Case series: Pregnancy Outcome in Patients with Uterine Fibroids

Feasibility, safety and efficacy of high intensity focused ultrasound ablation as a preoperative treatment for challenging hysteroscopic myomectomy

PURPOSE

To investigate the feasibility, safety and efficacy of high intensity focused ultrasound ablation (HIFU) as a preoperative treatment for challenging hysteroscopic myomectomies.

MATERIALS AND METHODS

A total of 75 patients diagnosed with types 0-III of uterine fibroids were enrolled. Based on the Size, Topography, Extension of the base, Penetration and lateral Wall position (STEPW) classification scoring system, 25 cases with a score ≥ 5 points were treated with HIFU followed by hysteroscopic myomectomy (HIFU + HM group), whereas 50 cases with a score < 5 points were treated with hysteroscopic myomectomy (HM group).

RESULTS

The median preoperative STEPW score was 7 in the HIFU + HM group and 2 in the HM group. The average non-perfused volume (NPV) ratio achieved in fibroids after HIFU was 86.87%. Patients in the HIFU + HM group underwent hysteroscopic myomectomy one to four days after HIFU, and downgrading was observed in 81.81% of fibroids. The operation time for patients in the HIFU + HM group was 73 min and the success rate of myomectomy in a single attempt was 60%. The volume of distention medium used during the operation was greater in the HIFU + HM group than in the HM group (15,500 ml vs. 7500 ml). No significant difference was observed between the two groups in terms of intraoperative blood loss, the incidence of intraoperative and postoperative complications, menstrual volume score, or uterine fibroid quality of life score.

CONCLUSION

HIFU can be utilized as a preoperative treatment for large submucosal fibroids prior to hysteroscopic myomectomy. HIFU offers a novel approach in the management of this subset of patients.

Overcoming Obstacles During Caesarean Section with a Fibroid in the Uterus, from Diagnosis to Decision: A Case Series

BACKGROUND

We regularly face pregnancy with fibroid since pregnancy at advanced ages has been more prevalent and the prevalence of lower segment caesarean section (LSCS) has also increased over the previous three decades. Myomectomy with cesarean section has historically been avoided because of the danger of haemorrhage, but obstetricians now place more emphasis on it. Since fibroids can range widely in terms of location, size, and patient features, the intervention should be individualized. Under this article, we, therefore, provide a case series of seven pregnant women with uterine myomas who had delivery via LSCS.

METHOD

Seven pregnant patients who had uterine fibroid and undergone cesarean section were enrolled in this observational study done over the period of one year with consent and after taking ethical approval.  Results: The mean age was 27.7 years. Three of the cases were primigravida, while the remainder were multigravida. One patient had red degeneration and was hospitalized with abdominal discomfort at 29 weeks gestation. Four patients had a solitary fibroid, while the three had numerous. The biggest myoma size was 8×7 cm, while the smallest was 5×5 cm. Due to the presence of the fibroid in the lower segment of the uterus, three patients had a caesarean myomectomy, while in rest four cases it was not done. During cesarean myomectomy, two of them had uterine artery ligation to limit the moderate intraoperative haemorrhage.

CONCLUSION

If the patient is wisely chosen and the surgeon has the experience, a caesarean myomectomy can be performed safely and successfully during LSCS, especially if located in the lower uterine segment (LUS).

Do Large Uterine Fibroids Impact Pregnancy Outcomes?

Objectives

We sought to assess the prevalence of fibroids complicating pregnancy among Omani women who delivered and were followed-up at Sultan Qaboos University Hospital (SQUH) and correlate the presence of large fibroids (> 5 cm) with maternal and neonatal outcomes.

Methods

This retrospective cohort study was conducted at the Department of Obstetrics and Gynecology, SQUH, from 1 January 2011 to 31 December 2016. Demographic data included maternal age, gravidity, parity, body mass index (BMI), and history of preterm delivery. Ultrasonographic data included the total number of fibroids, number of fibroids > 5 cm in diameter, and location. The main outcomes measured were preterm delivery, preterm premature rupture of membranes (PPROM), malpresentation, intrauterine growth restriction (IUGR), mode of delivery, postpartum hemorrhage, retained placenta, and cesarean myomectomy. Fetal outcomes included birth weight and Apgar score. We used the chi-square test and t-test to calculate significant outcomes.

Results

The total number of deliveries over the study period was 24 800. Among these, 62 women had fibroids complicating pregnancy, giving an overall prevalence of 0.3%. Of the 62 women with documented uterine fibroids, 41 had fibroids > 5 cm in diameter and formed the study group, while the control group included 88 women with no fibroids and normal singleton pregnancies. The mean age, parity, BMI, and history of preterm delivery were comparable. The mean age of the study group was 32.6 years. There was no statistically significant difference in obstetric outcomes between the study and control group in terms of preterm labor (p =0.381), PPROM (p =0.536), malpresentation (p =0.237), IUGR (p =0.059), and retained placenta (p =0.296). Postpartum hemorrhage was significantly higher in the study group (p =0.018), the commonest cause was uterine atony (p =0.007). Women with large fibroids had a significantly increased cesarean section rate (p =0.002), the main indications were obstructed labor and failure to progress (62.5%). Five of the 44 women in the study group (12.8%) underwent cesarean myomectomy. Regarding neonatal outcomes, a statistically significant difference was noted in the Apgar scores.

Conclusions

Fibroids measuring > 5 cm in diameter are more likely to cause obstetric complications and are associated with higher cesarean rates. Pre-conception myomectomy is recommended for women with large fibroids.

Successful uterine-sparing surgical management in a patient with a large multi-fibroid uterus

Uterine fibroids are a common gynaecological condition. A key factor when deciding on surgical approach for fibroid management is a patient’s age and desire for fertility with uterine-sparing treatment generally recommended in women who are aiming for future pregnancies. This case report discusses a woman who presented with a very large multi-fibroid uterus. In this case, a hysterectomy was recommended due to safety concerns however, this advice was declined as the patient desired uterine preservation. Fertility testing showed that the patient was not peri-menopausal and abdominal myomectomy was safely performed to good effect. This case report outlines the surgical approach undertaken, in addition to considerations for fertility and pregnancy management.

Large Uterine Fibroids in Pregnancy with Successful Caesarean Myomectomy

Uterine fibroid is the commonest benign tumour of the female reproductive tract. It occurs in 20–40% of women, whereas the estimated incidence in pregnancy is 0.1–3.9%. Uterine fibroid in pregnancy is usually asymptomatic with complications occurring in 10–30% of cases. The first line of management is conservative with counselling for myomectomy after delivery. However, in the presence of intractable symptoms, both antepartum myomectomy and caesarean myomectomy have been reported to be successfully performed in carefully selected cases. We report a case of large subserous uterine fibroid in pregnancy that was referred to our centre at 14 weeks of gestation. She developed generalized body weakness, backache, and breathlessness at 27 weeks gestation. Thus, she was admitted and managed conservatively for eight weeks with significant relief of symptoms. She eventually had a caesarean myomectomy at 35 weeks of gestation; the outcome was a live female baby with a birth weight of 2.3 kg and a large subserous fibroid weighing 9.5 kg. We can therefore say that caesarean myomectomy can be safely performed in carefully selected cases.

The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair

OBJECTIVE

This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre.

STUDY DESIGN

Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application.

RESULTS

The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30-31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation - chorioamniotic membrane separation (6%), preterm premature rupture of membranes - preterm premature rupture of membranes (pPROM; 15%) and preterm labour - preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%).

CONCLUSION

Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children's Hospital of Philadelphia, and Vanderbilt University Medical Centre.

A Fuzzy Expert System to Predict the Risk of Postpartum Hemorrhage

Introduction:

The American College of Obstetricians and Gynecologists (ACOG) defines postpartum hemorrhage (PPH) as a blood loss of >500mL following vaginal delivery or >1000mL following cesarean section. PPH is widely recognized as a common cause of maternal death. However, there is currently no effective method to predict its risk of occurrence.

Aim:

To develop a fuzzy expert system to predict the risk of developing PPH and to evaluate its performance in the clinical setting.

Methods:

This system was developed using MATLAB software. Mamdani inference was used to simulate reasoning of experts in the field. To evaluate the performance of the system, a dataset of 1705 patients admitted at the Labor and Delivery ward of The Second Affiliated Hospital of Nanjing Medical University from 2017-10 to 2018-04, was considered.

Results:

The Negative Predictive value (NPV), Positive Predictive value PPV), Specificity and Sensitivity were calculated and were 99.72%, 18.50%, 87.48% and 92.16% respectively.

Conclusions:

Our findings suggest that the fuzzy expert system can be used to predict PPH in clinical settings and thus decrease maternal mortality rate due to hemorrhage.

Pregnancy outcomes in nulliparous women after ultrasound ablation of uterine fibroids: A single-central retrospective study

To explore the impact of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids in nulliparous women on subsequent pregnancy and delivery. A retrospective analysis was conducted of nulliparous women who received HIFU treatment at Chongqing Medical University, Chongqing,China, from January 1, 2010, to January 1, 2015. A total of 189 cases were enrolled, the median follow-up time was three years. Among them,there were 131 cases pregnancy with a total of 133 times,the pregnancy rate was 69.3% (131/189),and the spontaneous conception rate was 95.4% (125/131). Of 131 pregnant women, 19 were on-going pregnancy, terminated pregnancy 114 times,which include 93 times successfully delivery with a 76.3% (87/114) full-term birth rate,and the cesarean section rate was 72.0% (67/93). Of 94 newborns,the average birth weight was (3.3 ± 0.4)kg (range:1.5–4.8 kg), and a pair of them were identical twins. The incidence of complications during pregnancy and delivery were 10.8% (10/93) and 7.5% (7/93),respectively,except one woman failed on-going pregnancy and one woman suffered hysterectomy due to the complications,others all successful pregnant and delivered. Multiple-factor regression analysis found that age and infertility history were the important factors that may affect pregnancy after HIFU (P < 0.01). Nulliparous women who undergo HIFU treatment for uterine fibroids can subsequently have successful pregnancy and delivery safely.