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Department of Obstetrics and
Gynaecology, Guy’s and St.
Thomas’ Hospital NHS
Foundation Trust, London, UK
Correspondence to
Dr Alok Ash, Department of
Obstetrics and Gynaecology,
Guy’s and St Thomas’ Hospital
NHS Foundation Trust,
Consultants’ Office, Women’s
Services, 10th Floor, North
Wing, St Thomas’ Hospital,
Westminster Bridge Rd, London
SE1 7EH, UK;
alok.ash@gstt.nhs.uk
Received 11 July 2011
Accepted 16 July 2011
Published Online First
19 October 2011
Postgrad Med J 2011;87:819e828. doi:10.1136/postgradmedj-2011-130319
Fibroid in pregnancy: characteristics, complications,
and management
Ahmed Zaima, Alok Ash
ABSTRACT
Fibroid in pregnancy is common in clinical obstetric
practice. The topic is becoming more relevant in
contemporary obstetrics due to the demographic shift
towards delayed childbearing, the rising rate of obesity,
and many pregnancies occurring after the treatment of
fibroids. However, there are conflicting reports in the
literature on many so-called fibroid complications in
pregnancy, and there are inadequate data on the
optimum management strategy. An evidence base is
lacking on the pregnancy outcome of many conventional
and newer treatment modalities of fibroids. This review
addresses the characteristics and behaviour of fibroids
during pregnancy, their incidence and demography,
diagnosis, the complications that can arise during
pregnancy and their antenatal management, the labour
pattern, mode of delivery and the postpartum course,
with critical appraisal of the literature together with
certain special situations such as pregnancy after various
types of myomectomy and uterine arterial embolisation.
INTRODUCTION
Fibroids (leiomyomata or simply myomas) are the
most common benign tumour of the uterine
muscle. Fibroid in pregnancy is very commonly
encountered in clinical practice by junior doctors,
midwives, general practitioners, and senior special-
ists alike. There is a plethora of publications in the
medical literature and textbook chapters on the
gynaecological aspects of fibroid outside of preg-
nancy, but the literature is scanty and conflicting
on the fibroid features and management during
pregnancy and labour. There is a lack of knowledge
and basic research on the effect of fibroid on labour.
Inappropriate surgery on fibroid during pregnancy
and caesarean section (CS) is performed without
definite evidence of benefit. Myomectomy, regard-
less of the type and location of the fibroid(s), by
reproductive medicine specialists is widespread
despite lack of any causal relationship between
fibroid and subfertility. The practice of elective CS
after previous myomectomy encroaching into the
endometrial cavity has never been challenged, yet
the practice goes on. The topic is more relevant
than ever before in current obstetric practice due to
changes in the patient demographydmany women
are delaying childbearing, obesity is on the rise,
newer treatment modalities are employed, and an
increasing number of women are falling pregnant
after such treatments for fibroids. Yet there is no
evidence based guideline or protocol for fibroid
management in pregnancy. There is a poor under-
standing among postgraduate trainees and a lack of
experience among GPs about how to manage and
Review
counsel these patients. Many specialists manage
the cases by intuition rather than on the available
evidence.
This review addresses the characteristics of
fibroid and its incidence and demography during
pregnancy, with special emphasis on its topical
importance in contemporary medical practice, the
effect of pregnancy on fibroid and vice versa, the
clinical presentation, diagnosis and management.
Some less well known areasdfor example, the role
of fibroid and its effect on uterine contractions and
labour partogramdare also addressed. Some special
situations are also exploreddfor example, preg-
nancy after various types of myomectomy and
uterine arterial embolisation.
We have endeavoured to cover all aspects of
fibroid in pregnancy, from the basic facts through
evolving clinical practice to the wisdom of uncon-
ventional yet emerging concepts of fibroid
management in pregnancydfor example, the scope
and current thinking on caesarean myomectomy.
Lastly, the possible areas for future research on
the topic have been addressed.
We searched the PubMed database from
January 1980 to November 2010 by using MeSH
terms “leiomyoma”/“leiomyomata”/“fibroid”/“uterine
myoma” AND “pregnancy” or “pregnancy compli-
cation” or “pregnancy outcome” or “labour
contractions” or “delivery”. We also searched
Cochrane Review database on this topic. We first
evaluated each article abstract, read the relevant
original English language articles, and cross refer-
enced relevant articles to find related studies/publi-
cations on the subject. We particularly looked for
any study comparing pregnancy outcomes in
women with and without fibroids. We also searched
published case series, cohort studies, case reports,
and relevant specialty guidelines to obtain evidence
and good practice points before summarising the
findings on important obstetric issues.
INCIDENCE AND DEMOGRAPHY
The true incidence of fibroid in the general female
population is not known. There is no routine
screening programme for fibroid. Most studies on
fibroids have only included women with symp-
toms, and are cross-sectional or retrospective rather
than prospective or longitudinal or population
based. The incidence quoted for the non-pregnant
female population may not be an accurate reflec-
tion, because fibroids remain undiagnosed in about
50% of asymptomatic women until they undergo
routine ultrasound imaging during pregnancy.1
Typically, a woman can have several fibroids in
her womb, of different sizes, types and location
(box 1).
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Box 1 Fibroid characteristics
< Size: variable
– Ultrasonically measured in three perpendicular planes
– In clinical practice referred by the greatest diameter
< Number: solitary or multiple
< Type:
– Subserousddistorting the external contour of the uterus:
>50% of the fibroid must project outside the myometrium
– Intramuraldwithin the myometrium, distorting neither the
external contour nor cavity
– Submucousd>50% of the fibroid mass projects into the
uterine cavity covered by endometrium and distorting the
cavity (there may be multiple types)
< Connectivity with uterus:
– Pedunculated (attached to the uterus with a stalk), usually
subserous; when pedunculated, a submucous fibroid is
called a fibroid polyp
– Sessiledbroad based fibroid raised above the surface
< Location:
– Fundus, corpus or lower uterine segment
– Cervical
– Multiple sites
< Position: anterior, posterior or lateral
The timing of first fibroid formation is not known, but clinical
data indicate they are rare during the early reproductive years.2 3
Fibroid growth is dependent on ovarian hormonesdthey are
diagnosed only after menarche and they regress after menopause.3 4
Thus age is the most common risk factor for uterine fibroids,5
being more common in women aged 35 years or older. Black
women are 3e5 times more likely to have fibroids than white,
Asian and Hispanic women.5 The estimated prevalence outside
pregnancy is at least 15% in white women and 40% in black
women by the age of 35 years.1 6 Women who are overweight
are more likely to have fibroids because of higher concentrations
of oestrogen.7
There is a substantial amount of literature supporting the
contention that uterine fibroids are a cause of subfertility.
However, many women with considerably large fibroids
conceive without difficulty, although problems may arise during
the pregnancy.8 Approximately 20e50% of women suffer from
symptoms generated by fibroids at some stage of their lives: in
pregnancy there is a 10e40% incidence of obstetric complica-
tions,9 with a hospital admission rate of 1 in 50 pregnant
women.10 11 No specific factor such as fibroid location has been
identified that would predispose to complications.10
EFFECT OF PREGNANCY ON FIBROID
Effect on size
Given the hormonal dependence of fibroids, it is expected that
pregnancy would promote their growth. However, ultrasound
studies have shown that most fibroids do not actually increase in
size.12 13 Lev-Toaff and co-workers14 have shown a trimester
dependent fibroid growth in pregnancy: during the first
trimester fibroids of all sizes either remained unchanged or
increased in size, a possible early response to increased oestrogen.
During the second trimester, smaller fibroids (2e6 cm) usually
remained unchanged or increased in size, but those larger than
6 cm became smaller, probably resulting from the initiation of
oestrogen receptor downregulation. Regardless of initial size,
820
during the third trimester, fibroids usually remained unchanged
or decreased in size, reflecting again oestrogen receptor
downregulation. However, others15 found that 69% of women
had no increase in fibroid volume throughout pregnancy. Of
the remaining 31% who were noted to have an increase in
fibroid volume, the greatest increase occurred before the 10th
week of gestation,15 with a mean increase of 1266% and
a maximum growth of 25% of the initial volume.16 A reduction
of the fibroids to their pre-pregnancy size occurred 4 weeks
after delivery. No relationship has been found between the
initial fibroid volume and fibroid growth during gestational
weeks.15 A recent prospective study even showed a pregnancy
related reduction in women with ultrasonically diagnosed
fibroid during pregnancyd36% showed no identifiable fibroid
postpartum, while 79% of the remaining fibroids decreased in
size.17
However, it is important to keep in mind that these tumours
respond differently in individual women, so accurate prediction
of their growth is not possible. There are no studies that have
critically investigated the effect/contribution of various possible
factors on fibroid growth in pregnancy.
Effect on shape
Because they tend to become soft in pregnancy as a result of
interstitial oedema, fibroids may flatten out and become indis-
tinct.18 19 Subserous fibroids may be easily palpated as the uterus
enlarges and may on occasion be mistaken for fetal parts.18
Effect of parity on fibroid
In most epidemiological as well as cohort studies, parity has
been shown to be associated with reduced (about 20e30%
lower) fibroid risk (adjusted for age, body mass index, smoking,
alcohol, and other reproductive co-variables such as
infertility).20e23 Fibroid risk is lower among women who
have undergone more recent pregnancies than with remote
pregnancies.21 22 Studies reporting data on miscarriage or
induced abortion show little or no evidence of the protective
effect of early pregnancy on fibroids.22 The protective effect is
therefore likely to be linked in some way to events that occur in
late pregnancy, at delivery or during the postpartum period,
although the precise mechanism is unknown. It is hypothesised
that extensive remodelling of the postpartum myometrium by
apoptosis and de-differentiation may also induce involution of
the fibroid.24 Another theory postulates that the vessels
supplying fibroids regress during uterine involution postpartum,
depriving them of their source of nutrition.25 The possible role of
breastfeeding as an attributable factor due to its hypo-oestro-
genic effect has not been robustly investigated clinically, but
animal studies have ruled out this mechanism.26 27 In addition
to parity, an age related chronological ‘critical size effect’
hypothesis has been put forward26: Pregnancy before 25 years
may occur before the development of the fibroids, and concep-
tion after 30e35 years may be associated with already grown
fibroids which may be too large to regress by the remodelling
process. The expected greatest protective effect of parity would
be for pregnancies during the mid reproductive years (between
25e29 years of age).26
Effect of inter-pregnancy interval on fibroid
The protective effect of second and subsequent pregnancies
depends on the intervals between the previous pregnancies.
Short intervals provide little additional protection. Likewise,
intervals that are too long may also have little effect, because the
fibroids that develop after a previous pregnancy over a long
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period of time may grow beyond the critical size that may not
be susceptible to remodelling.26 However, the specific inter-
pregnancy interval for this effect, or lack of, on fibroid size
regression has not been defined.
EFFECT OF FIBROID ON PREGNANCY
The most important factors in determining morbidities in preg-
nancy include fibroid number, size, location, and relation to
placental implantation (retroplacental). Submucous fibroids have
the strongest association with lower ongoing pregnancy rate (OR
0.5, 95% CI 0.3 to 0.8), mainly due to defective implantation.28
However, there is no evidence that subserous or intramural
fibroids adversely affect pregnancy outcome.29 Large submucous
or multiple fibroids may distort the uterine cavity leading to
abnormal lie and presentation (risk of breech 13% (fibroids) vs 8%
(without fibroids)), pre-labour premature rupture of the
membranes (pPROM), pre-term labour (PTL) (19% (fibroids) vs
13% (without fibroids)) and risk of CS (49% (fibroids) vs 21%
(without fibroids).30 31 Cervical or low anterior fibroids may
obstruct labour and render CS technically difficult. Retroplacental
fibroids have been shown to be associated with a higher incidence
of miscarriage, PTL, placental abruption, and postpartum
haemorrhage (PPH) (8% (fibroids) vs 3% (without fibroids)).31 32
Pregnancy complications/symptoms
< Fibroids are usually asymptomatic during pregnancy
< Pressure symptoms
– There may be increased frequency of micturition due to
bladder irritation by an anterior cervical fibroid, aided by
increased vascularity in the early weeks of pregnancy.
Occasionally, pressure on the bladder neck can cause
urinary retention; if untreated, this can progress to over-
flow incontinence. Partial obstruction with intermittent
urinary retention increases the risk of urinary tract
infection. Rarely, obstruction may be due to pelvic
incarceration of the gravid uterus (see below). Interestingly,
constipation due to pressure on bowels is usually not
caused by fibroids.
< Pain is the most common complication of fibroid in
pregnancy, with 5e15% of women with fibroids requiring
hospitalisation at some point.9 The risk of pain increases with
size, and is high with fibroids >5 cm in diameter.33 34 It is
interesting that, in the same woman, fibroids can cause severe
pain in one pregnancy yet no pain in the next.35 Pressure on
the fibroid itself can cause a dull ache. Torsion of a peduncu-
lated fibroid is more likely to occur in the first trimester and
after delivery, when there is enough space in the abdomino-
pelvic cavity to permit a high risk of twist of the free and
mobile fibroid on its pedicle. Rapid body movements have
been ascribed to contribute to or aggravate this complication.
< Red or carneous degeneration is the most specific complication
of fibroid in pregnancy, occurring in about 5% of cases,30 36
most commonly in the first and early second trimester which
corresponds with the greatest fibroid growth. Two possible
pathophysiological mechanisms have been suggested: (1) with
the advancing pregnancy, the fibroid outgrows its own blood
supply leading to ischaemia and necrosis at the centre, and
release of prostaglandins; (2) there might be a change of
orientation of the fibroid in relation to its supplying blood
vessels with subsequent kinking and obstruction, leading to
fibroid ischaemia and infarction.37
Clinically, the condition is characterised by focal abdominal pain
of acute onset, mild fever, nausea and vomiting, localised
tenderness over the fibroid, rebound tenderness, and leucocy-
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tosis. However, a white cell count <103106/l is not uncommon,
and rebound tenderness can be frequently absent. Therefore
a diagnosis other than red degeneration must be considered.
Differential diagnoses include: appendicitis, PTL, placental
abruption, ureteric stone, or pyelonephritis. Thorough clinical
examination and appropriate laboratory tests aided by ultra-
sound imaging can help establish the diagnosis. The typical
ultrasound appearance of red degeneration comprises an-echoic
cystic spaces or coarse heterogeneous echogenic patterns. There
appears to be a correlation between these ultrasound echo
patterns and the severity of pain of red degeneration.14
Initial management of red degeneration
Conservative management is the rule with hospitalisation: rest,
symptomatic analgesia, hydration, and assurance. Oral para-
cetamol and dihydrocodeine are usually the first choice analge-
sics, and are safe and effective. Use of non-steroidal anti-
inflammatory drugsdalthough successfully described in older
studies to relieve pain, shorten hospital stay and reduce the rate
of re-admission10 34dshould be avoided, especially after
34 weeks, because of the risk of fetal nephropathy, premature
closure of ductus arteriosus, neonatal pulmonary hypertension,
and platelet dysfunction. Narcotic analgesics (opioids) should be
used only to control acute pain not relieved by other pain killers;
they have no role in maintenance therapy or prophylaxis.10
Antenatal corticosteroid should be administered to enhance fetal
lung maturity, particularly if gestation is <34 weeks in the
presence of clinical evidence of PTLdin which case tocolysis
should be considered, especially if the patient requires in utero
transfer to a secondary or tertiary centre.38
Conservative management is almost always successful. There
is no role for antibiotics and surgery, except for treating infection
and pain persisting beyond a reasonable period of time, or
a previously diagnosed pedunculated fibroid (with possible
torsion) or an uncertain diagnosis. MRI should be considered in
such situations to confirm the diagnosis and help fibroid
mapping before laparotomy. Only a pedunculated fibroid that is
torted should be considered for surgical removal during preg-
nancy; however, no fibroid with a stalk wider than 5 cm should
be removed.35 Laparoscopic myomectomy has been successfully
performed in the first and second trimester of pregnancy, as an
alternative to open myomectomy,39 with the advantage of
minimal invasion, minimal postoperative pain and analgesic
requirement, earlier postoperative ambulation, and shorter
recovery time. Certain safety precautions, however, are recom-
mendeddfor example, (1) open technique for trocar insertion
under direct vision as opposed to blind technique of pneumo-
peritoneum in conventional laparoscopy; (2) minimal manipu-
lation of the pregnant uterus avoiding retracting, pushing, and
pulling; (3) slow change of position to Trendelenburg with
minimal inclination, together with 158 left lateral tilt of the
operating table (to avoid the risk of utero-placental hypo-
perfusion); (4) slow intra-abdominal insufflation at low CO2
pressure (to avoid maternal and fetal hypercarbia and alteration
of acidebase balance due to CO2 absorption); (5) exsufflation
and return of the patient position from Trendelenburg inclina-
tion should also be slow; and (6) the fetal heart rate must be
monitored before and after surgery.39
Although pregnancy has been reported to progress without
complications after such treatment, the lack of randomised trials
or even large case series makes accurate evaluation of this
treatment modality difficult.
< A rare complication is a fixed retroversion with pelvic
incarceration of the gravid uterus due to a large posterior
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fibroid. Normally, the gravid uterus, even if retroverted, grows
out of the pelvis after 12 weeks gestation. However, the
weight and position of a large posterior fibroid may prevent
the ‘rise’ of the uterus above the pelvic cavity. This can be
aggravated by the extravasation of fluid from the surface of
the entrapped oedematous fibroid, leading to adhesions
between the uterus and the pelvic cavity. The continuing
upward growth of the pregnant uterus with a low anterior or
cervical fibroid, on the other hand, may cause trac-
tioneelongation of the cervix with stretching of the bladder
neck, resulting in urinary retention. Usually a full bladder is
obvious on clinical examination, which can be confirmed by
a bedside portable ultrasound. However, a clinical clue to the
cause of this condition may lie in the unusual length of the
catheter required to place in the bladder beyond the bladder
neck in order to empty it. An inexperienced heath care
professional may be caught on the wrong foot or may fail to
achieve catheterisation. A useful tip is to push up the cervix
and the anterior vaginal wall with the left hand to bring the
axis of the urethra and bladder neck in the same line before
introducing the catheter with the other hand. A silastic
catheter (which is stiffer than the malleable latex catheter)
under ultrasound guidance (portable scanner on the labour
ward) may be helpful in this situation.
< At times, a subserous pedunculated fibroid may become
attached to the omentum, develop an alternative source of
blood supply, and become separated from the uterus to form
a so-called ‘parasitic’ fibroid. Although there are case reports
in the literature of surgical complications caused by parasitic
fibroid outside of pregnancy,40 41 to date none has been
reported in pregnancy. In the absence of any symptom this
would go largely unnoticed, and therefore does not warrant
any intervention. It may only be diagnosed during a CS when
it should be left undisturbed.
< Recurrent pregnancy loss: Submucous fibroids (and polyps)
are associated with a higher incidence of miscarriage (14.0%
(fibroids) vs 7.6% (without fibroid); p<0.05)42 43 possibly
because of a distorted uterine cavity, altered endometrial
function, poor placentation or altered placental oxytocinase
activity.44 The loss rate is higher in women with multiple
fibroids than a single fibroid (23.6% vs 8.0% respectively,
p<0.05).43 However, not all authors found this difference
compared with controls.45 No association has been noticed
with fibroid size or location.43 There are no prospective data
showing any association between the presence of intramural
or subserous fibroids and pregnancy loss.29
< Threatened miscarriage: Some studies have reported a higher
incidence (1.7e2 times) of threatened miscarriage compared
with controls.34 46 Location of the fibroid in relation to the
placenta seems to be the most determinant factor, the
condition being eight times more common in women with
retroplacental fibroids compared with non-retroplacental
fibroids (72% vs 9% respectively).47 48
< Pre-term pre-labour rupture of the membranes (pPROM), pre-
term birth: A high but not statistically significant relative risk
of pPROM and pre-term birth has been described.11 This
seems to be related to the size (>3e6 cm)15 and location
(retroplacental) of the fibroid.14 47 Pre-term birth has been
reported usually 2e3 weeks before the expected date of
delivery, which, in clinical practice, is of little threat to the
baby.43 However, not all studies have shown fibroid
associated increased risk of pPROM or PTL.34 36 49
< Placental abruption: Some studies have shown a higher
incidence of placental abruption in fibroid pregnancies, with
822
submucous and retroplacental fibroids, and fibroids with
volumes >200 ml (w7e8 cm diameter), showing the stron-
gest correlation.33 34 46 Impaired placental perfusion in
a retroplacental fibroid and the adjacent myometrium
resulting in placental ischaemia and decidual necrosis has
been suggested as a possible mechanism for abruption.33
However, other studies have found no increased risk of
abruption.11 14 36 49 There is no reference in the literature on
abnormal placentation with an increased risk of placenta
accreta in association with submucous fibroids.
< Fetal/neonatal complications: Fetal malpresentation, predom-
inantly breech, and oblique lie are common due to a distorted
uterine cavity, multiple fibroids, and fibroid in the lower
uterine segment.33 34 46 50 Cumulative data from some studies
might suggest a slightly increased risk of small-for-gesta-
tional-age infants; however, these data do not control for
maternal or gestational age and there is no evidence to
suggest that myomectomy would ameliorate this risk.28
Other sporadic fetal problems have also been describeddfor
example, fetal anomalies (limb reduction defects, congenital
torticollis, and head deformities). Again, it is difficult to rule
out any effect of confounding variables in these cases.
Diagnosis and monitoring of fibroid(s) during pregnancy
Clinical examination has been reported to detect 42% of fibroids
>5 cm during pregnancy, but only 12.5% when they are
<5 cm.12 Imaging is superior to clinical assessment, ultrasound
being the first line investigative technique as well as the gold
standard. Both transabdominal and transvaginal scans are the
most widely used imaging modalities for detection of fibroids,
their types, location, size, and relationship with the placenta.
Ultrasound is rapid, non-invasive, inexpensive, easily available,
and uses no ionising radiation, making it the undisputed first
line investigation for fibroids. Even in unskilled hands, it will
diagnose pregnancy and differentiate between solid and cystic
lesions. With appropriate training and experience, the site and
nature of a pelvic mass can be predicted with an accuracy of over
80%. Serial ultrasound is of value in monitoring fibroid size
throughout pregnancy. However, caution should be exercised in
certain situations; the lower uterine segment may not develop
properly if the fibroid is low anterior. An anteriorly implanted
placenta in close proximity of such a fibroid may wrongly
simulate a placenta praevia.51
MRI is an excellent imaging modality for mapping the precise
location and size of the uterine fibroids, but its use is limited by
its expense, availability, and decision delay. While the accuracy
of ultrasound is operator dependent, MRI has an overall low
interobserver variability and excellent reproducibility with
minimal measurement discrepancies compared to ultrasound.52
Currently, its use in obstetrics for fibroids is limited except in
clinically obscure abdominal masses in symptomatic patients
when ultrasound is inconclusive.
Plain x-ray and CT have little to offer in the diagnosis and
assessment of fibroids, except in rare calcified fibroids where x-
ray can be useful; however, it is not recommended in pregnancy.
LABOUR AND DELIVERY
Fibroids and myometrial contractions
Inherent rhythmic uterine contractions (so called ‘uterine peri-
stalsis’) have been demonstrated in the inner third of the
myometrium of both pregnant as well as pre- and post-meno-
pausal non-pregnant women by transvaginal ultrasound.53 In
non-pregnant women, clinical experimental studies using an
intrauterine micro-transducer catheter before and after
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myomectomy have shown that fibroids may disturb sponta-
neous uterine contractions as well as its responsiveness to
oxytocin and vasopressin, which may be regulated up to 70% by
myomectomy.54 Kinematic evaluation of uterine contractions by
cine MR imaging in non-pregnant women has demonstrated
partial interruption of uterine peristalsis by submucous fibroids,
but not by intramural or subserous fibroids, suggesting
dysfunctional uterine contractility which may be related to
pregnancy loss in patients with submucous fibroids.55 Two
possible explanations have been suggested to account for these
findings: (1) fibroids may physically impede the propagation of
contraction waves throughout the uterus; and (2) fibroids
lack prostaglandin receptors that would mediate the effect of
PGF2a for physiological uterine peristalsis.
It is postulated that a similar decrease in the force of uterine
contractions or disruption of the coordinated spread of contrac-
tile waves may occur during labour, and lead to dysfunctional
labour.36 54 However, published reports in the literature are rather
conflicting. Increased prevalence of dysfunctional and prolonged
labour found by some authors36 46 50 has not been confirmed by
others.49 Most importantly, it is not known what effect, if any,
the uterine contractions caused by fibroid(s) would have on the
fetal heart rate pattern in labour. Qidwai et al56 reported a 70%
vaginal delivery rate in women with large (at least 10 cm) and
multiple fibroids. In these women, no statistical difference in the
median length of labour or abnormality in the labour curves
(partogram), either in the first or the second stage of labour, had
been shown between those with and those without fibroids.56
It is the general clinical experience that the uterus with
fibroid(s) is no less responsive to the use of oxytocics (eg, pros-
taglandins for induction of labour, oxytocin for stimulation of
labour, carboprost or misoprostol for the treatment of PPH) than
its non-fibroid counterpart. However, there are reports of a high
incidence of third stage complications with retention of placenta
and PPH >1000 ml (OR 4.0, 95% CI 2.2 to 6.7),57 especially with
large or multiple fibroids, as they interfere with efficient
myometrial retractiondan essential physiological uterine
activity in the third stage of labour to prevent PPH.
Risk and incidence of caesarean delivery in fibroid pregnancy
Although many women with fibroids achieve normal vaginal
deliveries, several recent studies have shown a higher rate of CS in
women with fibroids than in those with normal uteruses.4 43 56
A systematic review shows this risk to be increased 3.7-fold
(48.8% vs 13.3%, respectively) after the potential confounding
variables (maternal age, weight, ethnicity, parity, gestational age,
epidural use, and labour induction) were controlled for by
multivariate logistic regression techniques.28 The fibroid size, but
not the number, has been shown to be associated with the higher
CS rate, although the critical offending size differed between
studies, from 5 cm diameter57 to 10 cm.56
Fibroids and postpartum haemorrhage
Several studies have reported an increased risk of atonic PPH
following vaginal delivery, especially if the fibroids are >3 cm
and retroplacental.12 31 48 50 Others, however, have not reported
any PPH.14 36 49 Pooled cumulative data suggest that PPH is
significantly more likely in women with fibroids compared with
controls (2.5% vs 1.4%, respectively).28 The risk is higher in
caesarean delivery. Decreased force and an uncoordinated
pattern of uterine contractions are thought to be the patho-
physiological mechanisms behind PPH. However, it is difficult to
explain how effective and coordinated uterine contractions
during labour that achieve a normal delivery would revert to an
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uncoordinated pattern to cause PPH just because of fibroids,
unless there are other contributing factors such as prolonged
labour, intrapartum oxytocin stimulation, increased maternal
age, uterine distension, etc.
Retained placenta is more common (1.4%) in all women with
fibroids compared with the controls (0.6%), regardless of the
location of the fibroid.28
Fate of fibroid(s) after delivery
As discussed earlier, fibroids may regress after delivery. However,
torsion may complicate a pedunculated fibroid. Ischaemic
degeneration of a submucous fibroid due to reduced blood supply
during puerperium may provide an ideal culture medium for
anaerobic organisms. Rarely, sloughing and necrosis of a puer-
peral submucous fibroid can occur with fever and tachycardia.
This should be differentiated from retained products of concep-
tion by thorough clinical examination and use of appropriate
diagnostic imaging.
MANAGEMENT
Pre-pregnancy and antenatal management
Pregnancy should be considered high risk not only for the fibroid
(s) but also for other associated factorsdfor example, higher
maternal mean age and median parity,58 higher BMI, history of
prolonged infertility, previous recurrent pregnancy loss, previous
myomectomy, possible sickle cell disease in patients of African
Caribbean origin, difficulty in obtaining an accurate clinical
assessment, risk of malpresentation and CS due to the location
of the fibroid, etc. Therefore these patients should be referred to
and managed by a consultant obstetrician/gynaecologist.
< Pre-pregnancy management: This is outside the scope of this
article. Many patients are unaware of the presence of fibroids
until an incidental diagnosis by ultrasound during pregnancy.
Some women become pregnant with a prior knowledge of the
presence of fibroid(s). Small fibroids usually are of no clinical
consequence. Indeed many affected women would have
had a previously successful uncomplicated pregnancy and
childbirth.
< Treatment during pregnancy: Most fibroids are asymptomatic
during pregnancy, and therefore do not need any specific
intervention. Any complication (especially red degeneration)
during pregnancy should be managed as described above.
< Multiple fibroids or even a solitary large fibroid may obscure
an accurate clinical assessment, even by an experienced
healthcare professional. Serial ultrasound is useful to monitor
fetal growth and presentation, the size and location of the
fibroid(s), and its proximity/relationship with the placenta.
This, however, requires more frequent clinic attendances for
the patient, and uses more healthcare resources, manpower
and staffing hours for the organisation. Nevertheless, it helps
in clinical judgement for a surgical procedure (CS), advanced
risk assessment, proactive planning for labour and delivery,
and appropriate counselling of the patient. Haematinics
should be prescribed to correct anaemia and to boost up
pre-delivery serum haemoglobin values (Hb%).
Mode of delivery
Despite the increased risk of CS, uterine fibroids should not be
regarded as a contraindication to a trial of labour, unless they
obstruct the birth canal by their position (eg, cervical and
anterior isthmic fibroids). CS is advised for obstetric indications.
The common indications in labour as reported in the literature
include: fetal distress, dysfunctional labour, prolonged labour,
cephalo-pelvic disproportion, active genital herpes, previous
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Review

caesarean delivery, etc. The indications for caesarean delivery are Patient with known fibroid/s Incidental diagnosis
listed in table 1. Because of this and other potential risks Previous myomectomy with of fibroid/s by US
during pregnancy
or without residual fibroid/s?
(eg, PPH), these patients must be counselled during pregnancy
by a senior clinician and a care plan should be made for PPH Yes No
prophylaxis (eg, intravenous access, blood group and saving of
serum together with cross-matching, active management of Cavity Any Serial US for:
entered? No residual cervical Yes Fibroid size and location
third stage of labour, prompt and early recourse to various (Check previous operation or anterior lower Fetal growth, lie, presentation
note or discharge segment
oxytocics, etc). A detailed pregnancy and labour care plan should summary) fibroid?
be written in the notes (figure 1). Fibroid Size >7-8 cm Fibroid <5 cm
Fibroid location: cervical Favourable fetal lie
Yes or anterior lower segment and presentation
No
High fetal head at term, or Satisfactory fetal
Caesarean section Electine CS Non-cephalic presentation growth, AFI, etc
If possible, a lower segment CS is preferred. The usual practice is
to keep away from the fibroid and choose the best accessible Watch for:
pPROM
Elective CS Experienced surgeon
Cross-matched blood
incision line at least 2 cm from the fibroid margin. However, the Red degeneration Avoid CS myomectomy

location of the fibroid may preclude a lower segment CS, in Vaginal

which case a classical CS should be considered. It has the
advantage of avoiding the fibroid during the operation; but
the operation is technically challenging with difficult intra-
operative haemostasis, requires experience and expertise, and is
associated with a higher incidence of postoperative complica-
tions (eg, abdominal distension, ileus, bowel adhesion with the
uterine scar, reactive fever, etc). Most importantly, it compro-
mises the patient’s choice of labour and delivery in any future
pregnancy, as she would need an elective CS to avoid the high
risk of intrapartum (and even antenatal) scar rupture. In
most circumstances, the operation can be performed via
a suprapubic transverse (Pfannensteil’s) skin incision, even for
a classical CS. However, the patient should be counselled
regarding the possibility of a midline skin incision, with its pros
and cons.
It is a good practice to write a detailed operative note, pref-
erably with a sketch, with specific mention of the numbers, size,
and location of the fibroid(s) together with documentation
about the shape of the uterine cavity (regular or distorted). An
intraoperative photograph (with counselling and prior patient
consent) may help the documentation and postoperative
debriefing.
Caesarean myomectomy
Unless easily removable (eg, a free and mobile pedunculated
fibroid) or the fibroid is actually in the line of the CS incision, it
is strongly recommended to avoid a caesarean myomectomy
(CM) during CS, however tempting it may appear. Not only it is
a judicious clinical dictum to avoid combined surgical proce-
dures, myomectomy runs a high risk of troublesome bleeding
which is often difficult to control, with the risk of a caesarean
hysterectomy. On rare occasions, a CM may be the only way to
access the uterine cavity. Indeed, some authors have suggested
CM may be safe in carefully selected patients35; there are many
Table 1 Indications for caesarean section (CS) in fibroid in
pregnancy
Elective CS Emergency CS
1. Previous myomectomy with the incision 1. Fetal distress
encroaching into the endometrial cavity 2. Dysfunctional labour
2. Cervical or anterior isthmic fibroid (>5 cm) 3. Prolonged labour
close to the internal os 4. Cephalo-pelvic disproportion
3. Persistent abnormal fetal lie with 5. Active genital herpes
non-cephalic presentation 6. Previous CS
4. Placenta praevia $grade 2
5. $2 previous CS
6. Severe fetal growth restriction, where
vaginal delivery is considered unsafe
7. Patient declining vaginal delivery
delivery
Watch for PPH: active
3rd stage management
Emergency CS for
FTP, fetal distress
Figure 1 Flow chart of the management of fibroid(s) in pregnancy. AFI,
amniotic fluid index; CS, caesarean section; FTP, failure to progress;
PPH, postpartum haemorrhage; pPROM, pre-labour premature rupture of
membranes; US, ultrasound.
case series and caseecontrol studies in the literature which show
that, with the exception of an increased mean operative time
(w15 min), there are no significant differences in outcomes
(operative complications, mean change/difference in post-
operative Hb%, blood transfusion, postoperative complications,
length of hospital stay, incidence of hysterectomy, or any other
puerperal complications) in selected cases, indicating that CM is
a safe surgical modality and not necessarily a hazardous proce-
dure.23 59e61 However, the seemingly similar outcomes may be
attributed to a small sample size and therefore have insufficient
power to detect a significant difference. Also, the mean size of
removed fibroids in many of these case series was not large
enough (median size 3.5 cm; less than a quarter of them (22.7%)
were $6 cm in diameter) to make an accurate conclusion about
the complications of CM. If the fibroid is located in the area of
the uterine incision, the incision on the fibroid should be
transverse to coincide with the CS incision, so that both the
operations can be completed with one wound closure in the
uterus. The fibroid should be enucleated first before delivering
the baby by a careful dissection between the tissue planes and its
capsule to minimise bleeding. Separate incisions or myomec-
tomy after the delivery of the baby as reported by some23 is not
favoured in clinical practice. Various measures to minimise
bleeding and reduce postoperative complications have been
described in the literature.60
All patients with such a possibility must have prior counsel-
ling in this regard and consent must be obtained accordingly. If
CM is performed, the indication must be clearly documented. A
multidisciplinary team comprising a senior obstetrician,
consultant obstetric anaesthetist, midwife, neonatologist,
haematologist (cross-matched blood should be readily available),
interventional radiologist (uterine arterial embolisation may be
required), and intensivist (intensive therapy unit admission may
be needed) must be involved in the care. Unplanned CM by an
inexperienced doctor must be avoided. While CM has the
advantage of two operations in one go (‘buy one get one free’)
that may satisfy the patient’s needs and benefit the health sector
(by avoidance of an interval myomectomy, hence justifying the
cost effectiveness of the procedure), it may be fraught with
troublesome complications, as mentioned above. The alternative
is a classical CS avoiding the lower segment fibroid, with its
associated risk of uterine rupture or a repeat CS in subsequent
pregnancies.

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At present there are not enough data on the future pregnancy
and labour outcome after CM.62
Postnatal management
This depends on the mode of delivery and whether there have
been any complications, which should be appropriately
addressed; the patient must be debriefed accordingly, ideally by
the person who conducted the delivery. Any postpartum fibroid
infection should be treated aggressively with antibiotic therapy,
fluid management, and adequate analgesia. If the delivery has
been by CS, the scope for a future vaginal birth, or whether
there is need for a repeat elective CS, should also be discussed
with the mother. It is good clinical practice to write a compre-
hensive discharge summary.
Contraceptive advice
Anecdotal reports of growth of fibroids in connection with the
‘pill’ probably relate to older, high oestrogen-containing formula-
tions. Modern low dose oestrogen-containing combined contra-
ceptive pills are not contraindicated. With submucous fibroids or
multiple intramural fibroids, the shape of the uterine cavity may
be distorted, a fact to keep in mind before considering an intra-
uterine contraceptive device, as placement may be difficult or
unsuccessful with a high risk of spontaneous expulsion.
Interval management of fibroids
Before embarking on another pregnancy, patients may consider
definitive treatment of the fibroid(s)dfor example, medical,
non-surgical interventional (fibroid embolisation) or surgical
management (laparoscopic, hysteroscopic or open myomec-
tomy). The details of these management options are beyond the
scope of this article. Preconception myomectomy to improve
reproductive outcome may have a place in women who have
recurrent pregnancy loss, a large submucous fibroid, and no
other identifiable causes of miscarriage,9 but this should be
considered on an individual basis.
Special circumstances
< Pregnancy after myomectomy (laparoscopic, hysteroscopic
and open myomectomy)
< Pregnancy after fibroid embolisation
Myomectomy has been the most common operative procedure
to improve pregnancy rates and outcomes. Pregnancy rates
following myomectomy, via laparoscopy, hysteroscopy, and
laparotomy, are in the 50e60% range, with most having good
outcomes. Due to lack of enough data on its impact on future
fertility and pregnancy outcome, uterine artery embolisation
(UAE) is often advised against in women who want to preserve
their fertility.63 However, there are reports from several studies
that successful pregnancy is possible after UAE,8 64 65 although
pregnancy rates following UAE have not been established.58
Based on limited available data, pregnancies after UAE compared
with those after myomectomy appear to be at increased (but
non-significant) risk of complications.58 Although no difference
in intrapartum complications was reported between the groups,
with no uterine ruptures in particular, there was a higher inci-
dence of elective CS delivery in both groups.66 67 Most preg-
nancies following UAE have had good outcomes in small studies,
although no long term large studies have been published. At the
moment, it appears that myomectomy is preferred over UAE in
most patients desiring future fertility (evidence level: III).58
However, such comparison based on aggregate data in retro-
spective non-randomised heterogeneous patient groups can be
scientifically flawed.
Postgrad Med J 2011;87:819e828. doi:10.1136/postgradmedj-2011-130319
Review
Main messages
< Fibroids are very common in black women, although they
occur in white women too. The incidence of fibroids increases
after 30e35 years of age.
< Fibroids are expected to be encountered more frequently in
current obstetric practice due to demographic shifts.
< Women with fibroids can be reassured that, if they are eligible
for vaginal delivery and they initiate labour spontaneously,
they can expect rates of vaginal delivery to be similar to those
in the general obstetric population.
< Maternal and neonatal outcomes are usually good.
Risk of uterine rupture in pregnancy or labour after previous
myomectomy
The true incidence of uterine rupture after myomectomy is
difficult to assess from the existing literature. A large retro-
spective UK study on labour after myomectomy showed a high
rate (approximately 66%) of vaginal delivery after both
hysteroscopic and open myomectomy,68 a 10% rate of intra-
partum CS, but no intrapartum uterine rupture, even if the
original incision had breached the endometrial cavity at open
myomectomy. This study and many others69e71 question the
rationale for the conventional practice and recommendation of
elective CS or avoidance of oxytocics during labour in such
situations. A large Nigerian study reported a uterine rupture rate
of only 0.24% and a high rate of vaginal delivery, even after
Practice points
< Contrary to the commonly held belief, most fibroids do not
grow during pregnancy. Those fibroids that do will grow in the
first trimester; some even regress.
< MRI has no advantage over ultrasound in fibroid management
during pregnancy.
< Acute pain due to red degeneration is the most common
complication: conservative management is the mainstay.
< Most complications seem to be associated with retroplacental
fibroids, but the association with placental abruption is weak.
< Fibroids do not affect the mechanics of labour and most
women can have normal delivery. However, there is a risk of
postpartum haemorrhage.
< Elective caesarean section (CS) is indicated for fibroid
locations causing mechanical obstruction of the birth
passage. Emergency CS is performed for obstetric indications.
< Caesarean myomectomy is generally avoided, unless abso-
lutely essential. An experienced obstetrician and an obstetric
anaesthetist must be present, and cross-matched blood
available.
< Data on pregnancy outcome after uterine artery embolisation
(UAE) are limited; myomectomy appears to bestow a better
outcome for subsequent pregnancies than UAE.
< Previous laparoscopic myomectomy carries a higher risk of
uterine rupture in subsequent labour than previous open
myomectomy.
< There is no evidence for the risk of uterine rupture in labour
after previous myomectomy encroaching into the uterine
cavity.
825
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Review
Current research questions
< There is a need for a large prospective randomised controlled
trial to investigate the effect of fibroids on pregnancy and, in
particular, uterine contractions in labour.
< It is not known which factors predispose a particular fibroid to
red degeneration.
complex myomectomy with multiple uterine incisions and
a breach of the uterine cavity.72 There are, however, several case
reports in the literature of uterine rupture during the late third
trimester after laparoscopic myomectomy.68 Although the
absolute risk of rupture remains low at 0.5e1%,73 it is suggested
that uterine rupture after laparoscopic myomectomy may be
related to the method of closure of myomectomy incision or
injudicious use of electrosurgery.73 Interestingly, intrapartum
rupture after open myomectomy appears to be rare.68 At
present there is limited information on uterine rupture after
hysteroscopic myomectomy.65
CONCLUSION
The incidence of uterine fibroids in pregnancy is likely to
increase as women are delaying childbearing into their late 30s,
a time of greatest fibroid growth. The advent, access, and
improved diagnostic ability of ultrasound have improved our
knowledge of fibroids and their management in pregnancy.
Although women with fibroids have higher rates of breech
presentation and caesarean delivery compared with women
without, the majority (w70%) have a successful vaginal
delivery, unless it is a cervical or anterior isthmic fibroid. The
strategy of avoiding CM is gradually changing. There is an
emerging suggestion that, in selected patients and in experienced
hands, CM is generally a safe procedure.
The search for evidence based management of fibroids in
pregnancy has been fraught with limitations. Most studies have
been underpowered, retrospective or not properly controlled for
the confounding variables. Only two population based studies
have been identified in the literature, but there has been no
randomised controlled trial on the subject. It is therefore not
possible to synthesise a robust evidence grade based on the
available data in the literature. However, available data suggest
some good practice points for specialists in the management of
pregnancy, labour, and puerperium, as well as guidance for non-
specialists in the initial emergency management and appropriate
referral.
Even though fibroids are the most common tumours in young
women of reproductive age, and may be commonly encountered
Patient resources: some useful websites for further
reading
< http://www.uptodate.com/contents/management-of-pregnant-
women-with-uterine-leiomyomas-fibroids?source¼search_
result&;selectedTitle¼1%7E132
< http://www.nhs.uk/conditions/Fibroids/Pages/Introduction.
aspx
< http://www.womens-health.co.uk/fibroids.asp
< http://www.bbc.co.uk/health/physical_health/pregnancy/
pregnancy_fibroids.shtml
826
Key references
< Ouyang DW, Economy KE, Norwitz ER. Obstetric complica-
tions of fibroids. Obstet Gynecol Clin North Am
2006;33:153e69.
< Laughlin SK, Herring AH, Savitz DA, et al. Pregnancy-related
fibroid reduction. Fertil Steril 2010;94:2421e3.
< Lev-Toaff AS, Coleman BG, Arger PH, et al. Leiomyoma in
pregnancy: Sonographic study. Radiology 1987;164:375e80.
< Klatsky PC, Tran ND, Caughey AB, et al. Fibroids and
reproductive outcomes: a systematic literature review from
conception to delivery. Am J Obstet Gynecol 2008;198:357e66.
< Kelly BA, Bright P, MacKenzie IZ. Does surgical approach
used for myomectomy influence the morbidity in subsequent
pregnancy? J Obstet Gynaecol 2008;28:77e81.
in hospitals catering for a patient population of certain ethnic
origin with a high prevalence of fibroids, very few hospitals,
if any, have institutional protocols or guidelines for the
management of fibroids in pregnancy.
MULTIPLE CHOICE QUESTIONS (TRUE (T)/FALSE (F); ANSWERS
AFTER THE REFERENCES)
1. Fibroid in pregnancy: general points
A. Fibroids are very common in black, Asian and Hispanic
women
B. The incidence of fibroid in pregnancy remains more or less
unchanged over the last 3 or 4 decades
C. Fibroids remain undiagnosed in about 10% of asymptomatic
women
D. Age is the most common risk factor for uterine fibroids
E. About 1 to 4 in 10 patients with fibroid(s) suffer some
obstetric complications during pregnancy
2. Effect of pregnancy on fibroid and effect of fibroid on
pregnancy
A. Most fibroids grow during pregnancy due to the effect of
oestrogen
B. Regardless of their types (sub-serous, intramural or submu-
cous), fibroids are associated with a higher incidence of
recurrent pregnancy loss
C. Almost all studies in the literature show an increased
incidence of placental abruption and a higher incidence of
placenta accreta, especially in association with a submucous
fibroid
D. The most specific complication of fibroid in pregnancy is red
degeneration
E. Constipation is the most common pressure effect caused by
fibroid(s) in pregnancy
3. Diagnosis
A. About three quarters of large fibroids (>5 cm diameters) are
diagnosed clinically, but w20% can be missed if <5 cm.
B. Due to its superior resolution, MRI is recommended as the
gold standard and first line of investigation for the diagnosis
and monitoring fibroid(s) in pregnancy
4. Management
A. Due to higher incidence of obstetric complications, a preg-
nancy with fibroid(s) should regarded as high risk, and
managed in a consultant-led maternity unit
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B. Caesarean section should be considered a preferred mode of
delivery
C. Due to obvious technical difficulty and risk to the fetus,
laparoscopic myomectomy is contra-indicated in pregnancy
D. The practice of elective caesarean section in women with
a previous open myomectomy encroaching into the uterine
cavity is not backed by evidence.
E. Caesarean myomectomy is an absolute contra-indication.
5. Newer treatment modalities of fibroid(s): pregnancy and
labour
A. Uterine artery embolisation (UAE) for fibroid treatment
should be recommended in women who want to preserve
their fertility, as it has been reported to achieve same
pregnancy rate as laparoscopic and hysteroscopic myomec-
tomies
B. Previous laparoscopic myomectomy carries a higher risk of
uterine rupture compared to previous open myomectomy
6. Evidence base and research
A. There is a need of good quality research to investigate the
effect of fibroid(s) uterine contractions in labour, in particular
Competing interests None declared.
Contributors Both AZ and AA had the original idea for this review article. AA devised
the structure of the article. Both AZ and AA searched the literature and collected
primary and secondary data. AA wrote the first draft of the manuscript, which was
then revised several times by both AZ and AA. AA completed the final draft before
original submission. Both AZ and AA carried out the final amendment as
recommended by the PMJ editor and external peer reviewers before resubmitting the
revised manuscript.
Provenance and peer review Not commissioned; externally peer reviewed.
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828 Postgrad Med J 2011;87:819e828. doi:10.1136/postgradmedj-2011-130319
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Fibroid in pregnancy: characteristics,

complications, and management
Ahmed Zaima and Alok Ash

Postgrad Med J 2011 87: 819-828 originally published online October

19, 2011
doi: 10.1136/postgradmedj-2011-130319

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