Myoma of the uterus during pregnancy: is it dangerous and the effect on the fetus

Many women of childbearing age have a tumor developing in the muscular membrane of the uterus - myoma. And revealed during the examination of uterine fibroids during pregnancy can have a significant impact on the process of bearing a child. Although for some women, asymptomatic fibroids practically do not affect either their daily life or pregnancy.

How much pregnancy in the presence of fibroids will be problematic, depends on the variety, volume and location of this non-malignant education.

Is pregnancy possible with myoma?

When asked whether pregnancy is possible with myoma, gynecologists respond in the affirmative, since uterine fibroids, as a rule, are not the main cause of reproductive dysfunction, that is, an obstacle to fertilization of the ovum and implantation of the blastocyst into the endometrium of the uterus.

Although, it all depends on the place of development of the pathology or the size of education (which ranges from the size of a wheat grape or grape to a large apple). In most cases, the submucosal or submucous myoma and pregnancy leaving the uterine cavity and disturbing its shape are incompatible. Such myomatous nodes are located in the muscles under the endometrium of the uterus, and having a myoma of this species, it is difficult to conceive.

Partially compatible is the intrauterine or intermittent intramural myoma and pregnancy arising inside the muscular membrane of the uterus (between its layers). A large fibroids woman can also cause infertility: due to squeezing and blockage of the fallopian tubes, or localization during the transition of the cervix to her cavity.

But there are other types of fibroids, which almost do not affect the intrauterine cavity. So, compatible facing in the direction of the abdominal cavity of the subserous myoma and pregnancy. But this does not mean that there will be no problems during this pregnancy: the subserous myoma can grow to a solid size, in addition, it can grow according to the papillary type, that is, it has a leg (which can create its own problems, for example, its twisting).

Are myoma of the uterus and ectopic pregnancy possible? The answer to this question is also affirmative: the development of ectopic pregnancy due to the presence of fibroids is possible when the formation is localized in the area of the entrance of the fallopian tubes into the uterine cavity and blocks it.

It is also possible to plan pregnancy with myomas. And this does not mean the preliminary removal of all nodes: a thorough examination should reveal the nodes that interfere with the normal course of pregnancy, and doctors recommend to get rid of such formations before pregnancy.

Causes of the uterine myomas during pregnancy

Despite the fact that uterine fibroids are extremely common - with an overall incidence of up to 25% between the ages of 30-35 and twice the age of 50 - its exact etiology remains unclarified.

Gynecologists associate the causes of these formations, including the causes of uterine myoma in pregnancy as an intercurrent pathology - with excessive production of estrogen (17β-estradiol).

[1], [2], [3], [4]

Risk factors

Risk factors for myoma development: damage to the muscular layer of the uterine wall and its mucosa in inflammatory diseases of the reproductive organs, curettage of the uterine cavity (scraping with abortion), diagnostic manipulations on the uterus and appendages, as well as surgical interventions on the pelvic organs. In addition, experts consider metabolic disorders (diabetes, obesity, hypothyroidism) as risk factors.

This pathology often has a family character (up to 20-25% of cases), which is explained by the pointwise mutations of ESR1 and ESR2 genes encoding estrogen receptors and specific mutations of the MED12 gene (which encodes the transcription factor of the protein synthesis enzyme).

[5]

Pathogenesis

Pathogenesis is seen in the increased effect of estrogens on specific nuclear and membrane receptors of sex steroids in uterine tissues (ERα and ERβ) whose inadequate expression causes changes in the functions of smooth muscle cells of the uterus (myocytes), stimulates their proliferation and, apparently, provokes a disruption in the synthesis of basic myofibrillar proteins (myosin and actin).

The structure of the multilayered muscular membrane of the uterus also contains a branched system of blood and lymphatic vessels, and in the intercellular matrix - connective tissue fibers of elastin and collagen. Violation of one of the structures, especially if there is multiple fibroids or large fibroids in pregnancy, can lead to a decrease in the function of the myometrium, which provides for contraction and relaxation of the uterus, as well as its stretching during pregnancy.

It should also be noted that during pregnancy, significant morphological changes occur in the structure of the myometrium, which are manifested in an increase in the number of myocytes (due to accelerated mitosis), an increase in their size (due to hypertrophy of the cell nuclei) and increased collagen production.

[6], [7], [8], [9], [10]

Symptoms of the uterine myomas during pregnancy

At the initial stage of development of most types of this pathology, there are no symptoms. Myoma usually occurs before pregnancy, and the majority of women do not know about it: education is found during gynecological examination or during an ultrasound examination.

With the onset of pregnancy, the growth of education can begin, and then such symptoms of uterine myoma during pregnancy will appear, as unpleasant feelings of discomfort, pressure, severity or even pain if the pressure is exerted on surrounding organs or pelvic structures. Sometimes such feelings are accompanied by a slight fever and nausea.

When the front wall of the uterus is affected by myoma, urination increases, and when pregnancy and the uterine myoma of the uterus combine on the back wall, the problem of permanent constipation arises.

Acute pain in myoma during pregnancy in the lower abdominal cavity with irradiation into the lumbar region can be the result of nerve compression or the manifestation of fibroid degeneration in the cyst. The condition of the acute abdomen with fever and temporary leukocytosis occurs with a rare complication of myoma - internal hemorrhage in the tumor node (hemorrhagic infarction). A painful cramping in the abdomen or pain of a pulling character is observed when the stalk of the suberose fibroid is twisted.

Pain is the most common sign of fibroids at later gestational age and is most often manifested if a large fibroid occurs during pregnancy (> 5 cm).

In the early stages of bleeding with myomas during pregnancy is associated with the localization of education: when the placenta is formed in the immediate vicinity of the site of hypertrophied tissue with submucous myoma. In fact, such bleeding is a miscarriage, that is, spontaneous termination of pregnancy with uterine myomas.

Also cause bloody discharge in myomas during pregnancy, when the myoma is large or grows in the thickness of the myometrium. Gynecologists say that myoma can cause a relapse of an early miscarriage, which happens so early that a woman does not even know that she was pregnant.

The growth of fibroids in pregnancy

According to clinical observations using ultrasound, in almost a third of cases, the growth of fibroids in pregnancy was noted - especially during the first ten weeks. The average increase in tumor volume varies from 6 to 18%, but in some pregnant women the growth of fibroids may be 25-30% of the initial volume.

The growth of myoma during pregnancy depends on the individual characteristics of the woman's organism and occurs under the stimulating effect of a high level of estrogen and other hormones produced by the placenta. Also, the increase in myoma nodes is largely due to the type and level of placental and pituitary growth factors (CYT) that are present in the blood.

Can myoma dissolve during pregnancy? Experts argue that the full involution of fibroids during pregnancy does not undergo ever, but in almost 8% of cases it can decrease in the third trimester - up to 10%. But after childbirth, when the content of sex hormones in the blood decreases, the myomatous node can resolve.

Forms

[11], [12], [13], [14], [15]

Complications and consequences

The main question - what is dangerous myoma during pregnancy? Noting the negative impact of fibroids on pregnancy, experts emphasize the special importance of preliminary (in early terms) assessment of the degree of threat of complications. They admit that it is practically impossible to predict how a tumor will behave and it only remains to follow how the pregnancy progresses by regularly examining the uterus of a pregnant woman with ultrasound.

The size of myoma and its location in the uterus are among the factors that determine the possibility of obstetric complications. Especially often, the consequences and complications are observed with the growth of myomatous nodes centrally, that is, into the uterine cavity.

Spontaneous termination of pregnancy with uterine myomas happens twice as often as in pregnant women without fibroids. In this case, as experience shows, multiple myoma in pregnancy - in comparison with the presence of a single nodal fibroids - increases the incidence of miscarriages by three times. An early miscarriage happens more often with a submucous myoma located in the upper part of the uterus, at which the development of hypertension of the uterus.

The consequences and complications of fibroids in pregnancy include placental abruption, in particular, with retroplacentary myomas (leading to ischemia of decidual placental tissue), submucosal and multiple myomas; incorrect position of the fetus in the uterus and the need for caesarean section; premature onset of labor (especially often noted if there are several nodes or fibroids that is adjacent to the placenta).

Necrosis of uterine fibroids during pregnancy due to a violation of trophism of its tissues may be an indication for an emergency termination of pregnancy. For more information, see - Disruption of nutrition of the uterine myoma

Also, interruption of pregnancy with myomas can be necessary if it is impossible to reduce severe pain in uterine stretching; with abnormalities of the placenta and its detachment; with severe bleeding; with very voluminous myomatous nodes and uterine deformities, which are accompanied by spasm of the muscular fibers of the uterine wall.

Myoma and frozen pregnancy are associated with a disruption in the formation of the placenta, which causes a prolonged oxygen starvation of the fetus and a halt in its development.

[16], [17], [18]

Effects of fibroids in pregnancy for a child

Another important question: what could be the consequences of fibroids in pregnancy for a child?

In cases where uterine fibroids have a compression effect on the placenta, its functions are violated and placental insufficiency develops , which leads to hypoxia of the fetus (lack of oxygen) and hypotrophy (nutrient deficiency). Because of what the delay of prenatal development occurs.

With the delay in intrauterine development is associated not only insufficient body weight at birth, but also serious problems with his independent breathing and thermoregulation, as well as the work of internal organs and the central nervous system.

In addition, under the pressure of large-sized myomas, physical defects can arise in the form of twisting of the cervical spine, deformation of the shape of the skull, anomalies of the limb bones.

[19],

Diagnostics of the uterine myomas during pregnancy

Diagnosis of fibroids during pregnancy can be associated with certain difficulties and give mixed results. Even experienced gynecologists in ordinary examination find only slightly more than 35% of large fibroids (more than 5 cm) and 12-13% of small myomas (3-4 cm in size).

Instrumental diagnosis using transabdominal ultrasound, according to the International Societies of Obstetrics & Gynecology, reveals fibroids during pregnancy in 1.4-2.7% of cases, primarily due to the difficulty of differentiating myoma from the associated menstrual cycle of physiological thickening, local contraction of smooth muscle fibers of myometrium, as well as diffuse adenomyosis of the uterus. More informative is MRI, but it can only be done in the second and third trimesters. This diagnostic method is used only in difficult cases.

[20], [21],

Differential diagnosis

Differential diagnosis of fibroids in pregnant women is designed to prevent cases when "inadvertently" confused myoma with pregnancy during a palpation examination of the uterus. It is also necessary to differentiate myoma during pregnancy from other formations in the uterus, for example, endometrial cysts or polyps.

[22], [23], [24]

Treatment of the uterine myomas during pregnancy

The main treatment of uterine myoma during pregnancy is reduced to symptomatic therapy and constant monitoring of the state of the pregnant woman and the behavior of fibroids.

In gynecological practice, hormonal medications containing progesterone analogues - Dufaston and Utrozhestan - are prescribed for endometriosis (to neutralize the action of estrogen on the receptors of the uterine lining), and in cases of the threat of abortion (to achieve hormonal balance). For the treatment of fibroids they are not used: Utrozhestan and Dufaston in case of myoma during pregnancy (and in the absence of such) can cause accelerated proliferation of myometrium cells. Also read - Dufaston in Pregnancy

From the second trimester, if there are no constipation and increased gas formation, iron-containing preparations can be prescribed: Gyno-tardiferone (one tablet per day), Maltofer (100-200 mg once a day), etc. Also pregnant with fibroids need vitamins B6, B9, B12.

To improve the blood supply of the placenta and prevent its dystrophy, apply Curantil (Dipiridamol) - for more details, see Kurantil in Pregnancy

As a rule, surgical treatment - removal of fibroids during pregnancy (myomectomy) - during pregnancy is not carried out because of too much risk of damage to the uterus and miscarriage. Can perform enucleation of the node with subserous myoma only in case of necrosis.

Laparoscopy of uterine fibroids and pregnancy. The operation requires general anesthesia and three or four punctures of the abdominal wall; abortion is difficult to avoid, therefore such intervention is carried out exclusively in emergency cases.

Prevention

There are no ways to prevent the development of fibroids during pregnancy.

[25], [26]

Forecast

The prognosis regarding the course of pregnancy and its outcome with a small myoma is quite favorable (although doctors can not guarantee the absence of complications). Consolation for pregnant women can be the fact that after the birth of a child the increased uterine myoma during pregnancy is almost always reduced in size, which gives them the opportunity to re-article the mother.

[27], [28], [29], [30], [31], [32]