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Fibroids and Pregnancy

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Fibroids are a non-cancerous growth in the muscle of the uterus that is made up of the very same cells that make up the uterus. Now what really makes a fibroid worrying is its size, and believe me they can be as microscopic as it gets and also reach the size of a miniature football, or even larger at times (when neglected). They can grow anywhere in and around the uterus.

The most common type of fibroids are those that grow within the muscle wall of the uterus.  On an ultrasound examination the uterus appears to be bulky along with the very specific appearance and location of the fibroid. This variant of fibroids are called intramural (intra-within or inside, mural- wall)fibroids.

Subserosal (sub- below or close by from, serosa- membrane) fibroids grow outside the uterus resulting in symptoms caused by complications with surrounding structures.

The inner lining of the uterus is called the endometrium. The endometrium is shed during every menstrual cycle to maintain its function and integrity which is important to help with conception. When a fibroid grows under the endometrium it is called a submucosal fibroid (sub-below or close by from, mucosa- a lining). They are the least common type of fibroids, but can be the most concerning type as they can cause obstruction of the fallopian tubes or even the cervix preventing conception or implantation.

Cervical fibroids grow in the cervix which is the entrance of the uterus and presents with a common complication like submucosal fibroids, i.e. infertility.

Finally the last type of fibroids seen are more of a prefix to a diagnosis as they can develop in two of the above mentioned regions, the only difference being that they grow with a branch and are called pedunculated fibroids. Variants include pedunculatesubmucosal fibroids andpedunculatedsubserosal fibroids.

Now that we know what fibroids are and their various types let us come to the main topic of our socratic method of discussion thatis about how these fibroids can influence pregnancy and conception.

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As mentioned earlier, fibroids can influence pregnancy and conception and even result in infertility due to the following factors:

Size:

The size of a fibroid(s) can determine therisk it carries to causing symptoms in the individual and also affecting other functions. A larger fibroid can cause an increase in the size of the uterus making it bulky and more difficult to tolerate. The individual mainly complains of a very heavy uterus among other symptoms that include a heavy menstrual flow, irregular menstrual cycle, severe pelvic pain, and depending on its location even infertility (i.e. when it blocks the path through which the spermatozoa passes to reach the ova or the path through which the fertilized egg passes to get implanted on to the wall of the uterus)

Location:

Whether small or large the location makes an enormous difference as it can obstruct the pathway of either the spermatozoa or the fertilized egg (as discussed above)

Post-operative effects/complications:

Scar tissue develops as part of the body’s normal mechanism of healing, but it is important to note that scar tissue is not equivalent to normal tissue and so it is also not as strong as normal tissue. Once surgery is conducted to remove a fibroid, scar tissue formed results in weakening of the muscle wall and possibly even effect fertility

Fibroids during Pregnancy

As mentioned in our above discussion, the fetus grows on the endometrium after implantation, which is why the body goes about maintaining it by shedding and rejuvenating it every month. If at all pregnancy is confirmed and a fibroid (irrespective of location) is diagnosed, it is left untreated as any intervention can pose to be harmful to the fetus.

Careful monitoring of the pregnancy takes place to look for any possible interference by the fibroid on the pregnancy.

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The various symptoms that can occur with a fibroid uterus are:

These symptoms when seen in a pregnant woman due to the presence of fibroids are treated with a palliative approach (i.e. treat symptoms only to make the individual comfortable, and not the condition itself).

Although, in women who do not wish to retain pregnancy a surgical approach to remove the fibroid and discontinue pregnancy can be considered at the same time.

Complications of Fibroid Uterus in Pregnancy

In pregnant women, who have chosen to retain pregnancy and have been managed with a symptomatic approach the later stages of pregnancy (especially the third trimester) need to be well monitored. 

The possible complications can include:

  • Obstruction of the birth canal
  • More space being occupied by the fibroid leaving a lesser area for the fetus to grow in, resulting in growth restriction or even a miscarriage
  • Greater pelvic pressure and pain
  • Premature labor
  • Premature contractions that are caused by the fibroids when irritated

No matter what the situation or circumstance, trust your doctor and make sure you report every small detail or development to him/her and successful pregnancy, delivery,and a healthy fetus are not an unachievable target.

Treatment of fibroids during pregnancy

As mentioned earlier, only symptomatic treatment is considered during pregnancy, but postpartum a surgical approach can be considered a few months after delivery to remove the fibroid(s); or treat it conservatively, which can only help to reduce their size and minimize symptoms.

Surgical options include:

Myomectomy:

Removal of the fibroids without affecting the uterus. Can be performed laparoscopically or hysteroscopically.

Myolysis:

Procedure in which the blood circulation responsible for providing the fibroid(s) with nutrition are destroyed that in turn results in them slowly shrinking and eventually dying off.

Embolization:

Embolization is the process by which an embolus is introduced artificially into the blood circulation (usually into the target blood vessel). With uterine fibroid(s), we introduce embolic agents into the uterine artery, which is primarily responsible for supplying the fibroid(s) with nutrition. This again results in gradual shrinking and death of the fibroid(s).

Abdominal myomectomy:

Open surgery during which large, deep-seated or complicated multiple fibroids can be removed. Not always as effective, but is certainly a good substitute to hysterectomy.

Endometrial ablation:

During this process, the surgeon uses electric current to burn off and completely destroy the endometrium (inner lining of the uterus) along with destruction of the fibroids. Side effects include discontinuation of menstrual flow or cycle completely.

Hysterectomy:

Usually the last option, or considered in complicated cases, or in those women who have already served their reproductive age and do not wish to reproduce or have a menstrual cycle anymore. Includes complete surgical removal of the uterus. Can be accompanied with side effects like night sweats, hot flashes, early ageing, vaginal dryness, difficulty with sexual intercourse, reduced or loss of libido, mood fluctuations, etc.

Written by: Dr Shoaib Khan M.D (American system) General and Family Physician
Date posted:  May 05, 2015