pregnancy on the evolution of fibroids:

• Evolution of the size of the fibroids: Monitoring of the evolution of the size of the fibroids is provided by ultrasound. Lopes et al [6] showed that 42.9% of the fibroids monitored between the first and third trimester had regressed? and 53.9% of the fibroids observed between the second and third trimester had not varied? in size. According to Hammond et al [7], 55.1%of fibroids had decreased? between the first and second trimester of pregnancy and 75.1% had also decreased in size between the second and third trimester.

Aseptic necrobiosis:

• The observed percentage of aseptic necrobiosis during pregnancy varies from 1.5% in Strobelt to 28% in DiLucca [3]. In two thirds of cases, these occur in the second trimester, as in our case. The diagnosis is purely histological in myomectomies, but ultrasound can contribute to the diagnosis by looking for changes in the echostructure. According to Lopes et al [6], there is no evidence that pregnancy has an adverse effect on the development of necrobiosis. Only the symptoms of necrobiosis need to be treated during pregnancy. Rest, analgesics and ice are sufficient to relieve the patient and are usually sufficient. Simple tocolytics should be prescribed if uterine contractions are present [3].

Torsion of a pedicle sub serosal fibroid: It is a rare complication, the diagnosis of which is difficult. Di Lucca [3], in his series of 476 cases found? no cases.

Compression disorders: These complications are also rare. The fibroid may cause compression of the neighbouring organs, in particular the ureter with ureteral dilatation and impact on the upstream kidney.

Influence of fibroids on pregnancy:

The involvement of fibroids in various pregnancy complications is highly controversial in the literature. Some studies tend to affirm that fibroids can be responsible for certain complications of pregnancy [6-8-9]. While for others, the association of fibroids and pregnancy does not lead in the vast majority? of cases to any complication.

Spontaneous miscarriage: Classically, in cases of fibroids associated with pregnancy, spontaneous abortions are more frequent, and this is related to the remodelling of the endometrium and the structure of the myometrium, the deformations of the uterine cavity? lead to aberrant implantation and poor development of the egg. The frequency of spontaneous abortions varies from 4% to 18% according to the authors [7].

Intrauterine growth restriction (IUGR) : Rosati [10] reports in his study that IUGR is found in the case of large fibroids by diversion of blood flow, it is 3.5% in the series by Lopes [6] and 3.75% in the series by DiLucca [11]. In the study by Delabarre et al [3], of the ten cases of intra uterine growth restriction, five could be linked to the presence of fibroids, leading to the assumption that a large myoma, especially a sub-mucosal one, is present, or polymyomatous uterus caused diversion of blood flow to the placenta for feeding. Monitoring in our casedid not reveal IUGR with satisfactory growth.

Placental abnormalities: The fibroid favours the vicious insertion of the placenta, which may insert itself more frequently on the lower part of the uterus or opposite the fibroid. These abnormalities, diagnosed on ultrasound, can cause haemorrhage in the second or third trimester.

Threatened preterm birth (TPB) and preterm births: The percentage of threatened preterm delivery? varies from 17.02 to 24.6% depending on the series [6]. As for preterm deliveries, their rate varies from 8.5% to 17% [6]. In the study by Delabarre et all [3], PAD was found in 20.3%. But only 7.6% can be linked to the existence of fibroids and it is polymyomatous uteruses with large myomas that are most responsible for PAD, or the presence of large subserous myomas of more than 10 cm, ora myoma in aseptic necrobiosis.

Dystocic presentations: Presentation abnormalities are more frequent. In the series by Lopes et al [6], apex presentation represents 81.2% compared to 92.7% in the control population. Furthermore, in this series, the incidence of breech presentation increases from 4% in a healthy uterus to 11% in a fibroid uterus.

The study by Delabarre et al[3] found 76.7% cephalic presentations, 20.5% podalic presentations and 2.7% transverse presentations. 59% of these dystocic presentations may be related to the presence of fibroids: due to polymyomatous uteri or large myomas of more than 10 cm pushing the fetus towards the uterine fundus, or to the presence of large isthmic or even previa myomas. These results seem to be in agreement and even higher than those found in the literature, showing an increased risk of dystocic presentations in the presence of fibroids, which can be explained by a lack of accommodation of the presentation and ampliation of the lower segment, hindered by cervical, isthmic or voluminous fibroids deforming the uterine cavity.

Mode of Delivery:

Natural delivery is still possible if the fibroid is not a prævia obstacle. Thus, most deliveries are successfully achieved by vaginal delivery under appropriate supervision.

In contrast, several studies by Coronado et al, Benson et al, Delabarre et all and Qidway et al [3,9,12,13], converge on the fact that the rate of caesarean section was significantly higher in the population with myoma during pregnancy than in the control population. This increased caesarean rate

This is explained by an increase in mechanical and dynamic dystocia, scarred uterus due to previous myomectomies and the presence of large isthmic fibroids preventing vaginal delivery, described as rare in the literature but found on seven occasions in our study[3].

Myomectomy during caesarean section

Given the risks of haemorrhage and the fragility? of the uterine scar, it is accepted that only myomectomies of necessity should be performed, when the fibroid is located on the lower segment or if, in a sub-serous position,it causes a risk of torsion [6].

Prophylactic myomectomy may be useful in asymptomatic patients to preserve fertility, prevent obstetrical risk in future pregnancies, and avoid potential complications of myoma (placenta previa, dystocic presentation, pain). To date, there is no data to recommend myomectomy for any of these indications [14].

Indeed, as far as fertility preservation is concerned, t h e current state of knowledge does not allow us to recommend a preventive myomectomy in the case of asymptomatic intramural or subserous myomas, especially if a pregnancy occurred in the presence of this myoma [14]. Only hysteroscopic myomectomy, with limited morbidity, at a distance from the caesarean section may be justified in case of submucosal myoma (type 0,1,2) even if a pregnancy has occurred in the presence of this myoma, since submucosal myomas can later have an impact on fertility [14].

Delivery:

In the study by Lopes et al [6], delivery haemorrhage affected? 7.3% of the population of women with a myomatous uterus compared to 1.8% for the control population. According to the study by Delabarre et all [3], 23.3% of patients with a fibroid during their pregnancy had a delivery haemorrhage. The increased risk of delivery haemorrhage in a myomatous uterus can be explained by the difficulties of uterine retraction and involution linked to the presence of a fibroid. In view of these results, patients should always be warned of the risks of haemostasis hysterectomy.

Conclusion

The association of fibroids and pregnancy is not uncommon, and the mutual risks of this association are generally low, which allows patients to be reassured. Of course, prudence requires regular clinical follow-up, monitoring based essentially on ultrasound and management by a team that can deal with the various complications.

Bibliography

1. Chauveaud-Lambling A, Fernandez H. Fibroids and pregnancy. J Gynecol Obstet Biol Reprod (Paris) 2004;30:750-61.

2. Lopes P, Thibaud S, Simonnet R, Boudineau M. Recommendations for clinical practice. Fibroids and pregnancy: what are the risks? J Gynecol Obstet Biol Reprod (Paris) 1999;28:772-7.

3. Association fibroma and pregnancy: about a study of 79 cases recorded at the Nancy Regional Maternity Hospital between January 2002 and December 2008, M.-N. Delabarrea,∗ T. Routiotb, T. Bouina

4. Rongières C. Recommendations for clinical practice: Epidemiology of fibroids, risk factors and frequency. Impact in santé publique. J Gynecol Obstet Biol Reprod (Masson, Paris). 1999; 28: 701-706.

5. CNGOF. Recommendations for clinical practice: Management of uterine fibroids. J Gynecol Obstet Biol Reprod. 1999; 28: 778- 779.

6. Lopes P, Thibaud S, Simonnet R, Boudineau M. Recommendations for clinical practice. Fibroids and pregnancy: what are the risks? J Gynecol Obstet Biol Reprod. 1999; 28: 772-777.

7. Hammoud AO, Asaas R, Berman J, Treadwell MC, Blacwell S, Diamond MP. Volume change of uterine myomas during pregnancy: do myomas really grow? J Minim Invasive Gynecol. 2006; 13: 386-390.

8. Poncelet C, Benifla JL, Darai E, Madelenat P. Myoma and infertility: review of the literature (Masson, Paris). J Gynecol Obstet Biol Reprod. 1999; 28: 761-767.

9. Coronado G, Marshall L, Schwartz S. Complications in pregnancy, labor, and delivery with uterine leiomyomas: a population- based study. Obstetrics & Gynecology. 2000; 95: 764-9.

10. Rosati P, Bellati U, Exacoustos C. Uterine myomas in pregnancy: ultrasound study. Int J Gynecol Obstet. 1989; 28: 109-117.

11. DiLucca D. Fibroma and pregnancy. A propos de 476 cas. Thesis, Paris. 1981.

12. Qidway G, Caughey A, Jacoby A. Obstetric outcomes in women with sonographically identified uterine leiomyomata. Obstet Gynecol. 2006; 107: 376-82.

13. Benson CB, Chow JS, Chang-Lee W, Hill JA, Doubilet PM. Outcome of pregnancies in women with uterine leiomyomas identified by sonography in the first trimester. J Clin Ultrasound. 2001; 29: 261-264.

14. Legendre G, Brun JL, Fernandez H. Place of myomectomies in situation of spontaneous conception J Gynecol Obstet Biol Reprod (Paris) 2011;40:875-94