WOMEN’S HEALTH ISSUES
| FIBROIDS AND PREGNANCY —Alison F. Jacoby, MD, Associate Clinical Professor of Obstetrics, Gynecology and
Reproductive Science, and Director, Comprehensive Fibroid Center, University of California, San Francisco, School of
Medicine
|
| Prevalence: depends on definition of fibroid (defined by size); study of 1300 women screened by first-trimester endovaginal
ultrasonography (US) showed 10% had fibroids ≥0.5 cm in diameter, 4% had clinically significant fibroids;
as women delay childbearing, fibroids more common problem in pregnancy; study of 15,000 women
screened by routine second trimester US showed 2.7% had fibroids ≥1 cm
|
| Data on growth pattern of fibroids: 75% of small fibroids not seen late in pregnancy; 75% of fibroids <3 cm disappeared
(possible that consistency of fibroid changes and becomes more like surrounding myometrium, or that
fetus blocks fibroid from view); fibroids >5 cm not seen later in pregnancy; small percentage of fibroids shown to
increase throughout pregnancy; 50% of all fibroids did not change significantly in size during pregnancy; postpartum,
fibroids return to prepregnancy size; speaker recommends waiting ≥3 mo postpartum before performing surgery
(even with bulky fibroid) to see whether fibroid decreases in size on own
|
| First-trimester bleeding and miscarriage: prospective case control study of 1300 women— fibroids associated
with increased risk for miscarriage; risk for miscarriage independent of fibroid size or location; submucosal fibroids
not shown to be associated with miscarriage; case-control study—higher rates of first-trimester bleeding
in fibroid group, but no difference in rates of miscarriage between groups; case-control study of in vitro fertilization
(IVF) patients—no difference in rates of miscarriage between women with fibroids and those who did not
have fibroids
|
| Placental abruption: pregnant patient with fibroids at risk for placental abruption and should be followed closely;
data show almost 4-fold increase in abruption among women with fibroids (data may have been skewed); University
of California, San Francisco, study showed no difference between women with fibroids and those without; data
show 50% of patients with retroplacental fibroids had abruption; small study showed no placental abruption in 85
women with fibroids; preterm premature rupture of membranes (PPROM)—conflicting data
|
| Preterm labor and delivery: conflicting studies; 4 studies show association with fibroids; Qidwai showed fibroids
associated with preterm labor, but no correlation with number or size
|
| Degenerative fibroid syndrome: occurs in ≥10% of pregnant women with fibroids; most likely to occur in second
and third trimesters; characterized by mild fever, mild leukocytosis, cystic spaces on US, and tenderness over
site of fibroid (hallmark sign); treat with ibuprofen if <34 wk gestation; pregnancy complications (summary)—
association likely with placental abruption and preterm labor and miscarriage; data conflicting for PPROM and
preterm labor; data do not strongly support association with other conditions
|
| Labor and delivery complications: fibroids embedded in muscle wall believed to diminish contractions; fibroids
located in lower uterine segment can obstruct passage through vagina; can restrict movement and prevent fetus
from changing into cephalic presentation; cesarean delivery rate more than twice that of women with no fibroids;
rates of breech presentations statistically significant in pregnant women with fibroids; no statistically
significant increased rate of operative vaginal delivery, chorioamnionitis, or endomyometritis; risk for postpartum
hemorrhage (defined as >1000 mL for vaginal delivery or >1500 mL for cesarean delivery); counsel
pregnant patient with fibroids about risk for breech presentation, preterm labor, PPROM, and possibility of
need for cesarean delivery
|
| Cesarean myomectomy: associated with excessive hemorrhage leading to blood transfusion or hysterectomy; proceed
with caution; patient with pedunculated fibroids likely best candidate; conclusion—submucosal fibroids
(especially those directly under placenta) warrant close monitoring
|
| WHAT THE INTERVENTIONAL RADIOLOGIST CAN DO FOR YOU —Chieh-Min Fan, MD, Assistant Professor,
Harvard Medical School, and Associate Director of Interventional Radiology, Brigham and Women’s Hospital,
Boston, MA
|
| General considerations: leiomyomas, myomas, or fibromyomas medical terms used for fibroids; most common tumor
of female genital tract; benign lesion; can have malignant elements; fibroid result of muscle cells of myometrium
growing in circular pattern; estrogen and growth hormone stimulate growth; grow rapidly in pregnancy
and high estrogen states; prevalence, 30% to 50%; fibroid-related symptoms common cause for hysterectomy or
other intervention
|
| Types of fibroids: subserosal—attached to outside of uterus; attachment can be sessile (broad base of attachment)
or pedunculated (narrow stalk); not associated with excessive bleeding; bulk effect on pelvic organs; may develop
parasitic blood supply from other areas in pelvis; intramural—embed solidly in myometrium; growth enlarges
uterus; associated bulk causes pelvic pressure and discomfort; associated with heavy menstrual bleeding (fibroids
vascular tumors that draw blood supply); respond well to uterine fibroid embolization (UFE); submucosal—grow
near lining of uterus; associated with heavy bleeding and problems of infertility; pedunculated or sessile attachment;
common to see fibroid sloughing after embolization; symptoms—≈25% of women with fibroids have symptomatic
fibroids; heavy menstrual bleeding common presenting symptom; bulk symptoms (eg, pain, pressure,
urinary frequency, constipation, abdominal distention)
|
| Treatment: surveillance—fibroid may involute after menopause; hormonal therapy—gonadotropin-releasing hormone
agonists, (eg, leuprolide acetate [eg, Lupron]); regrowth or rebound after discontinuation; induces low-estrogen
state that shrinks fibroid; oral contraceptives can help regulate heavy bleeding; surgical—hysterectomy most
definitive solution; myomectomy performed hysteroscopically or laparoscopically, depending on size and number
of fibroids; 60% chance for successful pregnancy after myomectomy; lesion-specific treatment; regional ablative
techniques—cryoablation and focused US
|
| Uterine fibroid embolization (UFE): injected particles cut off blood supply to block flow in uterine artery; fibroid
dies, shrinks, and scars down; new application of old technique (historically, used for postpartum hemorrhage
and ectopic pregnancy); first performed in United States in 1996; good data about overall success and complications
related to procedure; ≈12,000 procedures performed annually in United States; estimated 100,000 performed
worldwide; ≈1200 interventional radiologists in United States formally trained to perform procedure;
embolization products approved specifically for procedure; procedure nonsurgical and minimally invasive
|
 | Procedure: catheter insertion site 0.25 in long; 1 wk for recovery; patient generally back to work in ≈7 to 10 days;
organ-specific treatment; do not treat asymptomatic patients or those who do not have fibroid-related problems;
single or multiple fibroids can be treated; location of fibroids has implications for recovery and complications;
≈50% reduction in fibroids achieved by 6 mo; not good option for excessively large lesions; uterus should be <20
wk (surgical debulking better option with large uterus); contraindications—fibroid not in optimal location; fibroid
too big; patient has other issue requiring further medical attention (eg, pelvic inflammatory disease,
chronic infection, ovarian problem, endometriosis, ovarian disease)
|
| Evaluation: patient should have had normal Papanicolaou (Pap) test within last 6 mo; endometrial biopsy 2 to 3 mo
before procedure if patient has heavy bleeding; magnetic resonance imaging (MRI) allows assessment of number
of fibroids, location, and other pathology; pregnancy test; blood work including kidney function and clotting factors
|
| Postoperative care: overnight observation, hydration, and pain management with oral narcotic or ibuprofen (eg,
Motrin) and antiemetic; procedure—performed under local anesthesia and conscious sedation; small catheter
inserted (under guidance) into target uterine artery; particles injected; fibroid recurs if not completely devascularized;
50% volume reduction at 6 mo usually provides resolution of symptoms
|
| Complications: postembolization syndrome—constellation of symptoms characterized by mild nausea, malaise,
low-grade fever, and pelvic cramping; 1 to 5 days; effect of fibroid dying and releasing factors causing inflammation;
postoperative considerations—unpredictable menses for ≈2 to 3 mo; speaker sees patient 2 wk after procedure;
obtains MRI to confirm shrinkage; persistent growth of fibroid 6 mo after UFE red flag for potential
malignancy; surgical removal of fibroid advised; early complications—<30 days; postembolization syndrome
not considered complication; classified as complication if patient readmitted to hospital for symptoms; treatment
consists of pain medication and hydration; uterine infection rare but serious; more likely to happen with sloughing
or fibroid-shedding event; occurs in ≈0.5% of cases; requires either hysterectomy or dilation and curettage
(D and C); prophylactic antibiotics; 4 reported deaths related to UFE; thrombolic disease rare; all patients should
have compression boots until ambulatory; nontarget embolization—particles go where not meant to be; few
case reports; late complications—transcervical fibroid expulsion or sloughing; fibroid dead, but attempts to
pass; usually self-limited process, but D and C may be required if fibroid obstructing cervix; occurs mostly with
submucosal fibroids; can occur any time between 2 wk and 2 yr after procedure; fibroid slowly shedding every
month may produce chronic vaginal discharge
|
| Amenorrhea after UFE: small risk for menopause after procedure; small blood vessels connect uterine artery and
ovarian blood supply; ≈7% risk (range 2%-14%); related to age of patient at time of UFE; risk ≈1% to 2% if patient
<40 yr of age, ≈15% if >45 yr of age (older ovary has less ovarian reserve to tolerate particles)
|
| Pregnancy and UFE: pregnancy-related outcomes understudied (every series shows few patients who achieved fertilization);
UFE not recommended for women who desire childbearing; speaker recommends myomectomy
(60% rate of successful pregnancy after myomectomy); UFE more cost-effective than surgery, with faster return
to activities of daily living; clinical outcomes—11 large series totaling 222 patients show ≈88% improvement in
bleeding; ≈71% of women had resolution of or significant improvement in pain or bulk symptoms; ≈20% volume
reduction at 2 mo, and ≈60% volume reduction at 12 mo; 0.3% rate of hysterectomy for complication of
UFE; patient satisfaction ≈80%; 15% had mixed feelings about UFE, and 6% did not feel it was a solution for
their problem and would not choose UFE again; American College of Obstetricians and Gynecologists’
position— UFE considered accepted treatment; alternative to myomectomy for certain patients with fibroids
who do not seek to preserve fertility
|
| Varicose veins: affect 60% of adults; women more predisposed than men because of pregnancy and high-estrogen
state; historically, saphenous vein stripping performed; prevalence increases with age; spider veins and small reticular
veins cosmetically troubling; large ropy veins associated with pain and bleeding; venous stasis ulcer
caused by severe venous reflux disease; anatomy—deep veins and superficial veins pump blood out of leg to
heart; 90% of blood pumped out by deep vein system, but 90% of venous problems in leg caused by superficial
veins; varicose veins primarily caused by valve failure; valve failure leads to hydrostatic pressure
|
| Saphenous vein stripping: clinical success 94%; requires general anesthesia; return to activity, on average, in 4
days; return to work, on average, in 12 days; complications—deep venous thrombosis (incidence 5%); saphenous
vein injury common, particularly when stripped down below knee; lymphatic injury, wound complications,
and scarring
|
| Endovenous laser ablation: thermal ablation of greater saphenous vein; laser system advanced into target vein; once
refluxing channel closed, distended branch veins shrink down and return to normal state; performed under local
anesthesia in outpatient setting; length of procedure ≈45 min; requires no stitches or crutches; requires only laser
drive unit and standard small laser set; compression stockings worn for 10 days after procedure; patient fully ambulatory
and able to return to normal activity immediately after procedure; data show 98% technical success and
94% persistent closure in symptom resolution at 5 yr; little neovascularization and recurrence because procedure
does not disrupt tissue; performed since 2000 and gaining in popularity
|
| Vertebroplasty/kyphoplasty: performed for osteoporotic vertebral compression fractures; osteoporosis—1 in 3
women and 1 in 8 men >50 yr of age affected; prevalence increases with age; results in fragility fractures of hip and
spine; spine most common place for osteoporotic compression fracture; 1.5 million fractures annually in United
States; one-third occur in spine; characterized by loss of bone mineral density with aging; osteoporosis, medications
(eg, steroids, leuprolide), and kyphotic spine predisposing factors for vertebral fracture; vertebroplasty—involves
mechanical buttressing of vertebral fracture with medical cement to prevent further fractures and to stop pain;
kyphoplasty—insertion of balloon into vertebral body (in attempt to regain loss of height) before injection of medical
cement; speaker believes both procedures equivalent in promoting symptom relief; patients with osteoporotic
vertebral fractures, malignant vertebral fractures, or malignant disease causing spine to weaken candidates for procedure;
MRI mainstay of work-up; procedures have been used to treat metastatic disease (eg, myeloma, giant cell hemangiomas);
risk—considered safe, but injection of too much medical cement can cause embolization (can get into
venous plexus from spine and travel to lungs); possible shifting of bone can narrow nerve root at exit sites; performed
under fluoroscopic guidance; 80% to 90% improvement in pain almost immediately; pain may recur, but
usually related to another fracture at another level
|
Suggested Reading
Coumans JV et al: Kyphoplasty for vertebral compression fractures: 1-year clinical outcomes from a prospective
study. J Neurosurg 99(1 Suppl):44,2003; Evans P, Brunsell S: Uterine fibroid tumors: diagnosis and treatment. Am
Fam Physicians 75:1503, 2007; Exacoustos C, Rosati P: Ultrasound diagnosis of uterine myomas and complications
in pregnancy. Obstet Gynecol 82:27, 1993; Koike T et al: Uterine leiomyoma in pregnancy: its influence on obstetric
performance. J Obstet Gynaecol Res 25(5):309, 1999; 2003; McLucas B et al: Uterine fibroid embolization: nonsurgical
treatment for symptomatic fibroid. J Am Coll Surg 192(1):95, 2001; Min RJ et al: Endovenous laser treatment
of the incompetent greater saphenous vein. JVIR 12(10):1167, 2001; Ouyang DW et al: Obstetric complications of
fibroids. Obstet Gynecol Clinic N Am 33:153, 2006; Qidwai GI et al: Obstetric outcomes in women with sonographically
identified uterine leiomyomata. Obstet Gynecol 107(2 Pt 1):376, 2006; Spies J et al: Long-term outcomes for
uterine fibroid embolization with tris-acryl gelatin microspheres: result of a multicenter study. JVIR 18(2):203, 2007;
Strobelt N et al: Natural history of uterine leiomyomas in pregnancy. J Ultrasound Med 13(5):399, 1997.
Educational Objectives
| The goal of this program is to improve management of fibroids and to increase awareness about interventional radiology
procedures that have relevance for medical problems specific to women. After hearing and assimilating this program,
the clinician will be better able to:
|
| 1. Discuss the natural history of fibroids during pregnancy.
|
| 2. Evaluate the evidence linking pregnancy and pregnancy complications to fibroids.
|
| 3. Counsel pregnant patients about complications related to fibroids.
|
| 4. Provide prenatal and postpartum care for women with fibroids.
|
| 5. Raise awareness about new procedures in the field of interventional radiology for treating common medical
problems affecting women.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care
and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported
nothing to disclose.
Acknowledgments
Dr. Jacoby was recorded at Antepartum and Intrapartum Management, sponsored by the University of California, San
Francisco, School of Medicine, held on June 7-9, 2007, in San Francisco, CA. Dr. Fan was recorded at 10th Annual Practical
Women’s Health Issues, sponsored by Boston University School of Medicine, held on October 27, 2007, in Dedham,
MA. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
|
