Large leiomyomata can also cause acute and subacute prolonged pelvic pain or pressure and menorrhagia.1,2
While we know fibroids originate from the myometrium, the underlying aetiology is still unclear. It is believed genetic predisposition and effects of oestrogen and progesterone on fibroid growth may both be significantly involved.3
What we do know is that fibroids are common in the majority of women of reproductive age. Up to 60% of women will develop fibroids by age 35 years and up to 80% by age 50 years.2 On ultrasound imaging most women will present with only one fibroid, however four or more fibroids are common in about 20% of women.4
Fibroids are classified by their location, which in turn affects the symptoms they cause and their influence on fertility.
least common fibroid
grow within myometrium
are associated with reduced fertility and increased miscarriage rate5
most common fibroid
grow within uterine wall
may be associated with reduced fertility & increased miscarriage rate5
grow on the outside serosa
can be attached by a stalk (pedunculated)
do not appear to have significant effect on fertility5
While the majority of fibroids do not show significant growth during pregnancy, approximately 10 to 30% of women with fibroids will develop complications during pregnancy.6 Around one third of fibroids will grow in the first trimester with little or no growth in the second or third trimesters.2 In fact, 22% to 32% of fibroids will most likely grow within the first 10 weeks of gestation.2
The most common complication of fibroids in the first trimester is spontaneous miscarriage. This is dependent on the location rather than the size or number of fibroids, with early miscarriage linked to submucosal and intramural fibroids as well as those in the center of the uterus.2 Close implantation of the placenta to the fibroid also increases the risk of first trimester bleeding.2
The most common complication of fibroids in the second and third trimesters is pain. Red degeneration or haemorrhagic necrosis of a growing fibroid is most commonly associated with severe, localised abdominal pain, fever.2 Larger fibroids, >5cm are also associated with pain in the second and third trimesters.2
Third trimester and delivery
In the third trimester, it is more common for fibroids to decrease in size.2 In contrast to first trimester miscarriage, multiple fibroids and those impacting on the placenta are risk factors for preterm labour.2
If medical management for third trimester fibroids is being considered, certain medications such as prostaglandin synthase inhibitors should be avoided beyond 32 weeks’ gestation to reduce foetal complications such as oligohydramnios and premature constriction of the ductus arteriosus.4
Considerations for delivery include scheduling caesarean section at 37 to 48 weeks,4 noting that in general, neonatal birth weight at delivery in women with fibroids can also be lower. In women with prior myomectomy, uterine rupture is also a consideration before and during labour.4
Third trimester fibroids also increase the risk of malpresentation (transverse lie and breech delivery). Furthermore, they may prevent a natural delivery especially if they are in the lower uterine segment, preventing the baby from descending into the birth canal. These are particularly troublesome with caesarean sections, often leading to difficulties with the surgeon having to cut through the fibroids in order to reach the baby.
Uterine fibroids may also hinder the contraction of the uterus, and hence increase the chances of postpartum haemorrhage. Bleeding can be difficult to control and may not response to usual treatment. A proper and careful planning of delivery with some of these fibroids is mandatory.
Overall postpartum, 36% of fibroids will resolve with the remainder reducing in size.4
Infertility and fibroid management
Fibroids are detected in 5 to 10% of women with infertility.1 Various factors may impact fertility including impaired gamete transport, impaired implantation, chronic endometrial inflammation, endometrial cavity anatomic distortion, impaired endometrial blood supply, increased uterine contractibility and local hormonal imbalance.1
Given the role of submucosal fibroids infertility and recurrent miscarriage, medical management is not recommended and it can delay conception efforts.5 Myomectomy remains the standard treatment for fibroids and it is established that myomectomy for submucosal and intramural fibroids significantly improves fertility outcomes.7
Hysteroscopic myomectomy in particular for submucosal fibroids has been shown to improve fertility outcomes.5 The current recommendation for intramural fibroids is surgical removal in infertile couples with two failed ART cycles who also have other unexplained infertility. There is no surgical recommendation for subserosal fibroids.
Robotic surgery and myomectomy
Robotic surgery has developed rapidly in gynaecology since it was first introduced in 2005.8 It is applied widely for hysterectomy, sacrocolpopexy, myomectomy, adnexal surgery and malignancy staging. At Hurstville Private we have been using robotic surgery over the last few years to remove fibroids.
The benefits of robotic myomectomy include a lower risk of complications, shorter hospital and faster recovery time. Further, robotic myomectomy is well placed to remove those fibroids, which are difficult to remove with conventional surgery or in patients who are obese.8
While submucosal fibroids are typically removed by hysteroscopy, robotic myomectomy is more common for intramural and subserosal fibroids and robotic assisted laparoscopy for hysterectomy.
As uterine fibroids significantly increase the risk of complications during pregnancy and delivery, it is recommended that all women with uterine fibroids undergo a pre-pregnancy planning review. At this consultation, a thorough discussion on the benefits and complications of removing fibroids before trying for pregnancy should be discussed in detail. Furthermore, a time line for falling pregnant, should a myomectomy be performed, should also be discussed.
In early pregnancy, close monitoring of fibroids is important. As we know, fibroids have several negative impacts on pregnancy including miscarriage. Close monitoring of the pregnancy is mandatory particularly during the second trimester as complications such as red degeneration of fibroids are common. A proper management plan for all these complications can improve outcomes.
Further, a management plan regarding delivery should be agreed upon. Preventing complications is mandatory and the mode of delivery needs to be discussed in detail, keeping in mind the safety of both mother and baby, while respecting a mother’s wishes at the same time.
Close monitoring post delivery is also required to prevent complications and particularly postpartum haemorrhage. Further, all surgical and medical staff should be prepared to implement management plans should complications occur.
Dr Tony Bushati is a highly experienced obstetrician and gynaecologist with a patient focused philosophy and a passion for providing high quality care in women’s health.
He has been practicing across Sydney for more than 15 years throughout the St George District and Sutherland Shire, as well as in the Northern Beaches.
Dr Bushati covers a broad range of obstetric and gynaecological services from emergency gynaecological care to advanced laparoscopic and hysteroscopic surgeries, to holistic pregnancy care and pre-pregnancy counselling.
Dr Bushati has a particular interest in robotic assisted gynaecological surgery and IVF and is committed to 24/7 availability for his patients.
T (02) 8524 2011
203/31 Dora Street
Hurstville, NSW, 2220
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3. Flake PG, Andersen J, Dixon D. Etiology and pathogenesis of uterine leiomyomas: a review. Environmental Health Perspectives. 2003;111(8):1037-1057.
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6. Katz VL, Dotters DJ, Droegemeuller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynecol. 1989 Apr;73(4):593-6.
7. 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;198:357-366.
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