CASE STUDY-UTERINE FIBROID/LEIOMYOMA IN PREGNANCY

INTRODUCTION

Uterine fibroids or leiomyomas represent benign hormone-dependent tumours of

smooth muscle on the uterine wall, occurring in 20–60% of women of reproductive
age and are a very common finding in premenopausal women, Pavone, D. et
al (2018). The development of fibroids is related to various risk factors, such as age,
race, hormonal factors, uterine infection, obesity and behavioural factors, but the
epidemiological data are inconsistent. Generally, as postulated by Parker, W.H
(2007), they are asymptomatic, and only about 30% of these fibroids are large enough
to be discovered by a health care practitioner during a physical examination. In
addition, approximately one-third of them develop serious clinical manifestations,
such as abnormal uterine bleeding, anaemia, back pain, pelvic pain and pressure,
constipation, urinary frequency or infertility, thus necessitating treatment.

Moreover, scientific data reports that fibroids have been linked to poor obstetric
outcomes, are found in 0.1–10.7% of pregnant women, and their prevalence rises if
women want to postpone having children until a later age. Pregnancy-related
hormones influence the size of uterine fibroids, and fibroids have many impacts on
pregnancy. Women with uterine fibroids in pregnancy generally have concerns related
to adverse outcomes. However, these women generally have uneventful outcomes in
pregnancy. Several studies have reported inconsistent relationships between uterine
fibroids and adverse obstetric outcomes. Miscarriage, premature labour, antepartum
haemorrhaging, malposition, malpresentation, obstructed labour, uterine inversion,
post-partum haemorrhaging and puerperal sepsis are among the obstetric
consequences of co-existing uterine fibroids in pregnancy.

It is known that uterine fibroids, especially multiple, intramural or sub-mucosal, are

associated with an increased risk of early pregnancy loss. Fibroids developed in the
uterine body are more likely to cause miscarriage than fibroids in the lower uterine
area. Enhanced uterine irritability and contractility are suggested factors that lead to
increased pregnancy loss when there is a co-existing fibroid (Klatsky, P.C. et al
2008), a compressive effect and a disruption of blood flow to the placenta and foetus.
This is more likely when the placenta implants close to a fibroid nodule, and this
depends on the location of the uterine fibroids. The pregnant patient in this case
presented to the radiology department with a history of abdominal pain, vaginal
bleeding, abdominal heaviness, nausea, vomiting and loss of appetite.

INDICATION
Lower abdominal pain and vaginal bleeding in pregnancy. ??? cause and foetal well
being.

EXAMINATION DATE

PATIENT INFORMATION
Date of Birth 22 March 1980
Parity 0
Gravida 1
Last Menstrual Period 27 May 2022
Contraceptive Nil
Marital Status Married
Sex Female
Level of Education Ordinary Level

EQUIPMENT
 Mindray DC-6 Ultrasound machine.
 3.5-5MHz curvilinear probe .
 Sony High glossy thermal paper.
 Ultrasound gel.
 Sony Ultrasound Printer.

PATIENT PREPARATION, PATIENT CARE AND PROTOCOL

Standard second trimester pregnancy transabdominal scan protocol documented in
appendix A attached
OBSERVATIONS AND FINDINGS
 A bulky gravid uterus was seen with a well-defined echogenic ring surrounding
an anechoic centre located centrally. The gestational sac had anechoic contents
embedding an echogenic embryo. The gestational sac occupies approximately
one-half of the uterine volume.
 A live embryo was seen lying horizontally in the gestational sac. Pulsations were
seen on the embryo resembling an embryonic heart motion and M-mode was used
to measure the heart rate.
 A yolk sac was not visualised.
 There were some high level echoes seen appearing as a group of echoes in a
crescentic shape in a subchorionic location, or between the gestational sac and the
decidual reaction.
 The cervix was relatively long and closed measuring 5.57 cm long and no
echogenic or hypoechoic signs of bleeding was seen in the cervix.
 Two anterior and posterior myometrial inhomogeneous, hypoechoic and well
defined subserosal masses solid masses were seen. The larger fundally located
mass measured 4.03 cm x 2.82 cm whilst the smaller one measured 1.76 cm x
1.57 cm.
 Both ovaries were not one in the uterine fundus and the other posterior to the
gestational sac visualised during scanning. No adnexal solid or cystic masses
were seen.
 There was no free fluid collection seen in the pouch of Douglas.
 The urinary bladder was distended with a smooth mucosal outline and anechoic
contents. There was no sonographic evidence of urinary bladder wall thickening,
urinary bladder calculi or wall masses seen.
Foetal Biometry And Dates
Serial Parameter Measurement (cm) Corresponding EGA

(a) (b) (c) (d)

1. GS 3.04 7 Weeks 4 Days
2. CRL 1.56 8 Weeks 0 Days

Uterine Measurements
Serial Parameter Measurement (cm)
 (a) (b) (c)
1. Uterine length 11.56
2. Uterine width 9.22
3. Uterine height 7.18
4. Uterine volume 400.3 cc
5. Uterine body 27.96
6. Cervix length 5.57

 Therefore the average EGA was 7 weeks 5 days

 The assigned EDD by scan was 10 march 2023 +/-2 days

Comment
1. Single live intrauterine embryo of 7 weeks 5 days gestational age by scan.
2. Perisac/ subchorionic bleeds ??? (Extra gestational bleeds).
3. The anterior and posterior myometrial inhomogeneous hypoechoic well
defined masses measuring 4.03 cm x 2.82 and 1.76 cm x 1.57 cm respectively are
suggestive of subserosal fibroids (Fibroids in Pregnancy).
4. Recommend a follow-up sonogram in one or two week to assess pregnancy
progression.
5. Correlate clinically.

Signed………………………………….S. TANGWADZANA
(Diagnostic Radiographer/Student Sonographer)

DISCUSSION
Etiology and Pathophysiology
Although, the exact etiology of fibroid is not known yet, the growth of uterine fibroid
is featured as a benign, hormone sensitive diffuse or nodulus hyperplasia of
myometrium, and is characterized by having multiple factors of pathogenesis and
systemic changes. Uterine fibroid is developed on the background of hyperestrogens,
progesterone deficits and hypergonadotropins. The majority of the researchers
consider that the growth of fibroid depends on concentration of cytosolic receptors to
the sexual hormones and their interactions with the endogenous or exogenous
hormones. In accordance to clinical observations, it can be admitted that both growth
and regression of fibroid are oestrogen-dependant; the tumour size gets increased
during pregnancy and is regressed after menopause.

Uterine Fibroid And Pregnancy

Effects of Pregnancy
The most frequent benign uterine tumour is leiomyoma/fibroma/fibroid which
originates from the uterine smooth muscle tissue (myometrium) whose growth is
dependent on progesterone and oestrogen. Normal rapid uterine expansion that occurs
during pregnancy is likely a more complex mechanism mediated in part by oestrogen,
progesterone, various growth factors especially platelet-derived growth factor and an
increase in cells with Ki-67 antigen, (Kurjak,. A and Chervenak,. F. A. 2011).

These observations support the concept that the same or similar hormonal and growth
factors that normally cause uterine growth during pregnancy also stimulate growth of
fibroid early in pregnancy. This may serve to explain the paradoxical observations
that large fibroids remain unchanged or increase in size late in pregnancy. It is likely
that during pregnancy, fibroid oestrogen receptors are down regulated due to massive
amounts of oestrogen. Without effective oestrogen receptors and thus oestrogen
action in the fibroids, epidermal growth factor binding is also decreased.

These fibroids frequently cause abnormal menstrual periods, pelvic pain, and pressure
symptoms on nearby tissues and organs. When the urinary bladder, ureters, and other
nearby organs are subjected to pressure, they can be lethal in some situations. (14)
The actual cause of uterine fibroids has yet to be determined. However, cytogenetic
and genetic investigations indicate that they are caused by somatic mutations in
myometrial cells with chromosome 6, 7, 12, and 14 abnormalities.

Possible Causes of Fibroids

Genetics: About 40% of fibroids contain alterations in genes that code for uterine
muscle cells. Patients with hereditary leiomyomatosis and renal cell carcinoma
(HLRCC cutaneous and uterine leiomyoma) are at risk for papillary renal cell
carcinoma (the incidence in women is greater than in men). They also have mutation
in fumarate hydratase gene. The chromosomal anomaly (12q13–15) is quite common
in myomatous cells. In fact, in 30–40% cases, the predisposition to uterine fibroid is
passed down from mothers to daughters on hereditary line. A form of fibroid so called
“family type” is present where uterine fibroid are seen in all the family line, i.e. in
grandmother, mother, aunts and sisters.
Heredity: If a mother or sister had fibroids, then there is an increased risk of
developing them.
Race: Black women are more likely to have fibroids than are women of other racial
groups. Also, black women have fibroids at younger age and they are more likely to
have more or larger fibroids.
Hormonal imbalance: Oestrogen and progesterone appear to promote the growth of
fibroids. Fibroids contain more oestrogen and oestrogen receptors than do normal
uterine muscle cells. Other chemicals that help the body maintain tissues, such as
insulin-like growth factor, may also affect fibroid growth.
Obesity: Overweight women have a greater risk of developing fibroids. Fibroids
rarely have malignant potential (leiomyosarcoma).

Pregnant patients with fibroids are exposed to a high rate of complications during
antepartum, intrapartum, and postpartum periods. The prevalence of uterine fibroids
during pregnancy reported in some studies ranges from 1.6 to 16.7%, varying from
one trimester to another, (Shavell, V.I. et al, 2012). Previous data show that the
number of fibroids increases with the patient’s age. Like the literature data, which
indicate that fibroid distribution in pregnant women increases beyond the age of 35,
the patient’s age in this case is 42 years, of black race and nulliparity. It seems that
nulliparity plays an important role in the etiology of fibroids. It is known that
circulating hormones, such as oestrogen and progesterone, are considered modulators
for tumour growth. Consequently, fibroids should develop more frequently in
pregnancy. Being of the black race, nulliparity, and being of reproductive age are all
risk factors in this patient.

The presence of fibroids in very young women can be correlated with a strong family
history, but in this case the patient had mentioned having a negative first-degree
relative with uterine fibroids and neither had she knew of anyone with fibroids in her
hereditary collateral history. Adipose tissue is a recognized extra source of oestrogen,
which is thought to play a role in the development of fibroids. The prevalence of
overweight and obesity is on the rise, being higher in urban area and among educated
women. However, in the present case study, the patient is not obese.

In this case study, diagnoses was made in the first trimester. This can be explained by
the fact that more and more pregnant women are going to the gynaecologist to
evaluate pregnancies from the first trimester, which makes it easier to establish the
diagnosis of associated fibroids, with the uterus and pregnancy being small. More-so,
this was due to patient’s anxiety as she was bleeding knowing that she was pregnant
for the first time which made her seek medical intervention.

The main effect of pregnancy on fibroids is related to the size of the uterine fibroids.
For decades, scientists have debated whether hormonal changes that occur during
pregnancy can affect the sizes of uterine fibroids. Uterine fibroids were considered to
enlarge during pregnancy for several decades, especially during the first trimester.
Benaglia et al., in their prospective cohort study on 25 women with fibroids, reported
that, during the first 7 weeks of pregnancy, the sizes of the fibroids grew significantly
to more than double their initial sizes. This therefore calls for the need to book follow-
up scans to assess the progression of pregnancy and monitoring the growth of the
identified fibroids.
Changes in gestational sac shape seen during scanning may be caused by external
compression due to an over-distended bladder or bowel or to fibroids in the uterine
wall. Myometrial contractions may distort the sac shape in the first trimester.
Ultrasound, which is utilised as a first diagnostic tool for myomas, is used to screen
them. The accuracy of diagnosis, size, and position of these fibroids tumours, as well
as differentiation from an adnexal mass, has greatly increased since the debut of MRI
scan as a diagnostic tool. However, MRI has been described as the most expensive
technology used for analysing uterine fibroid.

MANAGEMENT
Because of the high likelihood of uterine problems such as necrosis and malignant
transformation of benign fibroid tumours, treatment of uterine fibroids should be
tailored to the size and location of the tumour, patient’s age, presenting symptoms,
desire to maintain fertility and the gynaecologicals experience. Uterine artery
embolization, ablative treatments, expectant care, surgery, and medicinal management
are all options for treating this fibroid. Conservative, medicinal, or surgical treatment
options are available.

Patients who are asymptomatic are treated conservatively. This includes periodic
explanations, reassurances, and re-examinations. If anaemia is discovered in
symptomatic cases of menorrhagia, it should be treated. Menorrhagia can be treated
with tranexamic acid, combined oral contraceptives, or a levonogestrel-releasing
intrauterine device. Prescription of agonadotropin-releasing hormone analogue, which
has been used to limit oestrogen production and, as a result, reduces the mass of
existing fibroids, making them suitable for laparoscopic surgery.

In order to maintain productiveness and menstrual function in young female patients,

proper counselling and the possibility of myomectomy is recommended in patients
with symptomatic fibroids as well as those with large, asymptomatic fibroids.
Females who want to keep their fertility and uterus should have their treatment
focused on improving symptom alleviation and quality of life.

CONCLUSION
Because of the risk of excessive haemorrhaging, obstetricians usually avoid the
removal of uterine fibroids during cesarean deliveries unless they are tiny and
pedunculated. Despite the fact that the majority of fibroids are asymptomatic, their
location and size may have an impact on the pregnancy and delivery process.
Performing routine myomectomies during cesarean section is not indicated, but it is a
feasible and safe technique in some cases, with a good prognosis for the patient.
Consequently, the decision of performing myomectomies during pregnancy can be a
challenge and must be performed for select cases. This procedure may have several
benefits, such as avoiding another operation to remove fibroids. Therefore ultrasound
plays an important role in obstetrics for the evaluation of fibroids, their location as
well as their number for monitoring their growth and planning of mode of delivery
appropriately.
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