|
| |
 |
|
| ORIGINAL ARTICLE |
|
| Year : 2021 | Volume
: 5
| Issue : 1 | Page : 12-16 |
|
Obstetric Outcome in Pregnancies Complicated with Fibroids: A Prospective Observational Study
Sheema Posh1, Suhail Rafiq2, Azhar Un Nisa Quraishi1, Saima Wani1
1 Department of Obstetrics and Gynaecology, SKIMS, Srinagar, Jammu and Kashmir, India
2 Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir, India
| Date of Submission | 05-Aug-2020 |
| Date of Acceptance | 20-Aug-2020 |
| Date of Web Publication | 12-Jan-2021 |
Correspondence Address:
Dr. Suhail Rafiq
Department of Obstetrics and Gynaecology, SKIMS, Srinagar, Jammu and Kashmir
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/MTSM.MTSM_39_20
Background: Fibroid is the most frequently recorded benign, monoclonal smooth muscle tumor of the uterus, affecting 20%–60% women of reproductive age. Being remarkably common, fibroids are an important health concern. Fibroids are the most frequent indication for the performance of hysterectomy. The health-care consequences of these tumors are substantial both for the mother as well as the fetus. Objective: The objective is to study the obstetric outcome in pregnancies complicated with uterine fibroids. Materials and Methods: This is an observational study conducted in the Department of Obstetrics and Gynaecology, SKIMS, Soura, Srinagar, from May 2019 to February 2020. A prospective evaluation of a series of 28 antenatal patients presenting with fibroids (>1 cm), who delivered in our hospital was done. Maternal age, parity, size of fibroid, type of fibroid, complications during pregnancy, and mode of delivery were noted. Ultrasonogram was done at booking visit and during subsequent visits to assess the size of the fibroid and degeneration. Obstetric outcome was assessed in terms of abortion, premature delivery, malpresentation, abruption, postpartum hemorrhage (PPH), subinvolution, and puerperal pyrexia. Fetal outcome was assessed in terms of intrauterine growth retardation (IUGR), low-birth weight, and neonatal intensive care unit (NICU) admissions. Results: Majority of the patients belonged to the age group of 25–29 years (35.7%), majority 19 (67.9%) were multigravida, most 17 (60.7%) of the fibroids were >3 cm in size. There were 2 (7.1%) cases of miscarriage, 6 (21.4%) cases of malpresentation, abruption in 2 (7.1%) cases, 3 (10.7%) had PPH and only 1 (3.6%) needed blood transfusion. A total of 18 (69.2%) patients delivered by lower segment caesarean section and 8 (30.7%) had vaginal delivery. Of 26 babies, 6 (23.1%) had low-birthweight, 2 (7.7%) were IUGR and there were 2 (7.7%) NICU admissions. Conclusion: Even though most of the fibroids in pregnancy are asymptomatic but such pregnancies should be considered as high risk pregnancies. Hence, pregnancy has to be cautiously screened in the antenatal period, through regular follow-up, to detect any adverse obstetric complications thereby improving fetomaternal outcome. Our study also suggests that reduction in fibroid size pre-pregnancy may play a vital role in preventing maternal and fetal complications which became inevitable once pregnancy reaches advanced gestation.
Keywords: Fetal complication, fibroid, leiomyoma, obstetric complication
How to cite this article:
Posh S, Rafiq S, Nisa Quraishi AU, Wani S. Obstetric Outcome in Pregnancies Complicated with Fibroids: A Prospective Observational Study. Matrix Sci Med 2021;5:12-6 |
How to cite this URL:
Posh S, Rafiq S, Nisa Quraishi AU, Wani S. Obstetric Outcome in Pregnancies Complicated with Fibroids: A Prospective Observational Study. Matrix Sci Med [serial online] 2021 [cited 2021 Apr 15];5:12-6. Available from: https://www.matrixscimed.org/text.asp?2021/5/1/12/306856 |
| Introduction | |  |
Fibroids in pregnancy are a commonly encountered clinical entity. The incidence of uterine leiomyomas in pregnancy is not uncommon, ranging from 1.6% to 10.7% depending on the size considered and the trimester of assessment.[1] The increased thickness of the myometrium complicates the detection and hence the true prevalence of fibroids in pregnancy may be much higher.[2] Most leiomyomas are asymptomatic during pregnancy and are usually diagnosed on routine ultrasound examination; however, they can be missed on ultrasonography due to physiological thickening of myometrium. The incidence of fibroids increases with maternal age at pregnancy.[3] Fibroids <5 cm in diameter tend to remain stable or decrease in size[4],[5],[6] and larger fibroids (>5 cm) tend to grow during the pregnancy. The risk of adverse events in pregnancy increases with the size of the fibroid.[7] Different complications with variable rates of incidence have been reported in pregnancy with fibroids which include ante-partum hemorrhage, acute abdomen, laparotomy, preterm labor, fetopelvic disproportion, malposition of the fetus, retention of the placenta, postpartum hemorrhage, red degeneration, dysfunctional labor, retained placenta, and retained products of conception, intrauterine growth restriction (IUGR).[8],[9],[10],[11],[12] These complications are more commonly seen with large submucosal and retroplacental fibroids.[7] Despite the high incidence of all these adverse events during pregnancy, perinatal outcomes in these patients tend to be fair.[10]
Aims and objectives
The paramount aim of our study is to determine the maternal and fetal outcomes among pregnant women with leiomyoma to modify the course of obstetric care for improved caregiving.
Inclusion criteria
- Age between 20 and 40 years
- Singleton pregnancy
- Single or multiple fibroids with size >1 cm
- Patients with first-trimester USG available.
Exclusion criteria
- Age <20 or >40 years
- Multiple pregnancy
- Pregnancy with medical complications (gestational hypertension, gestational diabetes mellitus, and obstetric cholestasis)
- Any surgical manipulation of uterus such myomectomy, resection of uterine septum, any uterine malformation.
| Materials and Methods | | |
This is a prospective observational study conducted in the Department of Obstetrics and Gynaecology, SKIMS, Soura, Srinagar, from May 2019 to February 2020. A prospective evaluation of a series of 28 antenatal patients presenting with fibroids (>2 cm), who delivered in our hospital was done. Appropriate history taking, clinical examination and all routine investigations were done for all the women included in the study. Informed consent (verbal and written) was obtained from all participants. Maternal age, parity, size of fibroid, type of fibroid, complications during pregnancy, delivery and postpartum, and mode of delivery were noted. These parameters were analyzed using Epi info software 2020 Epicor Software Corporation, Mumbai, Maharastra, India. Ultrasonogram was done at booking visit and during subsequent visits to assess the size and type of fibroid, degeneration, and other obstetric complications such as malpresentation and abruption. Obstetric outcome was assessed in terms of miscarriage, malpresentation, abruption, post-partum hemorrhage (PPH), subinvolution, puerperal pyrexia, and need of blood transfusion. Fetal outcome was assessed in terms of IUGR, low-birth weight, and neonatal intensive care unit (NICU) admissions.
Statistical analysis
Categorical variables described in terms of frequency. P value was calculated to assess the level of significance using Chi-square test with P < 0.05 being statistically significant.
| Results | | |
A total of 28 women who were having pregnancy with fibroids >1 cm were included in the study.
The majority of patients (35.7%) belonged to the age group of 26–30 years as shown in [Table 1].
The fibroids were more frequent in multigravidae 19 (67.9%) than in primigravidae 9 (32.1%) [Table 2].
The size of the fibroids was >*3 cm in 17 (60.7%) patients and <3 cm in 11 (39.3%) patients [Table 3].
The most common type of fibroid was intramural 17 (60.7%) [Figure 1],[Figure 2],[Figure 3],[Figure 4], while as submucosal type was found in 7 (25%) patients and subserosal in 4 (14.3%) patients [Table 4]. | Figure 1: Large anterior wall intramural fibroid extending to lower uterine segment seen during caesarean section.
Click here to view |
 | Figure 2: Anterior wall intramural fibroid seen during caesarean section.
Click here to view |
 | Figure 3: Ultrasound image revealing large posterior wall fibroid with small cystic degeneration adjacent to fetal head.
Click here to view |
 | Figure 4: Ultrasound image revealing large anterior wall fibroid with pregnancy.
Click here to view |
Of 28 women, 12 (42.9%) patients were asymptomatic. There were 2 (7.1%) cases of miscarriage, 6 (21.4%) cases of malpresentation and 2 (7.1%) cases of abruption. In our study, there were 3 (10.7%) cases of PPH and 1 (3.6%) patient needed blood transfusion. There was 1 (3.6%) case of puerperal pyrexia and 1 (3.6%) case of subinvolution [Table 5].
Out of 26 patients who continued with pregnancy, 8 (30.7%) patients delivered vaginally out of which 6 (75%) patients delivered at term and 2 (25%) patients had preterm delivery. Lower segment caesarean section (LSCS) was done in 18 (69.2%) patients out of which 14 (77.8%) patients had term delivery and 4 (22.2%) patients had preterm delivery [Table 6].
There were 2 (7.6%) cases of myomectomy.
Fetal complications were reported in 16 (23.07%) babies among which there were 6 (23.1%) cases of low-birth weight babies, 2 (7.7%) babies with IUGR, and 2 (7.7%) NICU admissions [Table 7].
There was no perinatal and maternal mortality in our study.
| Discussion | | |
In our study, most of the fibroids were seen in the age group of 26–30 years. It was similar to the studies conducted by Sarwar et al. and Poovathi et al.[13] proving its incidence in second and third decade of life. Most of the fibroids occurred in multigravida than in primigravida. This is inconsistent with earlier studies by Noor et al.[14] (73.33% multigravida and 23.66% primigravida) and Sarwar et al.,[15] (63% multigravida and 37% primigravida). High incidence of abortions in patients with fibroids is in agreement with results from earlier studies. The proposed mechanism is compressed endometrial vascular supply, affects the fetus adversely resulting in abortion.[16]
We noted 6 (21.4%) cases of malpresentation and 2 (7.14%) cases of abruption in our study. In our study, 3 (10.7%) patients had PPH, which is slightly less, compared with 14% in the study by Lam et al.[17] Only 1 (3.5%) patient needed blood transfusion in our study and there was only 1 (3.5%) case of subinvolution.
Regarding the mode of delivery, 8 (30.7%) patients had spontaneous onset of labor and vaginal delivery and 18 (69.2%) patients had LSCS. Women with fibroids have a 3.7-fold increased risk of cesarean delivery. Cesarean incidence in our study is similar to studies by Klatsky et al.[16] The incidence of preterm delivery was low (23.07%) in our study compared to study by Sarwar et al., (33.3%).[15]
In our study, 2 (7.6%) patients underwent myomectomy. One was 4 cm fibroid on anterior wall just near the stitch line and another was 5 cm subserosal fibroid with cystic degeneration. Myomectomy at the time of caesarean delivery causes severe hemorrhage and should be reserved only for subserous, pedunculated fibroids, and in selected cases of submucous fibroids.[18] However certain authors (Machado and colleagues) have demonstrated relative safety of caesarean myomectomy with fibroids >5 cm size in experienced hands in tertiary care centers with step wise devascularization and use of intrauterine Foley's balloon catheter use.[19]
Puerperal pyrexia was noticed in 1 (3.5%) patient with retained uterus which was managed conservatively.
| Conclusion | | |
Our study concludes that even though most of the fibroids in pregnancy are asymptomatic but pregnancy with fibroids should be considered as a high risk pregnancy as complications do occur thereby affecting the course of pregnancy and labor. Hence, pregnancy has to be cautiously screened in the antenatal period, through regular follow-up, to detect any adverse obstetric complications and so improve the fetomaternal outcome. Our study also suggests that reduction in fibroid size pre-pregnancy may play a vital role in preventing maternal and fetal complications which became inevitable once pregnancy reaches advanced gestation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Ouyang DW, Norwitz ER. Uterine Fibroids (leiomyomas): Issues in Pregnancy. UptoDate; 2019.  |
| 2. | Katz VL, Dotters DJ, Droegemeuller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynecol 1989;73:593-6. |
| 3. | Laughlin SK, Baird DD, Savitz DA, Herring AH, Hartmann KE. Prevalence of uterine leiomyomas in the first trimester of pregnancy: An ultrasound-screening study. Obstet Gynecol 2009;113:630-5. |
| 4. | Rice JP, Kay HH, Mahony BS. The clinical significance of uterine leiomyomas in pregnancy. Am J Obstet Gynecol 1989;160:1212-6. |
| 5. | Strobelt N, Ghidini A, Cavallone M, Pensabene I, Ceruti P, Vergani P. Natural history of uterine leiomyomas in pregnancy. J Ultrasound Med 1994;13:399-401. |
| 6. | Akhtar N, Sulthana S, Zabin F. Successful Outcome of pregnancy with large fibroid uterus-a case report. Bangladesh J Obstet Gynaecol 2010;25:87-9. |
| 7. | Ciavattini A, Clemente N, Delli Carpini G, Di Giuseppe J, Giannubilo SR, Tranquilli AL. Number and size of uterine fibroids and obstetric outcomes. J Matern Fetal Neonatal Med 2015;28:484-8. |
| 8. | Hasan F, Arumugam K, Sivanesaratnam V. Uterine leiomyomata in pregnancy. Int J Gynaecol Obstet 1991;34:45-8. |
| 9. | Katz VL, Dotters DJ, Droegemeuller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynecol 1989;73:593-6. |
| 10. | Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol 2008;198:357-66. |
| 11. | Koike T, Minakami H, Kosuge S, Usui R, Matsubara S, Izumi A, et al. Uterine leiomyoma in pregnancy: its influence on obstetric performance. J Obstet Gynaecol Res 1999;25:309-13. |
| 12. | Lev-Toaff AS, Coleman BG, Arger PH, Mintz MC, Arenson RL, Toaff ME. Leiomyomas in pregnancy: Sonographic study. Radiology 1987;164:375-80. |
| 13. | Sarwar I, Habib S, Bibi A, Malik N, Parveen Z. Clinical audit of foetomaternal outcome in pregnancies with fibroid uterus. J Ayub Med Coll Abbottabad 2012;24:79-82. |
| 14. | Noor S, Fawwad A, Sultana R, Bashir R, Qurat-ul A, Jalil H, et al. Pregnancy with fibroids and its and its obstetric complication. J Ayub Med Coll Abbottabad 2009;21:37-40. |
| 15. | Sarwar I, Habib S, Bibi A, Malik N, Parveen Z. Clinical audit of foeto maternal outcome in pregnancies with fibroid uterus. J Ayub Med Coll Abbottabad 2012;24:79-82. |
| 16. | Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: A systematic literature review from conception to delivery. Am J Obstet Gynecol 2008;198:357-66. |
| 17. | Lam SJ, Best S, Kumar S. The impact of fibroid characteristics on pregnancy outcome. Am J Obstet Gynecol 2014;211:395.e1-5. |
| 18. | Ouyang DW, Economy KE, Norwitz ER. Obstetric complications of fibroids. Obstet Gynecol Clin North Am 2006;33:153-69. |
| 19. | Machado LS, Gowri V, Al-Riyami N, Al-Kharusi L. Caesarean myomectomy: Feasibility and safety. Sultan Qaboos Univ Med J 2012;12:190-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
|
Search Pubmed for