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Pregnancy in women with uterine leiomyomas (fibroids)

Authors
David W Ouyang, MD
Errol R Norwitz, MD, PhD, MBA
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG

INTRODUCTION

Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus. The potential effects of fibroids on pregnancy and the potential effects of pregnancy on fibroids are a frequent clinical concern since these tumors are common in women of reproductive age. Most pregnant women with fibroids do not have any complications during pregnancy related to the fibroids. Pain is the most common problem, and there may be a slightly increased risk of obstetrical complications such as miscarriage, premature labor and delivery, abnormal fetal position, and placental abruption.

This topic will review issues specifically relating to pregnant women with uterine fibroids. Fibroids in nonpregnant women, including fertility issues, are discussed separately. (See "Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)" and "Reproductive issues in women with uterine leiomyomas (fibroids)".)

LIMITATIONS OF AVAILABLE INFORMATION

Several factors make it difficult to assess the impact of fibroids on pregnancy outcome and identify specific fibroid characteristics that are important. For example, the mechanisms whereby fibroids may cause adverse obstetric outcomes are not clearly understood. In addition, available evidence is difficult to interpret due to the heterogeneity of the study populations in these reports, which differ in fibroid number, size, location (lower uterus, fundus), and type (submucosal, intramural, or subserosal; pedunculated or sessile); gestational age at diagnosis; and method of ascertainment (eg, prospective versus retrospective study design). Lastly, small fibroids (<4 to 5 cm) may not be detected consistently because they can be difficult to distinguish from physiologically thickened myometrium.

PREVALENCE

The prevalence of uterine fibroids in pregnancy varies between 1.6 and 10.7 percent, depending upon the trimester of assessment and the size threshold [1-5]. In one study, 4 percent of 12,708 pregnant patients had fibroids with a diameter >3 cm [2]. In another, 1.6 percent of 12,600 consecutive pregnant patients had fibroids >1 cm [3]. A third series in over 15,000 women with nonanomalous singleton pregnancies undergoing routine second trimester ultrasonography reported that 2.7 percent had fibroids ≥1 cm [1]. A fourth series of 4271 first trimester or post-miscarriage ultrasound examinations observed 10.7 percent of women had a fibroid of ≥0.5 cm [4]. (See "Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)", section on 'Prevalence'.)

The prevalence of fibroids increases with age and is higher in African-American women than in white or Hispanic women [4]. Increasing parity and prolonged duration of breastfeeding are associated with a small, but statistically significant, reduction in prevalence [6].

                             

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Literature review current through: Nov 2016. | This topic last updated: Mon Jul 11 00:00:00 GMT 2016.
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References
Top
  1. Qidwai GI, Caughey AB, Jacoby AF. Obstetric outcomes in women with sonographically identified uterine leiomyomata. Obstet Gynecol 2006; 107:376.
  2. Exacoustòs C, Rosati P. Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obstet Gynecol 1993; 82:97.
  3. Strobelt N, Ghidini A, Cavallone M, et al. Natural history of uterine leiomyomas in pregnancy. J Ultrasound Med 1994; 13:399.
  4. Laughlin SK, Baird DD, Savitz DA, et al. Prevalence of uterine leiomyomas in the first trimester of pregnancy: an ultrasound-screening study. Obstet Gynecol 2009; 113:630.
  5. Stout MJ, Odibo AO, Graseck AS, et al. Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstet Gynecol 2010; 116:1056.
  6. Terry KL, De Vivo I, Hankinson SE, Missmer SA. Reproductive characteristics and risk of uterine leiomyomata. Fertil Steril 2010; 94:2703.
  7. Lev-Toaff AS, Coleman BG, Arger PH, et al. Leiomyomas in pregnancy: sonographic study. Radiology 1987; 164:375.
  8. Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics, 22nd ed, McGraw-Hill, New York 2005. p.962.
  9. Muram D, Gillieson M, Walters JH. Myomas of the uterus in pregnancy: ultrasonographic follow-up. Am J Obstet Gynecol 1980; 138:16.
  10. Winer-Muram HT, Muram D, Gillieson MS, et al. Uterine myomas in pregnancy. Can Med Assoc J 1983; 128:949.
  11. Aharoni A, Reiter A, Golan D, et al. Patterns of growth of uterine leiomyomas during pregnancy. A prospective longitudinal study. Br J Obstet Gynaecol 1988; 95:510.
  12. Rosati P, Exacoustòs C, Mancuso S. Longitudinal evaluation of uterine myoma growth during pregnancy. A sonographic study. J Ultrasound Med 1992; 11:511.
  13. Neiger R, Sonek JD, Croom CS, Ventolini G. Pregnancy-related changes in the size of uterine leiomyomas. J Reprod Med 2006; 51:671.
  14. De Vivo A, Mancuso A, Giacobbe A, et al. Uterine myomas during pregnancy: a longitudinal sonographic study. Ultrasound Obstet Gynecol 2011; 37:361.
  15. Ozturk E, Ugur MG, Kalayci H, Balat O. Uterine myoma in pregnancy: report of 19 patients. Clin Exp Obstet Gynecol 2009; 36:182.
  16. Ciavattini A, Delli Carpini G, Clemente N, et al. Growth trend of small uterine fibroids and human chorionic gonadotropin serum levels in early pregnancy: an observational study. Fertil Steril 2016; 105:1255.
  17. Benaglia L, Cardellicchio L, Filippi F, et al. The rapid growth of fibroids during early pregnancy. PLoS One 2014; 9:e85933.
  18. Hammoud AO, Asaad R, Berman J, et al. Volume change of uterine myomas during pregnancy: do myomas really grow? J Minim Invasive Gynecol 2006; 13:386.
  19. Laughlin SK, Hartmann KE, Baird DD. Postpartum factors and natural fibroid regression. Am J Obstet Gynecol 2011; 204:496.e1.
  20. Rice JP, Kay HH, Mahony BS. The clinical significance of uterine leiomyomas in pregnancy. Am J Obstet Gynecol 1989; 160:1212.
  21. Katz VL, Dotters DJ, Droegemeuller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynecol 1989; 73:593.
  22. Dildy GA 3rd, Moise KJ Jr, Smith LG Jr, et al. Indomethacin for the treatment of symptomatic leiomyoma uteri during pregnancy. Am J Perinatol 1992; 9:185.
  23. Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 2007; 87:725.
  24. Pollio F, Staibano S, Mansueto G, et al. Erythropoietin and erythropoietin receptor system in a large uterine myoma of a patient with myomatous erythrocytosis syndrome: possible relationship with the pathogenesis of unusual tumor size. Hum Pathol 2005; 36:120.
  25. Rahil A, Khan FY. Humoral hypercalcemic crisis in a pregnant woman with uterine leiomyoma. J Emerg Trauma Shock 2012; 5:87.
  26. Tarnawa E, Sullivan S, Underwood P, et al. Severe hypercalcemia associated with uterine leiomyoma in pregnancy. Obstet Gynecol 2011; 117:473.
  27. Lynch FW. Fibroid tumors complicating pregnancy and labor. Am J Obstet 1913; 68:427.
  28. Segars JH, Parrott EC, Nagel JD, et al. Proceedings from the Third National Institutes of Health International Congress on Advances in Uterine Leiomyoma Research: comprehensive review, conference summary and future recommendations. Hum Reprod Update 2014; 20:309.
  29. De Carolis S, Fatigante G, Ferrazzani S, et al. Uterine myomectomy in pregnant women. Fetal Diagn Ther 2001; 16:116.
  30. Benson CB, Chow JS, Chang-Lee W, et al. Outcome of pregnancies in women with uterine leiomyomas identified by sonography in the first trimester. J Clin Ultrasound 2001; 29:261.
  31. Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and problem pregnancies, 4th ed, Churchill Livingstone, Pennsylvania 2008. p.739.
  32. Wallach EE, Vu KK. Myomata uteri and infertility. Obstet Gynecol Clin North Am 1995; 22:791.
  33. Blum M. Comparative study of serum CAP activity during pregnancy in malformed and normal uterus. J Perinat Med 1978; 6:165.
  34. 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.
  35. Chen YH, Lin HC, Chen SF, Lin HC. Increased risk of preterm births among women with uterine leiomyoma: a nationwide population-based study. Hum Reprod 2009; 24:3049.
  36. Lai J, Caughey AB, Qidwai GI, Jacoby AF. Neonatal outcomes in women with sonographically identified uterine leiomyomata. J Matern Fetal Neonatal Med 2012; 25:710.
  37. Lam SJ, Best S, Kumar S. The impact of fibroid characteristics on pregnancy outcome. Am J Obstet Gynecol 2014; 211:395.e1.
  38. Shavell VI, Thakur M, Sawant A, et al. Adverse obstetric outcomes associated with sonographically identified large uterine fibroids. Fertil Steril 2012; 97:107.
  39. Roberts WE, Fulp KS, Morrison JC, Martin JN Jr. The impact of leiomyomas on pregnancy. Aust N Z J Obstet Gynaecol 1999; 39:43.
  40. Davis JL, Ray-Mazumder S, Hobel CJ, et al. Uterine leiomyomas in pregnancy: a prospective study. Obstet Gynecol 1990; 75:41.
  41. Vergani P, Ghidini A, Strobelt N, et al. Do uterine leiomyomas influence pregnancy outcome? Am J Perinatol 1994; 11:356.
  42. Coronado GD, Marshall LM, Schwartz SM. Complications in pregnancy, labor, and delivery with uterine leiomyomas: a population-based study. Obstet Gynecol 2000; 95:764.
  43. Winer-Muram HT, Muram D, Gillieson MS. Uterine myomas in pregnancy. J Can Assoc Radiol 1984; 35:168.
  44. Forssman L. Distribution of blood flow in myomatous uteri as measured by locally injected 133Xenon. Acta Obstet Gynecol Scand 1976; 55:101.
  45. Heinonen PK, Saarikoski S, Pystynen P. Reproductive performance of women with uterine anomalies. An evaluation of 182 cases. Acta Obstet Gynecol Scand 1982; 61:157.
  46. Worthen NJ, Gonzalez F. Septate uterus: sonographic diagnosis and obstetric complications. Obstet Gynecol 1984; 64:34S.
  47. Phelan JP. Myomas and pregnancy. Obstet Gynecol Clin North Am 1995; 22:801.
  48. Szamatowicz J, Laudanski T, Bulkszas B, Akerlund M. Fibromyomas and uterine contractions. Acta Obstet Gynecol Scand 1997; 76:973.
  49. Hasan F, Arumugam K, Sivanesaratnam V. Uterine leiomyomata in pregnancy. Int J Gynaecol Obstet 1991; 34:45.
  50. Sheiner E, Biderman-Madar T, Katz M, et al. Higher rates of tachysystole among patients with clinically apparent uterine leiomyomas. Am J Obstet Gynecol 2004; 191:945.
  51. Koike T, Minakami H, Kosuge S, et al. Uterine leiomyoma in pregnancy: its influence on obstetric performance. J Obstet Gynaecol Res 1999; 25:309.
  52. Vergani P, Locatelli A, Ghidini A, et al. Large uterine leiomyomata and risk of cesarean delivery. Obstet Gynecol 2007; 109:410.
  53. Michels KA, Velez Edwards DR, Baird DD, et al. Uterine leiomyomata and cesarean birth risk: a prospective cohort with standardized imaging. Ann Epidemiol 2014; 24:122.
  54. Graham JM, Miller ME, Stephan MJ, Smith DW. Limb reduction anomalies and early in utero limb compression. J Pediatr 1980; 96:1052.
  55. Romero R, Chervenak FA, DeVore G, et al. Fetal head deformation and congenital torticollis associated with a uterine tumor. Am J Obstet Gynecol 1981; 141:839.
  56. Matsunaga E, Shiota K. Ectopic pregnancy and myoma uteri: teratogenic effects and maternal characteristics. Teratology 1980; 21:61.
  57. Ciavattini A, Clemente N, Delli Carpini G, et al. Number and size of uterine fibroids and obstetric outcomes. J Matern Fetal Neonatal Med 2015; 28:484.
  58. Monga AK, Woodhouse CR, Stanton SL. Pregnancy and fibroids causing simultaneous urinary retention and ureteric obstruction. Br J Urol 1996; 77:606.
  59. Feusner AH, Mueller PD. Incarceration of a gravid fibroid uterus. Ann Emerg Med 1997; 30:821.
  60. Courban D, Blank S, Harris MA, et al. Acute renal failure in the first trimester resulting from uterine leiomyomas. Am J Obstet Gynecol 1997; 177:472.
  61. Lee WL, Chiu LM, Wang PH, et al. Fever of unknown origin in the puerperium. A case report. J Reprod Med 1998; 43:149.
  62. Nguyen QH, Gruenewald SM. Sonographic appearance of a postpartum pyomyoma with gas production. J Clin Ultrasound 2008; 36:186.
  63. Laubach M, Breugelmans M, Leyder M, et al. Nonsurgical treatment of pyomyoma in the postpartum period. Surg Infect (Larchmt) 2011; 12:65.
  64. Mason TC, Adair J, Lee YC. Postpartum pyomyoma. J Natl Med Assoc 2005; 97:826.
  65. Kobayashi F, Kondoh E, Hamanishi J, et al. Pyomayoma during pregnancy: a case report and review of the literature. J Obstet Gynaecol Res 2013; 39:383.
  66. Lin YH, Hwang JL, Huang LW, Chen HJ. Pyomyoma after a cesarean section. Acta Obstet Gynecol Scand 2002; 81:571.
  67. Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981; 36:433.
  68. Febo G, Tessarolo M, Leo L, et al. Surgical management of leiomyomata in pregnancy. Clin Exp Obstet Gynecol 1997; 24:76.
  69. Wittich AC, Salminen ER, Yancey MK, Markenson GR. Myomectomy during early pregnancy. Mil Med 2000; 165:162.
  70. Celik C, Acar A, Ciçek N, et al. Can myomectomy be performed during pregnancy? Gynecol Obstet Invest 2002; 53:79.
  71. Michalas SP, Oreopoulou FV, Papageorgiou JS. Myomectomy during pregnancy and caesarean section. Hum Reprod 1995; 10:1869.
  72. Glavind K, Palvio DH, Lauritsen JG. Uterine myoma in pregnancy. Acta Obstet Gynecol Scand 1990; 69:617.
  73. Mollica G, Pittini L, Minganti E, et al. Elective uterine myomectomy in pregnant women. Clin Exp Obstet Gynecol 1996; 23:168.
  74. Vitale SG, Tropea A, Rossetti D, et al. Management of uterine leiomyomas in pregnancy: review of literature. Updates Surg 2013; 65:179.
  75. Tower AM, Cronin B. Myomectomy after a vaginal delivery to treat postpartum hemorrhage resulting from an intracavitary leiomyoma. Obstet Gynecol 2015; 125:1110.
  76. Niebyl JR, Witter FR. Neonatal outcome after indomethacin treatment for preterm labor. Am J Obstet Gynecol 1986; 155:747.
  77. Moise KJ Jr. Effect of advancing gestational age on the frequency of fetal ductal constriction in association with maternal indomethacin use. Am J Obstet Gynecol 1993; 168:1350.
  78. Vermillion ST, Scardo JA, Lashus AG, Wiles HB. The effect of indomethacin tocolysis on fetal ductus arteriosus constriction with advancing gestational age. Am J Obstet Gynecol 1997; 177:256.
  79. Daniel S, Koren G, Lunenfeld E, et al. Fetal exposure to nonsteroidal anti-inflammatory drugs and spontaneous abortions. CMAJ 2014; 186:E177.
  80. Treissman DA, Bate JT, Randall PT. Epidural use of morphine in managing the pain of carneous degeneration of a uterine leiomyoma during pregnancy. Can Med Assoc J 1982; 126:505.
  81. Kwon SY, Lee G, Kim YS. Management of severely painful uterine leiomyoma in a pregnant woman with epidural block using a subcutaneous injection port. Acta Obstet Gynecol Scand 2014; 93:839.
  82. Moridaira T, Yamamoto G, Hiraishi M, et al. [A case of continuous epidural anesthesia for pain relief in a pregnant woman with uterine myoma in the second trimester of pregnancy]. Masui 2013; 62:1253.
  83. Straub HL, Chohan L, Kilpatrick CC. Cervical and prolapsed submucosal leiomyomas complicating pregnancy. Obstet Gynecol Surv 2010; 65:583.
  84. Kilpatrick CC, Adler MT, Chohan L. Vaginal myomectomy in pregnancy: a report of two cases. South Med J 2010; 103:1058.
  85. Tian J, Hu W. Cervical leiomyomas in pregnancy: report of 17 cases. Aust N Z J Obstet Gynaecol 2012; 52:258.
  86. Ehigiegba AE, Ande AB, Ojobo SI. Myomectomy during cesarean section. Int J Gynaecol Obstet 2001; 75:21.
  87. Liu WM, Wang PH, Tang WL, et al. Uterine artery ligation for treatment of pregnant women with uterine leiomyomas who are undergoing cesarean section. Fertil Steril 2006; 86:423.
  88. Spong CY, Mercer BM, D'alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118:323.
  89. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol 2013; 121:908.
  90. Gambacorti-Passerini Z, Gimovsky AC, Locatelli A, Berghella V. Trial of labor after myomectomy and uterine rupture: a systematic review. Acta Obstet Gynecol Scand 2016; 95:724.
  91. Nezhat C. The "cons" of laparoscopic myomectomy in women who may reproduce in the future. Int J Fertil Menopausal Stud 1996; 41:280.
  92. Matsunaga JS, Daly CB, Bochner CJ, Agnew CL. Repair of uterine dehiscence with continuation of pregnancy. Obstet Gynecol 2004; 104:1211.
  93. Gyamfi-Bannerman C, Gilbert S, Landon MB, et al. Risk of uterine rupture and placenta accreta with prior uterine surgery outside of the lower segment. Obstet Gynecol 2012; 120:1332.
  94. Levine D, Hulka CA, Ludmir J, et al. Placenta accreta: evaluation with color Doppler US, power Doppler US, and MR imaging. Radiology 1997; 205:773.