Uterine fibroids associated with pregnancy – is myomectomy during pregnancy feasible? Review and case presentation

Abstract

Uterine myomas affect 2-10% of pregnant women. They are hormone-dependent tumors, and 30% of them will increase in response to hormonal changes during pregnancy. Therefore, significant growth is expected in pregnancy, but, actually, most of them do not change in size. They are usually asymptomatic, but they may be associated with severe abdominal pain and adverse pregnancy outcomes. Conservative management is the first option. If the conservative treatment fails and the symptoms are severe, a myomectomy can be performed, with serious risks of severe hemorrhage, uterine rupture, miscarriage and preterm labor. We present the case of a 31-year-old primigravida presenting in our service for severe abdominal pain, pollakiuria and constipation. The ultrasound examination revealed a 13-week pregnancy, with no ultrasound signs of fetal structural abnormalities, and several fibroids, in contact with each other, developed as one fibroid mass, intramural and subserous, in the lower uterine segment and into both parametria, with a diame­ter of 100/95/87 mm. During the following weeks, the symptoms progressed, and the fibroid volume almost doubled. At 17 weeks of pregnancy, due to the severity of the symptoms, rapidly growing myomas and suggestive ultrasound aspect of degeneration, we performed a myomectomy. The surgery was uneventful. The patient was monitored weekly. Detailed second-trimester and third-trimester scans confirmed the normal pregnancy evolution. Doppler evaluation of both uterine arteries showed a normal spectrum. The fetal growth was favorable, at a percentile of 50 at 32 weeks of pregnancy. No short-term or long-term complications of the surgery have been noted so far. Myomectomy during pregnancy should be considered in cases of symptomatic uterine fibroids not responding to conservative management or in large or rapidly growing myomas, large or medium myomas located in the lower uterine segment, or deforming the placental site, following appropriate counseling of the patient regarding the associated risks.