Dr amirah zainab binti mamat@muhammad

111303208
melaka manipal medical college

 Fibroids are the most

common benign tumors in
females and typically found
during the middle and later
reproductive years. While
most fibroids are
asymptomatic, they can
grow and cause heavy and
painful menstruation, painful
sexual intercourse, and
urinary frequency and
urgency. Some fibroids may
interfere with pregnancy
although this appears to be
very rare

Classified according to their

position within the uterine
wall:
Intramural (the majority).
Growing into the uterine
cavity; either submucosal,
pedunculated submucosal or
pedunculated vaginal.
Growing outwards from the
uterus - can be:

Cervical
Subserous
Intraligamentous
Pedunculated subserous
(abdominal

 Presentation
Up to half of women with fibroids
have no symptoms. The presence
of symptoms depends on their
size, position and condition.
They usually present between the
ages of 30 and 50 years.
They may cause excessive or
prolonged heavy periods, leading
to iron-deficiency anaemia and
therefore lethargy and pallor.
Submucosal fibroids are more
likely to causemenorrhagia.
Pedunculated submucosal
fibroids can cause persistent
intermenstrual bleeding.

They can cause dysmenorrhoea and

dyspareunia; acute pain occurs
when a fibroid degenerates or there
is torsion of a pedunculated fibroid.
An enlarging uterus may cause
lower abdominal cramps, discomfort,
and heaviness. Pressure on the
bowel may cause constipation and
pressure on the bladder may cause
urinary frequency.
They may present with
recurrent miscarriageor infertility.
Examination:
Palpable abdominal mass arising from
the pelvis.
Enlarged, often irregular uterus palpable
on bimanual pelvic examination.
Signs of anaemia due to menorrhagia.

 differential diagnosis for fibroids

depends on the symptoms they
are causing but includes:
Dermatofibroma
Glomus Tumor
Mastocytosis
Neurilemoma
Dysfunctional uterine bleeding.
Endometrial polyps,
endometrial carcinoma.
Endometriosis.
Chronic pelvic inflammatory
disease.

Tubo-ovarian abscess.
Uterine sarcoma.
Ovarian tumour.
Pelvic masses (other
causes of a pelvic
mass include tumour
of the large bowel,
appendix abscess,
and diverticular
abscess).
Pregnancy.

 Effect of Fibroids on Pregnancy

Outcome
Approximately 10% to 30% of women with
uterine fibroids develop complications
during pregnancy.11However, these
adverse pregnancy outcomes have been
reported in incomplete settings with
selection bias, small and differing
populations, varying inclusion criteria, low
occurrence of adverse outcomes, and
inadequate confounding variables. As a
result, these studies have reported
inconsistent relationships between fibroids
and adverse obstetric outcomes. Although
decreased uterine distensibility or
mechanical obstruction may explain some
adverse outcomes, the precise mechanism
by which uterine fibroids induce obstetric
complications is not clear. 4

Early Pregnancy
Miscarriage.Spontaneous miscarriage rates are
greatly increased in pregnant women with fibroids
compared with control subjects without fibroids (14%
vs 7.6%, respectively).14The weight of evidence in the
literature suggests that the size of the fibroid does not
affect the rate of miscarriage, but multiple fibroids
may increase the miscarriage rate compared with the
presence of a single fibroid only (23.6% vs 8.0%). 14
The location of the fibroid may also be important.
Early miscarriage is more common in women with
fibroids located in the uterine corpus (body) than in
the lower uterine segment10and in women with
intramural or submucosal fibroids.7,1517The
mechanism by which fibroids cause spontaneous
abortion is unclear. Increased uterine irritability and
contractility, the compressive effect of fibroids, and
compromise to the blood supply of the developing
placenta and fetus have all been implicated. 18
Bleeding in early pregnancy.The location of the
fibroid determines the risk for bleeding. Bleeding in
early pregnancy is significantly more common if the
placenta implants close to the fibroid compared with
pregnancies in which there is no contact between the
placenta and fibroid (60% vs 9%, respectively). 2,19

 Late Pregnancy
Preterm labor and preterm premature
rupture of membranes.Pregnant
women with fibroids are significantly more
likely to develop preterm labor and to
deliver preterm than women without
fibroids (16.1% vs 8.7% and 16% vs
10.8%, respectively;Table 1).7Multiple
fibroids and fibroids contacting the
placenta appear to be independent risk
factors for preterm labor.10,19In contrast,
fibroids do not appear to be a risk factor
for preterm premature rupture of
membranes (PPROM). Indeed, a recent
systematic review suggests that fibroids
are associated with a decreased risk of
PPROM (Table 1).7
Table 1
Cumulative Risk of Adverse Obstetric
Outcomes in Pregnant Women With
Fibroids

Placental abruption.Although reports are conflicting, pooled

cumulative data suggest that the risk of placental abruption is
increased 3-fold in women with fibroids (Table 1).7Submucosal
fibroids, retroplacental fibroids, and fibroid volumes > 200
cm3are independent risk factors for placental abruption.20One
retrospective study reported placental abruption in 57% of
women with retroplacental fibroids in contrast with 2.5% of
women with fibroids located in alternate sites.3One possible
mechanism of placental abruption may be diminished blood
flow to the fibroid and the adjacent tissues which results in
partial ischemia and decidual necrosis in the placental tissues
overlaying the leiomyoma.3
Placenta previa.The relationship between fibroids and
placenta previa has been examined in only 2 studies, both of
which suggest that the presence of fibroids is associated with a
2-fold increased risk of placenta previa even after adjusting for
prior surgeries such as cesarean section or myomectomy (
Table 1).4,7,21
Fetal growth restriction and fetal anomalies.Fetal growth
does not appear to be affected by the presence of uterine
fibroids. Although cumulative data and a population-based
study suggested that women with fibroids are at slightly
increased risk of delivering a growth-restricted infant, these
results were not adjusted for maternal age or gestational age (
Table 1).7,22Rarely, large fibroids can compress and distort the
intrauterine cavity leading to fetal deformities. A number of
fetal anomalies have been reported in women with large
submucosal fibroids, including dolichocephaly (lateral
compression of the fetal skull), torticollis (abnormal twisting of
the neck), and limb reduction defects

Complications
Iron-deficiency anaemia.
Bladder frequency, constipation
(due to increased pelvic
pressure).
Hyaline degeneration
(asymptomatic).
Torsion of pedunculated fibroid.
Ureteral obstruction causing
hydronephrosis.
Infertility; this may occur as a
result of narrowing of the isthmic
portion of the Fallopian tube or
as a consequence of interference
with implantation (especially
with submucosal fibroids).

In pregnancy:
Recurrent miscarriage.
Fetal malpresentation.
Red degeneration:
presents with fever,
pain and vomiting.
Intrauterine growth
restriction.
Premature labour.
Postpartum
haemorrhage.
Hydronephrosis.

 Uterine fibroids are a very

common finding in women of
reproductive age. The majority of
fibroids do not change their size
during pregnancy, but one-third
may grow in the first trimester.
Although the data are conflicting
and most women with fibroids
have uneventful pregnancies, the
weight of evidence in the literature
suggests that uterine fibroids are
associated with an increased rate
of spontaneous miscarriage,
preterm labor, placenta abruption,
malpresentation, labor dystocia,
cesarean delivery, and postpartum
hemorrhage.

 Effect of Uterine Fibroids on

Pregnancy Management
Pain Management
Fibroid pain during pregnancy is usually
managed conservatively by bed rest,
hydration, and analgesics. Prostaglandin
synthase inhibitors (eg, nonsteroidal antiinflammatory drugs) should be used with
caution, especially prolonged use (> 48
hours) in the third trimester where it has
been associated with both fetal and
neonatal adverse effects, including
premature closure of the fetal ductus
arteriosus, pulmonary hypertension,
necrotizing enterocolitis, intracranial
hemorrhage, or oligohydramnios. 46
Rarely, severe pain may necessitate
additional pain medication (narcotic
analgesia), epidural analgesia, or surgical
management (myomectomy).47,48

Myomectomy.Prior to pregnancy, myomectomy

can be considered in women with unexplained
infertility or recurrent pregnancy loss,49,50
although whether such surgical interventions
actually improve fertility rates and perinatal
outcome remains unclear.
It is rare for fibroids to be treated surgically in
the first half of pregnancy. If necessary, however,
several studies have reported that antepartum
myomectomy can be safely performed in the first
and second trimester of pregnancy.12,20,48,5155
Acceptable indications include intractable pain
from a degenerating fibroid especially if it is
subserosal or pedunculated, a large or rapidly
growing fibroid, or any large fibroid (> 5 cm)
located in the lower uterine segment. Obstetric
and neonatal outcomes in women undergoing
myomectomy in pregnancy are comparable with
that in conservatively managed women,20,53
although women who had a myomectomy
during pregnancy were far more likely to be
delivered by cesarean due to concerns about
uterine rupture (Table 2).12,20,5155
Table 2

 Obstetric and Neonatal Outcomes in

Normal Pregnant Women and Women
With/Without Antepartum Myomectomy
Although not supported by all studies,56,
57most authorities agree that every
effort should be made to avoid
performing a myomectomy at the time
of cesarean delivery due to the wellsubstantiated risk of severe hemorrhage
requiring blood transfusion, uterine
artery ligation, and/or puerperal
hysterectomy.20,31,58,59Myomectomy at
the time of cesarean delivery should
only be performed if unavoidable to
facilitate safe delivery of the fetus or
closure of the hysterotomy.
Pedunculated subserosal fibroids can
also be safely removed at the time of
cesarean delivery without increasing the
risk of hemorrhage.31

Uterine artery embolization.Bilateral

uterine artery embolization (UAE) has
long been performed by interventional
radiologists to control postpartum
hemorrhage. More recently, UAE has
been used as an alternative procedure
for treating large symptomatic fibroids in
women who are not pregnant and, most
importantly, do not desire future fertility. 7
A recent prospective study reported that
UAE performed immediately after
cesarean delivery in women with uterine
fibroids may be effective in decreasing
postpartum blood loss and minimizing
the risk of myomectomy or hysterectomy
by inducing shrinkage of the fibroids. 60
Although not recommended, there are
several reports of successful and
uneventful pregnancies after UAE for
uterine fibroids

 Intramural fibroids are located within the wall of the uterus and are the most common
type; unless large, they may be asymptomatic. Intramural fibroids begin as small nodules
in the muscular wall of the uterus. With time, intramural fibroids may expand inwards,
causing distortion and elongation of the uterine cavity.
Subserosal fibroids are located underneath the mucosal (peritoneal) surface of the uterus
and can become very large. They can also grow out in a papillary manner to become
pedunculated fibroids. These pedunculated growths can actually detach from the uterus
to become a parasitic leiomyoma.
Submucosal fibroids are located in the muscle beneath the endometrium of the uterus
and distort the uterine cavity; even small lesions in this location may lead to bleeding
andinfertility. A pedunculated lesion within the cavity is termed an intracavitary fibroid
and can be passed through the cervix.
Cervical fibroids are located in the wall of the cervix (neck of the uterus). Rarely fibroids
are found in the supporting structures (round ligament,broad ligament, oruterosacral
ligament) of the uterus that also contain smooth muscle tissue.
Fibroids may be single or multiple. Most fibroids start in an intramural location, that is the
layer of the muscle of the uterus. With further growth, some lesions may develop
towards the outside of the uterus or towards the internal cavity. Secondary changes that
may develop within fibroids are hemorrhage, necrosis, calcification, and cystic changes.

 Subserosal Fibroids
Subserosal fibroids typically develop on the outer uterine wall. This type of fibroid tumor can continue to grow outward increasing in size.
The growth of a subserosal fibroid tumor will put additional pressure on the surrounding organs. Therefore, symptoms of subserosal
fibroid tumorsusually do notincludeabnormal or excessive menstrual bleeding or interfere with a womens typical menstrual flow. These
fibroid tumors instead cause pelvic pain and pressure. Depending on the severity and the location of the fibroids other complications can
accompany this pain and pressure.
Intramural Fibroids
Intramural fibroid tumors typically develop within the uterine wall and expand from there. These uterine fibroids are the most common.
When an intramural fibroid tumor expands, it tends to make the uterus feel larger than normal, which can sometimes be mistaken for
pregnancy or weight gain. This type of fibroid tumor can also cause bulk symptoms: excessive menstrual bleeding, which can cause
prolonged menstrual cycles and clot passing and pelvic pain which is caused by the additional pressure placed on surrounding organs by
the growth of the fibroid which consequently can cause frequent urination and pressure.
Submucosal Fibroids
The least common of the various types of fibroid tumors are submucosal fibroids. These fibroids develop just under the lining of the
uterine cavity. Large submucosal fibroid tumors may increase the size of the uterus cavity, and can block the fallopian tubes which can
cause complications with fertility. Some fibroid tumors dont produce any symptoms at all, while others can be severely symptomatic.
Associated symptoms with submucosal fibroids include very heavy, excessive menstrual bleeding and prolonged menstruation. These
symptoms can also cause the passing of clots, and frequent soiling which can take its toll on your everyday lifestyle. Untreated,
prolonged or excessive bleeding can cause more complicated problems such as anemiaand/orfatigue, which could potentially lead to a
future need for blood transfusions.
Pedunculated Fibroids
Pedunculated uterine fibroids occur when a fibroid tumor grows on a stalk, resulting in pedunculated submucosalor subserosal fibroids.
These fibroids can grow into the uterus and also can grow on the outside of the uterine wall. Symptoms associated with pedunculated
fibroid tumors include pain and pressure as the fibroids can sometimes twist onthe stalk.
A woman may have one or all of these types of fibroids. It is common for a woman to have multiple fibroid tumors and it may be difficult
to understand which fibroid is causing your symptoms. Because fibroid tumors can be multiple and can bespread out in the uterus, there
are usually more fibroids present than can be detected because of their small size. Even a woman who has only one visible fibroid needs
to consider that there may be multiple uterine fibroids present when discussing therapy. Uterine fibroids may also be referred to as
myoma, leiomyoma, leiomyomata, and fibromyoma.

 Fibroids aremonoclonaltumors and approximately 40 to 50% showkaryotypically detectable

chromosomal abnormalities . When multiple fibroids are present they frequently have unrelated genetic defects. Specific
mutations of theMED12protein have been noted in 70 percent of fibroids. [15]
Exact aetiology is not clearly understood, but the current working hypothesis is that genetic predispositions, prenatal
hormone exposure and the effects of hormones, growth factors andxenoestrogens cause fibroid growth. Known risk
factors are African descent,nulliparity,obesity,polycystic ovary syndrome ,diabetesandhypertension .[16]
Fibroid growth is strongly dependent onestrogenandprogesterone . Although both estrogen and progesterone are
usually regarded as growth-promoting they will also cause growth restriction in some circumstances. Paradoxically,
fibroids rarely grow during pregnancy despite very high steroid hormone levels and pregnancy appears to exert a
certain protective effect.[2]This protective effect might be partially mediated by an interaction between estrogen and
theoxytocin receptor .[17]
It is believed that estrogen and progesterone have amitogeniceffect on leiomyoma cells and also act by influencing
(directly and indirectly) a large number ofgrowth factors,cytokinesand apoptotic factors as well as other hormones.
Furthermore, the actions of estrogen and progesterone are modulated by the cross-talk between estrogen,
progesterone andprolactinsignalling which controls the expression of the respective nuclear receptors. It is believed
that estrogen promotes growth by up-regulatingIGF-1,EGFR,TGF-beta1, TGF-beta3 andPDGF, and promotes aberrant
survival of leiomyoma cells by down-regulatingp53, increasing expression of the anti-apoptotic factorPCP4and
antagonizingPPAR-gamma signalling. Progesterone is thought to promote the growth of leiomyoma through upregulatingEGF, TGF-beta1 and TGF-beta3, and promotes survival through up-regulatingBcl-2expression and downregulatingTNF-alpha. Progesterone is believed to counteract growth by downregulating IGF-1. [18][19][20]Expression of
transforming growth interacting factor (TGIF) is increased in leiomyoma compared with myometrium. [21]TGIF is a
potential repressor ofTGF-pathways in myometrial cells. [21]
Whereas in premenopausal fibroids theER-beta,ER-alphaandprogesterone receptors are found overexpressed, in the
rare postmenopausal fibroids only ER-beta was found significantly overexpressed. [22]Most studies found that
polymorphisms in ER and PR gene encodings are not correlated with incidence of fibroids in Caucasian populations [23][24]
however a special ER-alpha genotype was found correlated with incidence and size of fibroids. The higher prevalence of
this genotype in black women may also explain the high incidence of fibroids in this group. [25]

 Uterine leiomyoma was more sensitive than normal myometrium toPPAR-gammareceptor activation resulting in
reduced survival and apoptosis of leiomyoma cells. The mechanism is thought to involve negative cross-talk between
ER and PPAR signaling pathways. Several PPAR-gamma ligands were considered as potential treatment. [26]PPARgamma agonists may also counteract leiomyoma growth by several other mechanisms of action such as TGF-beta3
expression inhibition.[27]
Hypertensionis significantly correlated with fibroids. Although a causal relationships is not at all clear the hypothesis
has been formulated that atherosclerotic injury to uterine blood vessels and the resulting inflammatory state may
play a role. Furthermore endocrine factors related to blood pressure such asangiotensin IIare suspected to cause
fibroid proliferation via angiotensin II type 1 receptor. [28][29]
Aromatase and 17beta-hydroxysteroid dehydrogenase are aberrantly expressed in fibroids, indicating that fibroids
can convert circulating androstenedione into estradiol. [30]Similar mechanism of action has been elucidated in
endometriosisand other endometrial diseases.[31]Aromatase inhibotors are currently considered for treatment, at
certain doses they would completely inhibit estrogen production in the fibroid while not largely affecting ovarian
production of estrogen (and thus systemic levels of it). Aromatase overexpression is particularly pronounced in AfroAmerican women[32]
Genetic and hereditary causes are being considered and several epidemiologic findings indicate considerable genetic
influence especially for early onset cases. First degree relatives have a 2.5-fold risk, and nearly 6-fold risk when
considering early onset cases.Monozygotic twinshave double concordance rate for hysterectomy compared to
dizygotic twins.[33]
Likekeloids, fibroids have disregulated production ofextracellular matrix. Recent studies suggest that this production
may represent an abnormal response to ischemic and mechanical tissue stress. [34]Several factors indicate significant
involvement ofextracellular signaling pathwayssuch asERK1andERK2, which in fibroids are prominently influenced
by hormones.[35]Paradoxically and unlike most other conditions involving significant fibrosis theCyr61gene has been
found downregulated in fibroids.[36]
Cyr61 is also known for its role as tumor suppressing factor and inangiogenesis. Hence fibroids are one of the very
few tumors with reduced vascular density

 Coexisting disorders[edit]
Fibroids that lead to heavy vaginal bleeding lead toanemia
andiron deficiency. Due to pressure effects
gastrointestinal problems such asconstipationand
bloatedness are possible. Compression of the ureter may
lead tohydronephrosis. Fibroids may also present
alongsideendometriosis, which itself may cause infertility.
Adenomyosismay be mistaken for or coexist with fibroids.
In very rare cases, malignant (cancerous) growths,
leiomyosarcoma, of the myometrium can develop.[38]In
extremely rare cases uterine fibroids may present as part
or early symptom of thehereditary leiomyomatosis
and renal cell cancersyndrome.

 Most fibroids do not require treatment unless they

are causing symptoms. After menopause fibroids
shrink and it is unusual for fibroids to cause
problems.
Symptomatic uterine fibroids can be treated by:
medication to control symptoms
medication aimed at shrinking tumours
ultrasound fibroid destruction
myomectomy or radio frequency ablation
hysterectomy
uterine artery embolization

 Intramural
These are located in the wall of the uterus. These are the most common
types of fibroids.

Subserosal fibroids
These are located outside the wall of the uterus. They can develop into
pedunculated fibroids (stalks). Subserosal fibroids can become quite large.

Submucosal fibroids
These are located in the muscle beneath the lining of the uterus wall.

Cervical fibroids
These are located in the neck of the womb (the cervix).

 Treating fibroids with medicationGnRHA

GnRHA (gonadotropin released hormone agonist), administered by injection. GnRHAs
make the woman's body produce much lower quantities of estrogen, which makes the
fibroids shrink. GnRHA stops the woman's menstrual cycle. It is important to remember
that GNRHAs are not contraceptives, and they do not affect a woman's fertility when she
stops treatment.
GNRHAs are also very helpful for women who have heavy periods and discomfort in their
abdomen. GNRHAs may have menopause-like symptoms as their main side-effect, this
might include hot flashes (UK: flushes), a tendency to sweat more, and vaginal dryness.
Although thinning of the bones (osteoporosis) is also a possible side-effect, it is rare.
GnRHAs may be administered to the patient before surgery in order to shrink the fibroids.
GNRHAs are for short-term, not long-term use.
GNRHAs combined withHRT(hormone replacement therapy) are sometimes prescribed
to prevent menopause-like symptoms.

 Other drugs may be used to treat fibroids; however, they are less effective for larger
fibroids. These include:
Tranexamic acid- they are presented in tablet form and are taken by the patient from the day
pre menstrual period starts for up to 4 days. This is done each month. If symptoms do not
improve within three months the patient should stop taking this medication. Tranexamic acid
helps blood in the uterus clot, which reduces bleeding. A woman's fertility will not be affected
by this treatment as soon as it is over.

Anti-inflammatory drugs- these medications are taken for a few days during the patient's
menstrual period. They may include such drugs as mefanamic and ibuprofen. Anti-inflammatory
medications reduce the amount of prostaglandins the body produces. Prostaglandins are
hormones which are associated with heavy periods. These drugs are also painkillers. They do
not affect a woman's fertility.

The contraceptive pill- these are used to stop menstruation from occurring.

LNG-IUS (Levonorgestrel intrauterine system)- this is a plastic device which is placed

inside the uterus. LNH-IUS releases levonorgestrel (progestogen hormone). This hormone stops
the lining of the uterus from growing too fast, which effectively reduces bleeding. One of the
side-effects of this treatment is irregular bleeding for up to six months,headaches, breast
tenderness, andacne. In very rare cases it can stop the woman's periods.

 Surgery to treat fibroids

When medications have not worked, the patient may have to undergo surgery. The following surgical
procedures may be considered:Hysterectomy- removing the uterus. This is only ever considered if the
fibroids are very large, or if the patient is bleeding too much. Hysterectomies are sometimes considered as an
option to stop recurrences of fibroids (stop them coming back). Hysterectomies have two possible side-effects:
1. Reduced libido. 2. Early menopause.

Myomectomy- the fibroids are surgically removed from the wall of the uterus. This option is more popular for
women who want to get pregnant (as opposed to a hysterectomy). Women with large fibroids, as well as those
whose fibroids are located in particular parts of the uterus may not be able to benefit from this procedure.

Endometrial ablation- this involves removing the lining of the uterus. This procedure may be used if the
patient's fibroids are near the inner surface of the uterus. This procedure is considered as an effective
alternative to a hysterectomy.

UAE (Uterine Artery Embolization)- this treatment stops the fibroid from getting its blood supply. UAE is
generally used for women with large fibroids. UAEs effectively shrink the fibroid. A chemical is injected through
a catheter into a blood vessel in the leg - it is guided by X-ray scans.

Magnetic-resonance-guided percutaneous laser ablation- anMRI(magnetic resonance imaging) scan

is used to locate the fibroids. Then very fine needles are inserted through the patient's skin and pushed until
they reach the targeted fibroids. A fiber-optic cable is inserted through the needles. A laser light goes through
the fiber-optic cable, hits the fibroids and shrinks them.

Magnetic-resonance-guided focused ultrasound surgery-" an MRI (magnetic resonance imaging) scan

locates the fibroids, and then sound waves are aimed at them. This procedure also shrinks the fibroids.
Most experts say Magnetic-resonance-guided percutaneous laser ablation and Magnetic-resonance-guided
focused ultrasound surgery are both effective - however, there is some uncertainty regarding their benefits vs.
risks.

 Complications may include:Menorrhagia (heavy periods)- the most common

complication being a disruption of the woman's ability to function normally when periods
are present, and also the possibility ofdepressionbecause of this. In some cases,
menorrhagia can lead to anemia andfatigue.

Abdominal pains- if the patient's fibroids are large she may experience swelling and
discomfort in the lower abdomen. She may also have a sensation of being constipated.
Some women with large fibroids say their bowel movements are painful.

Premature birth, labor problems, miscarriages- as estrogen levels rise significantly

during pregnancy, and as estrogen can speed up fibroid growth, some women may
experience early labor, miscarriages or complications during labor.

Infertility- in some cases fibroids can make it more difficult for the fertilized egg to
attach itself to the lining of the uterus. A fibroid that grows outside the uterus
(submucosal fibroid) may change the uterus' shape, making it harder for the woman to
get pregnant.

Leiomyosarcoma- this is extremely rare. This is a form ofcancer, and it can develop
inside the fibroids.

 The following surgical procedures

may be considered:
Hysterectomy - removing the
uterus. ...
Myomectomy - the fibroids are
surgically removed from the wall of
the uterus. ...
Endometrial ablation - this involves
removing the lining of the uterus.

 Uterine fibroids are very common in

women of reproductive age. Most are
asymptomatic; however, severe
localized abdominal pain can occur if a
fibroid undergoes so-called red
degeneration, torsion, or impaction.
Pain is the most common complication
of fibroids in pregnancy, and is seen
most often in women with fibroids > 5
cm during the second and third
trimesters of pregnancy.
Approximately 10% to 30% of women
with fibroids develop complications
during pregnancy, although these
adverse pregnancy outcomes have
been reported in incomplete settings
with selection bias, small and differing
populations, varying inclusion criteria,
low occurrence of adverse outcomes,
and inadequate confounding variables.

In early pregnancy, spontaneous miscarriage

rates are greatly increased in pregnant women
with fibroids compared with those without
fibroids (14% vs 7.6%, respectively), and
bleeding is significantly more common if the
placenta implants close to the fibroid. In late
pregnancy, such complications include preterm
labor, placental abruption, placenta previa, and
fetal anomalies.
Pain is the most common complication of fibroids
during pregnancy. The symptoms can usually be
controlled by conservative treatment (bed rest,
hydration, and analgesics), but may require
definitive surgical resection in rare instances.
Prior to pregnancy, myomectomy can be
considered in women with unexplained infertility
or recurrent pregnancy loss, although whether
this intervention improves fertility rates and
perinatal outcome remains unclear. Uterine
artery embolization is an alternative procedure to
operative intervention, but is contraindicated in
pregnancy and in women desiring future fertility.

 Uterine fibroids may lead to some

complications during pregnancy
including:
Bleeding during the first trimester(ref. 2).
Placenta Displacement(ref. 2)- Increased
estrogen may cause accelerated fibroid
growth. If the fibroid growsduring pregnancy
then there is a risk that it will move or tear the
placenta.
Caesarian Section(ref. 4)- Multiple fibroids
located in the lower part of the uterus may
block the birth canal. In this case a caesarian
birth is necessary.
Premature Labor(ref. 4)- A pregnant woman
with uterine fibroids is at greater risk of
premature delivery, depending on the location
and shape of the fibroid(s).
Miscarriages(ref. 2)- Fibroids may act as an
obstruction in the uterus which prevents the
embryo from developing and ultimately
causes a miscarriage.

 Treatment for myoma during

pregnancy
Generally, myomas are not removed
during pregnancy due to the increased
risk of hemorrhage. It is possible that
between weeks 12-22 the blood supply
to the fibroid may stop causing it to
turn red and die, this is called Red
Degeneration(ref. 4).

When this occurs it causes intense

abdominal pains and contractions
which may lead to premature labor or
even miscarriage.
In spite of the various complications,
many patients with myoma, who do
get pregnant, have normal
pregnancies and successful deliveries

 Drugs contraindicated
in bronchial asthma :
1-histamine
2parasympathomimetic
s as acetylcholine
3-non-selective betablocker as timolol
4-aspirin
5-morphine
6-aspirin , NSAIDs

 Preterm birth(Latin:partus
praetemporaneusorpartus
praematurus) is thebirthof a
babyof less than 37 weeks
gestational age; such a baby is
sometimes referred to as a
"preemie" or "premmie",
depending on local
pronunciation. The cause of
preterm birth is in many
situations elusive and unknown;
many factors appear to be
associated with the
development of preterm birth,
making the reduction of preterm
birth a challenging proposition.

Premature birthis defined

either as the same as preterm
birth, or the birth of a baby before
the developing organs are mature
enough to allow normal postnatal
survival. Premature infants are at
greater risk for short and long
term complications, including
disabilities and impediments in
growth and mental development.
Significant progress has been
made in the care of premature
infants, but not in reducing the
prevalenceof preterm birth.[1]
Preterm birth is among the top
causes of death in infants
worldwide