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4/1/2014

Management of Women with Multiple Fibroids who are Attempting Pregnancy

Author: Daniel Breitkopf, MD

Mentor: Martin Olsen, MD
Editor: Regan Theiler, MD

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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. Cesarean delivery is frequently recommended after abdominal or laparoscopic myomectomy, especially if the removal of the myomas required repair of significant myometrial defects. The risk of uterine rupture during labor, however, is similar to that for 1 prior cesarean section at about 1%. 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.

Further reading:

American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008 Aug;112(2 Pt 1):387-400. doi: 10.1097/AOG.0b013e318183fbab. PMID: 18669742.

Claeys J, Hellendoorn I, Hamerlynck T, et al. The risk of uterine rupture after myomectomy: a systematic review of the literature and meta-analysis. Gynecol Surg. 2014;11:197–206.

Stewart EA. Clinical practice. Uterine fibroids. N Engl J Med. 2015 Apr 23;372(17):1646-55. doi: 10.1056/NEJMcp1411029. PMID: 25901428.

Initial Approval:  November 2015; Reviewed May 2016; Reaffirmed November 2017; Minor Revision May 2019, Minor revision November 2020

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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