TO THE QUESTION ON UTERINE FIBROIDS DURING PREGNANCY

Uterine fibroids is an extremely common tumor of the female reproductive system, among whose manifestations are infertility, spontaneous abortions, incorrect fetal position, placenta previa, premature delivery, bleeding during and after delivery, and an increased risk of cesarean section. According to the literature, myomas are changing in size during pregnancy and in the postpartum period. Aim of the study. To assess the dynamics of uterine fibroid size change during pregnancy and the effect of an existing uterine fibroid on the course of pregnancy and labor. Materials and methods. Outpatient records of patients aged 24 to 45 years (mean age 33.36 ± 4.63 years) who were diagnosed with Pregnancy and uterine fibroids from 2016 to 2021 at Verum Medical Center were evaluated (n = 57). The size of the fibroids (volume and diameter) before, during (I or II prenatal screening) and after pregnancy (first pelvic ultrasound after delivery) was used for statistical analysis. Forty-one of the 57 patients had pelvic ultrasound before, during, and after pregnancy and were included in the statistical analysis of changes in uterine myoma size. Results. Among the patients included in the statistical analysis, uterine fibroids increased in volume by 194.38% ± 86.9 (40.98% ± 18.4 in diameter) during pregnancy, and decreased by 53.98% ± 14.93 in diameter and by 54.28% ± 29.62 of baseline in the postpartum period. A significant number of fibroids (39.47%) did undergo involutionary changes and were not visualized in the first postpartum ultrasound. The live birth rate was high at 90% (64% of deliveries were through natural childbirth and 26% through cesarean section). Conclusions. There was no effect of intramural, intramural-subserosal, and subserosal uterine fibroids with an average diameter of £20 mm on pregnancy and live birth in women. A great amount of uterine fibroids nearly triple in size during pregnancy, but after delivery they return to their original size and even halve in size. This can be regarded as a confirmation of the absence of a negative effect of pregnancy, or, possibly, a positive effect on uterine fibroid size, which requires further investigation.

Download Full-text

A case series of caesarean myomectomy

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20213487 ◽

2021 ◽

Vol 10 (9) ◽

pp. 3580

Author(s):

Shazia Parveen ◽

Nasreen Noor ◽

Iti Madan ◽

Ummay Kulsoom

Keyword(s):

Smooth Muscle ◽

Caesarean Section ◽

Observational Study ◽

Cesarean Section ◽

Patient Selection ◽

Uterine Fibroid ◽

Uterine Fibroids ◽

Case Series ◽

Operative Morbidity ◽

Cesarean Myomectomy

Uterine fibroids are benign, monoclonal tumors of smooth muscle cells of the myometrium. Most fibroids do not increase in size during pregnancy and are not always removed when encountered during cesarean section. Objective was to see the outcome of patients undergoing cesarean myomectomy. The study design was observational study. All patients undergoing cesarean section with uterine fibroid of size more than 5 cm. In carefully selected patients and with use of intraoperative vasopressin, myomectomy may be safely accomplished at the time of caesarean section by experienced surgeons. cesarean myomectomy is safe and successful if patient selection is done carefully and does not add to any additional post-operative morbidity.

Download Full-text

Myomectomy during cesarean section

Serbian Journal of Anesthesia and Intensive Therapy ◽

10.5937/sjait2104073s ◽

2021 ◽

Vol 43 (3-4) ◽

pp. 73-80

Author(s):

Radmila Sparić ◽

Đina Tomašević ◽

Mladen Anđić ◽

Miljan Pupovac ◽

Aleksandra Pavić ◽

...

Keyword(s):

Caesarean Section ◽

Cesarean Section ◽

Perioperative Complications ◽

Uterine Fibroids ◽

Surgical Site Infections ◽

Reproductive Age ◽

Benign Tumors ◽

Uterine Torsion ◽

Perioperative Bleeding ◽

Increased Risk

Myomas (fibroids, leiomyomas) are the most common benign tumors of genital organs in women of reproductive age and represent a significant problem in women's health care. The frequency of cesarean section is higher in women with uterine fibroids. Absolute indications for myomectomy during caesarean section are: fibroids that prevent hysterotomy during caesarean section, impede uterine incision suture, hamper safe fetal extraction and cause uterine torsion. Relative indications for myomectomy during caesarean section are: subserous and pedunculated fibroids, anterior uterine wall fibroids, fibroids that can cause immediate perioperative, and puerperal complications, the patient's desire, fibroids that can cause complications in subsequent pregnancies, and fibroids that can be enucleated without additional hysterotomy. Myomectomy during caesarean section is a complex surgical procedure, associated with the possibility of considerable complications, and defining their actual frequency and risk factors for their occurrence requires further research. Myomectomy during caesarean section is associated with an increased risk of perioperative bleeding. Other perioperative complications of myomectomy during cesarean section are: disseminated intravascular coagulation, paralytic ileus, surgical site infections, sepsis, postoperative febrile morbidity, increased incidence of blood transfusions, and prolonged hospitalization.

Download Full-text

Venous Thromboembolism in Women with Uterine Fibroids

Blood ◽

10.1182/blood-2020-136678 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 28-29

Author(s):

Hira Latif ◽

Valentina Baez Sosa ◽

Saira Farid ◽

Stephen Fernandez ◽

Nicholas Hazen ◽

...

Keyword(s):

Platelet Count ◽

Venous Thromboembolism ◽

Uterine Fibroid ◽

Tertiary Care ◽

Uterine Fibroids ◽

Reproductive Age ◽

Hypercoagulable State ◽

Morbidly Obese ◽

Average Weight ◽

Increased Risk

Background:Uterine fibroids, also called leiomyomas, are diagnosed in over two-third of females of reproductive age; about a quarter warrant treatment. Venous thromboembolism (VTE) is a challenging complication in patients with fibroids due to the increased risk of bleeding with anticoagulation, especially in the setting of associated menorrhagia. The incidence of deep vein thrombosis (DVT) is increased with higher uterine weight which may be related to the extrinsic venous compression of the iliac veins or the inferior vena cava. However, there is reported discordance between the site of uterine fibroid and the site of the DVT along with pulmonary embolism (PE) without evidence of lower extremity DVT suggesting an underlying hypercoagulable state that is more complex than mere hormonal and mechanical factors. Data regarding VTE in patients with uterine fibroids in the US is sparse and is limited to case reports. We performed a retrospective case control study to describe the rate and associated risk factors of VTE in patients with uterine fibroids. Objectives:Evaluate the incidence of VTE events in patients with uterine fibroids and explore trends and associations. Methods:A retrospective chart review of patients at our single, academic, DC metropolitan hospital was conducted. Patients were identified using electronic medical records via ICD-10 codes. Those seen as an inpatient or outpatient in our tertiary care fibroid center with a new diagnosis of uterine fibroids between January 1, 2015, and December 31, 2019 were included and compared to age matched controls of patients with uterine fibroids without VTE in a 1:2 ratio. Statistical analysis was reported as means and medians for descriptive data. Pearson's correlation was performed to determine associations. Results:A total of 6095 patients were diagnosed with uterine fibroids in 5 years, of which 2.2% (n=139) were found to have VTE after the diagnosis of uterine fibroid was made (see table 1). Of the patients with VTE, 88 had DVTs,63 had PE and 12 developed both DVT and PE. The mean age at diagnosis of VTE was 54 (SD=14.95) years. The majority of the patients in the VTE group were African Americans (86%) and mean BMI was 34.52 (SD =9.53), of which about 2/3 were obese or morbidly obese. Average weight of fibroid(s) for those who underwent surgical resection who had available records was noted to be 321 grams (n=11). Data regarding anticoagulation was available for 78% of the patients; the anticoagulant of choice being enoxaparin in 59%, warfarin in 9% and DOACs in 10% of the patients. Two Hundred and thirty-six age matched controls were identified. Statistically significant associations with BMI, race and comorbidities (including atrial fibrillation, congestive heart failure, diabetes, hypertension, HIV, pregnancy and cancer) were found in cases when compared to the control population. Furthermore, cases were found to have a lower mean hemoglobin (10.4 mg/dL) and higher platelet count (311,000/microL) which were statistically significant (p=0.0003). The use of non-steroidal anti-inflammatory drugs and iron supplementation was significantly more in cases than controls. D-dimer and ferritin levels seemed to trend higher and iron saturation lower in cases than controls but were not found to be statistically significant. Conclusions:VTE was found in 2.2% of patients with uterine fibroids, which is higher than the reported VTE incidence of 1-2 per 1000 in the general population. A significant association was found with race, which is consistent with literature that suggests African American patients have a higher rate of incident VTE and also comorbid conditions. Women with low hemoglobin and higher platelet count were more likely to experience VTE. The next steps include understanding more associations, laboratory and clinical, that will assist in risk stratification and tailoring management. Future prospective studies to recognize biomarkers that contribute the hypercoagulable state of uterine fibroids is warranted. Disclosures Morozov: Medtronic:Consultancy;Lumenis:Speakers Bureau;AbbVie:Speakers Bureau.Fitzpatrick:Pfizer:Honoraria.

Download Full-text

Perinatal complications of pregnancies complicated by uterine fibroids

Srpski medicinski casopis Lekarske komore ◽

10.5937/smclk2101016s ◽

2021 ◽

Vol 2 (1) ◽

pp. 16-24

Author(s):

Radmila Sparić ◽

Đina Tomašević

Keyword(s):

Cesarean Section ◽

Placenta Previa ◽

Perioperative Complications ◽

Uterine Fibroids ◽

Bed Rest ◽

First Trimester ◽

Reproductive Age ◽

Perinatal Complications ◽

Increased Risk ◽

In Pregnancy

Fibroids (myomas) are the most common tumors of the female reproductive organs, consisting of smooth muscle cells, fibroblasts, and extracellular matrix. They develop from menarche to menopause. They are diagnosed in 10-20% women of reproductive age. Their size varies from barely visible nodules to large tumors. Change in the size of fibroids during pregnancy and after childbirth is the subject of numerous studies. Most studies indicate a significant increase in the size of fibroids during the first trimester, unchanged size during the second and the third trimester, and a decrease in their size after the delivery. The effect of fibroids on pregnancy depends on their number, location, and size. Myomas are associated with numerous perinatal complications: bleeding in pregnancy, miscarriages, pain due to red degeneration, preterm birth, placental abruption, placenta previa, intrauterine growth restriction, fetal malpresentation, prolonged labor, increased cesarean section rate, uterine atony, and postpartum hemorrhage. Treatment of fibroids in pregnancy includes bed rest and follow-up with symp-tomatic therapy in case of pain, as well as intensive monitoring of the fetus. Very rarely, myomectomy may be necessary during pregnancy. Myomectomy during cesarean section has been considered contraindicated for years. Recent research demonstrates that this procedure may not be associated with an increased risk of perioperative complications. Its advantages include performing two operations within one surgical procedure while avoiding the risks of repeated laparotomy and anesthesia. The most common postpartum complications of fibroids are bleeding and infection.

Download Full-text

Newborns at risk of Covid-19 ― lessons from the last year

Journal of Perinatal Medicine ◽

10.1515/jpm-2021-0258 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Malika D. Shah ◽

Ola Didrik Saugstad

Keyword(s):

Horizontal Transmission ◽

Mode Of Delivery ◽

Newborn Infants ◽

World Health ◽

Premature Delivery ◽

Mortality And Morbidity ◽

Skin Contact ◽

Cord Clamping ◽

Increased Risk ◽

Health Organization

Abstract After more than 1 year of the SARS-CoV-2 pandemic, a great deal of knowledge on how this virus affects pregnant women, the fetus and the newborn has accumulated. The gap between different guidelines how to handle newborn infants during this pandemic has been minimized, and the American Academy of Pediatrics (AAP)’s recommendations are now more in accordance with those of the World Health Organization (WHO). In this article we summarize present knowledge regarding transmission from mother to the fetus/newborn. Although both vertical and horizontal transmission are rare, SARS-CoV-2 positivity is associated with an increased risk of premature delivery and higher neonatal mortality and morbidity. Mode of delivery and cord clamping routines should not be affected by the mother’s SARS-CoV-2 status. Skin to skin contact, rooming in and breastfeeding are recommended with necessary hygiene precautions. Antibodies of infected or vaccinated women seem to cross both the placenta and into breast milk and likely provide protection for the newborn.

Download Full-text

Endometriosis and Risk of Adverse Pregnancy Outcome: A Systematic Review and Meta-Analysis

Journal of Clinical Medicine ◽

10.3390/jcm10040667 ◽

2021 ◽

Vol 10 (4) ◽

pp. 667

Author(s):

Kjerstine Breintoft ◽

Regitze Pinnerup ◽

Tine Brink Henriksen ◽

Dorte Rytter ◽

Niels Uldbjerg ◽

...

Keyword(s):

Preterm Birth ◽

Cesarean Section ◽

Placental Abruption ◽

Gestational Hypertension ◽

Adverse Pregnancy Outcome ◽

Placenta Previa ◽

Meta Analysis ◽

Increased Risk ◽

Spontaneous Hemoperitoneum ◽

In Pregnancy

Background: This systematic review and meta-analysis summarizes the evidence for the association between endometriosis and adverse pregnancy outcome, including gestational hypertension, pre-eclampsia, low birth weight, and small for gestational age, preterm birth, placenta previa, placental abruption, cesarean section, stillbirth, postpartum hemorrhage, spontaneous hemoperitoneum in pregnancy, and spontaneous bowel perforation in pregnancy. Methods: We performed the literature review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), by searches in PubMed and EMBASE, until 1 November 2020 (PROSPERO ID CRD42020213999). We included peer-reviewed observational cohort studies and case-control studies and scored them according to the Newcastle–Ottawa Scale, to assess the risk of bias and confounding. Results: 39 studies were included. Women with endometriosis had an increased risk of gestational hypertension, pre-eclampsia, preterm birth, placenta previa, placental abruption, cesarean section, and stillbirth, compared to women without endometriosis. These results remained unchanged in sub-analyses, including studies on spontaneous pregnancies only. Spontaneous hemoperitoneum in pregnancy and bowel perforation seemed to be associated with endometriosis; however, the studies were few and did not meet the inclusion criteria. Conclusions: The literature shows that endometriosis is associated with an increased risk of gestational hypertension, pre-eclampsia, preterm birth, placenta previa, placental abruption, cesarean section, and stillbirth.

Download Full-text

Transcriptome Analyses of Myometrium from Fibroid Patients Reveals Phenotypic Differences Compared to Non-Diseased Myometrium

International Journal of Molecular Sciences ◽

10.3390/ijms22073618 ◽

2021 ◽

Vol 22 (7) ◽

pp. 3618

Author(s):

Emmanuel N. Paul ◽

Gregory W. Burns ◽

Tyler J. Carpenter ◽

Joshua A. Grey ◽

Asgerally T. Fazleabas ◽

...

Keyword(s):

Uterine Fibroid ◽

Three Dimensional ◽

Uterine Fibroids ◽

Principal Component ◽

Leading Edge ◽

Gene Set Enrichment ◽

Phenotypic Differences ◽

False Discovery ◽

Gene Sets ◽

High Concordance

Uterine fibroid tissues are often compared to their matched myometrium in an effort to understand their pathophysiology, but it is not clear whether the myometria of uterine fibroid patients represent truly non-disease control tissues. We analyzed the transcriptomes of myometrial samples from non-fibroid patients (M) and compared them with fibroid (F) and matched myometrial (MF) samples to determine whether there is a phenotypic difference between fibroid and non-fibroid myometria. Multidimensional scaling plots revealed that M samples clustered separately from both MF and F samples. A total of 1169 differentially expressed genes (DEGs) (false discovery rate < 0.05) were observed in the MF comparison with M. Overrepresented Gene Ontology terms showed a high concordance of upregulated gene sets in MF compared to M, particularly extracellular matrix and structure organization. Gene set enrichment analyses showed that the leading-edge genes from the TGFβ signaling and inflammatory response gene sets were significantly enriched in MF. Overall comparison of the three tissues by three-dimensional principal component analyses showed that M, MF, and F samples clustered separately from each other and that a total of 732 DEGs from F vs. M were not found in the F vs. MF, which are likely understudied in the pathogenesis of uterine fibroids and could be key genes for future investigation. These results suggest that the transcriptome of fibroid-associated myometrium is different from that of non-diseased myometrium and that fibroid studies should consider using both matched myometrium and non-diseased myometrium as controls.

Download Full-text

Sonographic Signs of Adenomyosis in Women with Endometriosis Are Associated with Infertility

Journal of Clinical Medicine ◽

10.3390/jcm10112355 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2355

Author(s):

Dean Decter ◽

Nissim Arbib ◽

Hila Markovitz ◽

Daniel S. Seidman ◽

Vered H. Eisenberg

Keyword(s):

Laparoscopic Surgery ◽

Retrospective Study ◽

Statistical Analysis ◽

Conservative Management ◽

Transvaginal Ultrasound ◽

Control Group ◽

Study Group ◽

Control Groups ◽

Increased Risk ◽

And Control

We compared the prevalence of ultrasound signs of adenomyosis in women with endometriosis who underwent surgery to those who were managed conservatively. This was a retrospective study of women evaluated at a tertiary endometriosis referral center who underwent 2D/3D transvaginal ultrasound. Adenomyosis diagnosis was based on the presence of at least three sonographic signs. The study group subsequently underwent laparoscopic surgery while the control group continued conservative management. Statistical analysis compared the two groups for demographics, symptoms, clinical data, and sonographic findings. The study and control groups included 244 and 158 women, respectively. The presence of any, 3+, or 5+ sonographic signs of adenomyosis was significantly more prevalent in the study group (OR = 1.93–2.7, p < 0.004, 95% CI; 1.24–4.09). After controlling for age, for all findings but linear striations, the OR for having a specific feature was higher in the study group. Women in the study group with ≥ 5 sonographic signs of adenomyosis had more than twice the risk of experiencing infertility (OR = 2.31, p = 0.012, 95% CI; 1.20–4.45). Sonographic signs of adenomyosis are more prevalent in women with symptomatic endometriosis who underwent surgery compared with those who continued conservative management. Women with 5+ findings have a significantly increased risk of infertility. Adenomyosis on ultrasound should be considered in the management decisions regarding these patients.

Download Full-text

Distinct features of youth-onset primary antiphospholipid syndrome

Lupus ◽

10.1177/09612033211038054 ◽

2021 ◽

pp. 096120332110380

Author(s):

Carla Baleeiro Silva ◽

Camila SC Duran ◽

Flavio Signorelli ◽

Gustavo GM Balbi ◽

Eloisa Bonfá ◽

...

Keyword(s):

Pregnancy Outcomes ◽

Fetal Death ◽

Early Recognition ◽

Disease Onset ◽

Obstetric Outcomes ◽

Premature Delivery ◽

Primary Antiphospholipid Syndrome ◽

Adult Onset ◽

Increased Risk ◽

Onset Group

Background Characteristics of primary APS (PAPS) in the youth population have never been studied. In contrast with children, pregnancy is genuinely relevant in the youth age, and understanding clinical characteristics of PAPS patients within this specific age stratum may also provide insights regarding the well-known risk of poor obstetric outcomes during the adolescence. Objective To evaluate clinical and laboratory characteristics of patients with youth-onset PAPS (15–24 years) and compare them with adult-onset PAPS (over 24 years old). Methods This was a cross-sectional study derived from two rheumatology outpatient clinics. Patients who fulfilled Sidney criteria and who were 15 years of age or older at disease onset were included. Secondary APS patients were excluded. We subdivided patients into two groups: youth- (15–24 years) and adult-onset (over 24 years) and compared them regarding demographic characteristics, criteria and non-criteria manifestations, cardiovascular risk factors, and aPL status. For the pregnancy outcomes analysis, ever-pregnant patients were divided in three groups: youth-onset, early adult-onset (25–34 years), and late adult-onset (35–49 years). Results A total of 250 consecutive PAPS patients were included. Groups had a comparable female and Caucasian distribution. We found a similar disease duration (14.0±7.9 vs 17.0±10.1 years, p = 0.079) and similar rates of thrombotic arterial (34.2% vs. 42.0%, p = 0.250) and venous events (69.7% vs. 69.5%, p = 0.975) between them. Skin ulcers were more frequent in the youth-onset group (17.1% vs. 4.0%, p = 0.001), whereas nephropathy was less common (1.3% vs. 8.0%, p = 0.039). No differences were observed for the other criteria and non-criteria manifestations. The adult-onset group presented more frequently with hypertension ( p = 0.002), hyperlipidemia ( p = 0.008), and smoking ( p = 0.003). The youth-onset group presented a higher frequency of obstetric events as the first manifestation of PAPS (30.3% vs. 21.7%, p = 0.005), with worse pregnancy outcomes, namely, fetal death (58.5% vs. 46.4% vs. 24.1%, p = 0.012) and premature delivery (35.8% vs. 19.0% vs. 10.3%, p = 0.016). Of note, all groups had a comparable number of pregnancies (2.81±2.52 vs 2.74±2.07, p = 0.899). Conclusion This study provides novel evidence that youth-onset PAPS presents a higher frequency of obstetric complications as its first manifestation, with an increased risk of fetal death and preterm delivery. Early recognition of this condition by obstetricians is essential to improve prognosis.

Download Full-text

Stroke in Pregnancy and Puerperium: Validated Incidence Trends With Risk Factor Analysis in Finland 1987–2016

Neurology ◽

10.1212/wnl.0000000000011990 ◽

2021 ◽

pp. 10.1212/WNL.0000000000011990

Author(s):

Liisa Karjalainen ◽

Minna Tikkanen ◽

Kirsi Rantanen ◽

Karoliina Aarnio ◽

Aino Korhonen ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Postpartum Period ◽

First Trimester ◽

Class Iii ◽

Hypertensive Disorders Of Pregnancy ◽

Risk Factor Management ◽

Incidence Trends ◽

Hypertensive Disorders ◽

Increased Risk

Objective:To investigate whether previously reported increasing incidence of pregnancy-associated stroke (PAS) is observed in chart-validated register data in Finland. In an exploratory analysis, we studied risk factors for PAS.Methods:We performed a retrospective population-based cohort study and nested case-control study in Finland 1987-2016. The Medical Birth Register (MBR) was linked with the Hospital Discharge Register to identify women with incident stroke (ischemic stroke, cerebral venous thrombosis, intracerebral or subarachnoid hemorrhage) during pregnancy or puerperium. Cases were verified from patient records. Incidence of PAS over the study period, in 5-year age groups and pregnancy/postpartum period were calculated per number of deliveries. Three matched controls were selected for each case from MBR to compare risk factors.Results:After chart review, 29.6% (257/868) of cases were PAS. The incidence of PAS was 14.5 (95%CI: 12.8-16.3) per 100,000 deliveries. Incidence increased from 11.1 to 25.2 per 100,000 deliveries from 1987-1991 to 2012-2016 (p<0.0001). Incidence increased by age from 9.8 to 29.9 per 100,000 deliveries from ages 20-24 to ages >40 (p<0.0001). During early postpartum period, incidence was 5-fold greater compared to the first trimester. Maternal mortality was 6.6%. In the multivariable adjusted model, smoking beyond 12 gestational weeks (odds ratio [OR] 1.8, 95%CI: 1.2-2.7), migraine (OR 16.3, 95%CI: 5.3-49.8), and hypertensive disorders of pregnancy (OR 4.0, 95%CI: 2.5-6.3) were the most important risk factors for PAS.Conclusion:PAS incidence is increasing stressing the importance of careful pregnancy surveillance and risk factor management, particularly in older expectant mothers and extending to puerperium.Classification of Evidence:This study provides Class III evidence that smoking beyond 12 gestational weeks, migraine and hypertensive disorders of pregnancy are associated with an increased risk of PAS.

Download Full-text