2. Definition
“A benign(non-caseous) tumor arising from the smooth
muscles layer and accompanying connective tissue of the
uterus”
fibroid is chiefly composed of smooth muscle fibres & a small
amount of connective tissue.
The name fibroid is a misnomer, more appropriate term for
this tumor of smooth muscle is Myoma or Leiomyoma.
3. Classification of fibroids
• Intramural fibroids
• Subserosal fibroids
• Submucous fibroids
Within Body of
uterus
Cervical
Intraligamentary
5. EFFECTS OF FIBROID ON
PREGNANCY
May be none
Abortion (submucous fibroid)
Pressure symptoms due to impaction of
(a) Bladder - retention of urine
(b) Rectum - constipation
Red degeneration
Malpresentation (Four fold risk)
Preterm labor and prematurity
Non-engagement of the presenting part
6. EFFECTS ON LABOR
May be unaffected
Uterine inertia
Dystocia
Obstructed labor
Postpartum hemorrhage due to atonicity or adherent
placenta
Difficult cesarean section (Eight fold risk)
7. EFFECTS ON PUERPERIUM
Subinvolution
Inversion of uterus
Secondary PPH
Sepsis
Lochiometra and pyometra.
8. EFFECTS OF PREGNANCY ON
FIBROID
Changes in size – increases (?)
Changes in position
Changes in shape - becomes flattened
Degenerative changes specially, red degeneration
Torsion of pedunculated subserous fibroid
Infection and polypoidal changes are more in
puerperium.
9. EFFECTS OF PREGNANCY ON
FIBROID
Changes in size – increases (?)
Fibroid is an estrogen dependent tumor.
Pregnancy is a progesterone predominant state.
So how does fibroid increases in size during pregnancy?
10. EFFECTS OF PREGNANCY ON
FIBROID
Actually, most fibroids do not increase in size during
pregnancy.
69% - had no increase in fibroid volume throughout
pregnancy
31% - noted increase in fibroid volume, greatest increase
before 10th week of gestation and a reduction to baseline
value 4 weeks after delivery
11. EFFECTS OF PREGNANCY ON
FIBROID
The main reason for the fibroid to increases in size
during pregnancy is due to
Increased vascularity
Edema
Hypertrophy and hyperplasia of the fibromuscular
tissues.
13. RED DEGENERATION
• Red degeneration (carneous degeneration) occurs in
a large fibroid mainly during second half of pregnancy
and puerperium. Partial recovery is possible and as
such called necrobiosis.
Red degeneration is a result of softening of the surrounding
supportive connective tissue, the capillaries tend to rupture and
blood effuses out into the myoma causing a diffuse reddish
discolouration of the same.
14. Clinical features of Red Degeneration
These patients typically present with acute lower abdominal pain, with
may be severe and is often associated with nausea, vomiting and even
fever.
Examination may show a tender palpable mass in the uterus. In severe
cases, there may be signs of localized peritonism.
15. Naked eye appearance of the tumor shows dark
areas with cut section revealing raw-beef appearance
often containing cystic spaces.
The odor is often fishy due to fatty acids.
Color is due to the presence of hemolysed red cells and
hemoglobin.
Microscopically, evidences of necrosis are present.
Vessels are thrombosed but extravasation of blood is
unlikely.
Gross Appearance:
16. Diagnosis
1. Ultrasound scanning is the primary modality of diagnosis,
and typically shows a fibroid corresponding to the area of
tenderness over the uterus. Most often, the degenerating
fibroid has a mixed echogenic appearance.
2. MRI : Where sonography is inconclusive, abdominal MRI
may be considered. In red degeneration, the typical finding
is an uterine fibroid with increased T1 signal intensity.
17. Treatment
Red degeneration is a self-limiting condition and is almost always
managed conservatively.
The pain should be managed symptomatically, with either NSAIDs or
opioids. Where opioids are ineffective, a 24 to 48 hour course of
indomethacin has been shown to be efficacious.
Note that NSAIDs are best avoided during the third trimester, as there is
an increased risk of premature closure of the ductus arteriosus and
oligohydramnios
18. It is often difficult to diagnose a fibroid during pregnancy
because of
Marked softening
Alteration in the shape (flattening)
In early months, fibroid is diagnosed but pregnancy is
missed whereas in later months, pregnancy is
diagnosed but the fibroid is missed.
DIAGNOSIS
23. DURING PREGNANCY
Uncomplicated :
Usual antenatal care is followed.
All cases to be assessed at 38 weeks to
formulate the method of delivery.
Acute pain following red degeneration
Conservative management
TREATMENT
24. DURING LABOR
Fibroid situated above the presenting part:
Usually results in uneventful vaginal delivery
Fibroid situated below the presenting part:
Spontaneous vaginal delivery may occur.
If it fails, cesarean section is to be done.
TREATMENT
25. Fibroid in lower uterine segment
Cervical fibroid, even if it is small
Fibroid impacted in pelvis
Malpresentation
Obstetric complications
INDICATION FOR ELECTIVE
CESAREAN SECTION
Cesarean delivery for a large leiomyoma in
the lower uterine segment
26. TECHNICAL ASPECTS ON
ELECTIVE CESAREAN SECTION
Myomectomy should be avoided during cesarean section
Be alert for postpartum hemorrhage and retained placenta.
Reverts to a smaller size during puerperium
27. DC Dutta’s – Textbook of
Gynecology : 6th edition
Shaw’s Textbook of Gynaecology :
15th edition
DC Dutta’s – Textbook of
Obstetrics : 6th edition
