Fibroid Complicating Pregnancy

Obstetrics

Clinicals - History

Fact Explanation
A female in the reproductive age Fibroids are benign neoplasms of the uterus which is common in the reproductive age of females. A female in the reproductive age
Fibroids are benign neoplasms of the uterus which is common in the reproductive age of females.
A family history of fibroids in first degree relative females There is a familial predisposition to have leiomyomas. A family history of fibroids in first degree relative females
There is a familial predisposition to have leiomyomas.
A history of subfertility/ assisted fertility Pre-existing uterine leiomyomas may interfere with fertility. A history of subfertility/ assisted fertility
Pre-existing uterine leiomyomas may interfere with fertility.
Abdominal pain Rapid onset/ sudden onset moderate-severe abdominal pain can indicate acute torsion of subserosal pedunculated leiomyomata or red degeneration of fibroid. Abdominal pain
Rapid onset/ sudden onset moderate-severe abdominal pain can indicate acute torsion of subserosal pedunculated leiomyomata or red degeneration of fibroid.
Probable red degeneration Patients with red degeneration presents with acute abdominal pain that could be severe and requiring sedation. The pathophysiology behind red degeneration is rapidly growing tumors outgrowing its blood flow and developing anoxia, necrosis, and infarction. The other theories that have been proposed are the growing uterus results in a change in the architecture (kinking) of the blood supply to the fibroid leading to ischemia and necrosis even in the absence of fibroid growth, and that the pain results from the release of prostaglandins from cellular damage within the fibroid It's more common in larger fibroids. i.e. >5cm in diameter, and during the first 10 weeks of pregnancy as the maximum growth happens during that time. Probable red degeneration
Patients with red degeneration presents with acute abdominal pain that could be severe and requiring sedation. The pathophysiology behind red degeneration is rapidly growing tumors outgrowing its blood flow and developing anoxia, necrosis, and infarction. The other theories that have been proposed are the growing uterus results in a change in the architecture (kinking) of the blood supply to the fibroid leading to ischemia and necrosis even in the absence of fibroid growth, and that the pain results from the release of prostaglandins from cellular damage within the fibroid It's more common in larger fibroids. i.e. >5cm in diameter, and during the first 10 weeks of pregnancy as the maximum growth happens during that time.
Fever Infection of a fibroid, the commoner causative organisms are Staphylococci or Streptococci. Fever
Infection of a fibroid, the commoner causative organisms are Staphylococci or Streptococci.
Acute urine retention Due to compression of a bulky uterus against the bladder and resultant outflow obstruction. Acute urine retention
Due to compression of a bulky uterus against the bladder and resultant outflow obstruction.
Vaginal bleeding Could be due to spontaneous miscarriage, placental abruption or placenta previa. Vaginal bleeding
Could be due to spontaneous miscarriage, placental abruption or placenta previa.
Uterus small for gestational age Due to the restriction of uterine space that is available for fetal growth. Uterus small for gestational age
Due to the restriction of uterine space that is available for fetal growth.
Malpositions or malpresentations i.e. breech presentation, transverse lie. Due to restricted uterine space. Malpositions or malpresentations
i.e. breech presentation, transverse lie. Due to restricted uterine space.
Preterm labour It's a common complication of fibroids in pregnancy. Preterm labour
It's a common complication of fibroids in pregnancy.

Clinicals - Examination

Fact Explanation
A palpable pelvic mass Sometimes the fibroid is palpable as a pelvic mass. In some instances, the uterine size will be more than expected according to the dates. A palpable pelvic mass
Sometimes the fibroid is palpable as a pelvic mass. In some instances, the uterine size will be more than expected according to the dates.
Signs of labor Look for signs of labor. i.e. cervical dilation, vaginal watery discharge, vaginal bleeding, evident contractions. Signs of labor
Look for signs of labor. i.e. cervical dilation, vaginal watery discharge, vaginal bleeding, evident contractions.
Obstetric examination For fundus, fetal lie and presentation. Obstetric examination
For fundus, fetal lie and presentation.

Investigations - Diagnosis

Fact Explanation
Ultrasonography It is the most frequently employed investigation. Trans-abdominal and trans-vaginal ultrasound scans should be performed, but trans-vaginal route gives the best image. In skilled hands can detect fibroids as small as 5 mm on transvaginal ultrasounds. Calcifications, degenerations and cystic changes also can be viewed. Complications of large fibroids also can be viewed. i.e. ureteric obstruction, hydronephrosis. Ultrasonography
It is the most frequently employed investigation. Trans-abdominal and trans-vaginal ultrasound scans should be performed, but trans-vaginal route gives the best image. In skilled hands can detect fibroids as small as 5 mm on transvaginal ultrasounds. Calcifications, degenerations and cystic changes also can be viewed. Complications of large fibroids also can be viewed. i.e. ureteric obstruction, hydronephrosis.
Doppler ultrasonography It shows the circumferential vascularity of the fibroid. Doppler ultrasonography
It shows the circumferential vascularity of the fibroid.

Investigations - Management

Fact Explanation
Complete blood count To exclude anemia and thrombocytopenia because a surgical management option could be inevitable. Complete blood count
To exclude anemia and thrombocytopenia because a surgical management option could be inevitable.

Management - Supportive

Fact Explanation
Patient education Educating the patient about the pregnancy outcome and management options, as well as counseling to ease her fears about the future. Patient education
Educating the patient about the pregnancy outcome and management options, as well as counseling to ease her fears about the future.
Pain management Best managed conservatively by bed rest, hydration, and analgesics. Out of analgesics, prostaglandin synthase inhibitors (eg, nonsteroidal anti-inflammatory drugs) should be used with caution, especially prolonged use (> 48 hours) in the third trimester where it has been associated with both fetal and neonatal adverse effects, including premature closure of the fetal ductus arteriosus, pulmonary hypertension, necrotizing enterocolitis, intracranial hemorrhage, or oligohydramnios. Sometimes severe pain may require additional pain medication (narcotic analgesia), epidural analgesia, or surgical removal. Pain management
Best managed conservatively by bed rest, hydration, and analgesics. Out of analgesics, prostaglandin synthase inhibitors (eg, nonsteroidal anti-inflammatory drugs) should be used with caution, especially prolonged use (> 48 hours) in the third trimester where it has been associated with both fetal and neonatal adverse effects, including premature closure of the fetal ductus arteriosus, pulmonary hypertension, necrotizing enterocolitis, intracranial hemorrhage, or oligohydramnios. Sometimes severe pain may require additional pain medication (narcotic analgesia), epidural analgesia, or surgical removal.

Management - Specific

Fact Explanation
Myomectomy Myomectomy in the first half of the pregnancy is rarely done, though it has been proved to be safe. Laparoscopic techniques can be used to have the best outcome. The acceptable indications are intractable pain from a degenerating fibroid especially if it is subserosal or pedunculated, a large or rapidly growing fibroid, or any large fibroid (> 5 cm) located in the lower uterine segment. The concern is that once surgical removal has been done, the mother might need a cesarean section to deliver because of the risk for uterine rupture. Myomectomy at the time of cesarean delivery should only be performed if unavoidable to facilitate safe delivery of the fetus or closure of the hysterotomy. Pedunculated subserosal fibroids can also be safely removed at the time of cesarean delivery without increasing the risk of hemorrhage. Myomectomy
Myomectomy in the first half of the pregnancy is rarely done, though it has been proved to be safe. Laparoscopic techniques can be used to have the best outcome. The acceptable indications are intractable pain from a degenerating fibroid especially if it is subserosal or pedunculated, a large or rapidly growing fibroid, or any large fibroid (> 5 cm) located in the lower uterine segment. The concern is that once surgical removal has been done, the mother might need a cesarean section to deliver because of the risk for uterine rupture. Myomectomy at the time of cesarean delivery should only be performed if unavoidable to facilitate safe delivery of the fetus or closure of the hysterotomy. Pedunculated subserosal fibroids can also be safely removed at the time of cesarean delivery without increasing the risk of hemorrhage.
Uterine artery embolization Bilateral uterine artery embolization is done to stop postpartum hemorrhage following cesarean section. Uterine artery embolization
Bilateral uterine artery embolization is done to stop postpartum hemorrhage following cesarean section.
Managing the delivery Managemnet of the delivery with facilities for emergency c-section or surgical correction of postpartum hemorrhage should be done with utmost care. Good maternal and neonatal outcomes are expected in pregnancies with uterine fibroids. Conservative management options should be applied where there is no immediate threat to the mother or the fetus. Managing the delivery
Managemnet of the delivery with facilities for emergency c-section or surgical correction of postpartum hemorrhage should be done with utmost care. Good maternal and neonatal outcomes are expected in pregnancies with uterine fibroids. Conservative management options should be applied where there is no immediate threat to the mother or the fetus.

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