Management of Women with Multiple Fibroids who are Attempting Pregnancy
4/1/2014 - Daniel Breitkopf, MD
Mentor: Martin Olsen, MD
Editor: Eduardo Lara-Torre, MD and Abimbola O. Famuyide, MD
Although the presence of fibroids in most women will not impair their fertility or affect an ongoing pregnancy, some women with fibroids may face several pregnancy-related risks. Submucosal fibroids increase the risk of spontaneous abortion or subfertility, presumably from physical disruption of the uterine cavity or interference with implantation. Intramural fibroids may decrease the success rates of in-vitro fertilization. Subserosal fibroids do not appear to have a significant impact on fertility. There is some evidence that preterm delivery and malpresentation are increased with fibroids. Fibroids may cause pelvic or abdominal pain because of their size, rapid growth, or degeneration.
Women with asymptomatic fibroids do not require evaluation or treatment before attempting conception unless they have had a previous miscarriage or unexplained infertility. However, in a woman with fibroids who is contemplating pregnancy, related symptoms should be assessed. Heavy menstrual bleeding and bulk symptoms such as pelvic pain or pressure, urinary frequency, or difficulty evacuating stool are most common. Treatment is indicated for significant fibroid related symptoms. The impact of various treatments on pregnancy should be considered. Pelvic ultrasound and assessment of the uterine cavity by sonohysterography or hysteroscopy may be indicated to determine fibroid location and size.
Several therapies are available that preserve fertility. Removal of submucosal fibroids can usually be accomplished by hysteroscopic myomectomy which minimizes disruption of myometrial integrity. Intramural or subserosal fibroids may be removed by laparoscopic or abdominal myomectomy. Laparoscopic procedures require particular attention to ensure adequate closure of the myometrial defect. The estimated risk of uterine rupture following abdominal myomectomy is approximately 0.002%. While this is a low risk, it is likely that it reflects significant selection bias and includes labor in only very specific circumstances. Cesarean delivery is typically recommended after abdominal or laparoscopic myomectomy, especially if the removal of the myomas required repair of significant myometrial defects. Uterine artery embolization has been used prior to pregnancy to decrease fibroid volume; however there are concerns regarding fetal growth, abnormal placentation and ovarian function. Magnetic resonance guided focused ultrasound ablation is also available, but very little is known about subsequent pregnancy outcomes. For women with symptomatic fibroids who plan future pregnancy, the current evidence favors myomectomy over other approaches.
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Initial Approval: 11/1/15; Reviewed May 2016; Reaffirmed November 2017
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