Obstetric risks in uterine fibroids: age aspect.

Zhelezov D.M.

candidate of medical sciences,

teaching assistant of the department of obstetrics and gynecology №1

Odesa National Medical University

Salekh O.S.

intern, obstetrician-gynecologist,

Belgorod-Dnistrovsky municipal multi-profile hospital

Железов Д.М.

кандидат медичних наук, асистент кафедри акушерства та гінекології №1

Одеського національного медичного університету

Салех О.С.

лікар-інтерн акушер-гінеколог

Білгород-Дністровської міськрайонної багатопрофільної лікарні

Obstetric risks in uterine fibroids: age aspect.

Акушерські ризики при міомі матки: віковий аспект.

Summary: A reproductive function is postponed until a woman has already built a career in the world, and therefore, in most cases, pregnancy is planned after 35 years. However, this age category of women is characterized by a decrease in the fertile potential and the presence of both somatic and gynecological comorbid conditions, which include, in particular, myoma in the uterus. The prevalence of uterine fibroids during pregnancy, according to experts, is between 2 and 11%. The presence of a myoma not only affects the chances of a woman getting pregnant, but it can lead to obstetric complications. According to epidemiological studies, the incidence of the cesarean section in pregnant women with uterine myoma is 73%. We conducted a study on the basis of Odesa regional perinatal center during 2015-2018. The aim of the study was to evaluate the effect of uterine fibroids on the course of pregnancy in women of reproductive age. As a result of the study analysis, it was concluded that pregnancy against the background of uterine fibroids is accompanied by a number of obstetric complications.

Key words: pregnancy, cesarean section, uterine myoma.

Резюме: У світі все частіше реалізація репродуктивної функції відкладається до моменту, коли в жінки вже збудована кар’єра, а тому здебільшого, вагітність планується після 35 років. Проте дана вікова категорія жінок характеризується зниженням фертильного потенціалу та наявністю як соматичних так і гінекологічних коморбідних станів, до яких, зокрема, належить міома матки. Поширеність міоми матки під час вагітності, за оцінками експертів, становить від 2 до 11%. Наявність міоми не лише впливає на шанси жінки завагітніти, але й може призвести до акушерських ускладнень. За даними епідеміологічних досліджень частота кесаревого розтину у вагітних з міомою матки складає 73%. Нами було проведено дослідження на базі Одеського обласного перинатального центру впродовж 2015-2018 рр. Метою дослідження була оцінка впливу міоми матки на перебіг вагітності у жінок репродуктивного віку. В результаті аналізу даних дослідження був зроблений висновок, що вагітність на тлі міоми матки супроводжується рядом акушерських ускладнень та

Ключові слова: вагітність, кесарів розтин, міома матки.

The realization of the reproductive function in the world is more frequently postponed until a woman has already built a career. This age is over 35 years old [1]. But in addition to social status, it is characterized by a decrease in the fertile potential and the presence of both somatic and gynecological comorbid conditions, n particular, myoma in the uterus. On literature evidence, the presence of a myoma not only affects the chances of a woman getting pregnant, but it can lead to obstetric complications [2, 3]. According to experts, the prevalence of uterine fibroids in pregnancy is between 2 and 11%. In this case, the fibroids may remain asymptomatic, but often they cause the occurrence of various complications that can develop in any trimester of pregnancy. The most common are miscarriages, premature births, placental dysfunction, primary and secondary weakness of labor, bleeding. Childbirth in women with myoma is often complicated by untimely discharge of the amniotic fluid, anomalies of labor activity, disturbances of the placenta abscission. Often, such women give birth by surgery, with the risk of expanding the scope of surgery up to the uterine amputation in presence of uterine nodes of large size, their atypical location (cervical, precervical localization), with deformation of the uterine cavity or necrosis of the nodes [2, 3].

There are currently no reliable algorithms for predicting the growth of myoma during pregnancy, and there is still a scientific discussion about the possibility of using logistic regression models, complex multimodal models [4, 5].

Juhasz-Boss I. et al. (2016) proposed an algorithm for assessing the severity of the uterine fibroids, which can be used to make a clinical decision to choose a method of treatment and tactics of patient management [6].

According to epidemiological studies, the incidence of the cesarean section (CS) in pregnant women with uterine myoma is 73%. However, the performance of CS is associated with a high risk of bleeding, thromboembolic complications, anemia, and septic complications. Even 15 years ago, obstetricians avoided performing simulant conservative myomectomy during the cesarean section, motivating this decision with high perioperative risk. At present, the number of successful interventions for uterine fibroids performed during CS increases every year [].

The aim of the study was to evaluate the effect of uterine fibroids on the course of pregnancy in women of reproductive age.

Material and methods

The study was performed on the basis of Odesa regional perinatal center during 2015-2018. There was analyzed frequency of the cesarean sections in women with uterine myoma. The total number of clinical cases included in the study was 376 women who gave birth surgically in accordance with the order of the Ministry of Health №977 of 27.12.2011. This is 5.9% of the total number of the cesarean sections performed for the period of the retrospective study (n = 6329).

The total score of the manifestation of the pathological process was calculated and presented in the Table. 1

Table 1

Evaluation of the prevalence of the pathological process

Criteria Assessment in score
1 2 3
The number of nodes 1-2 3-4 5 and more
Localization Subserous/submucous Subserous/submucous involving intramural zones Intramural
The size of the biggest node Up to 2 см 2-4 см Over 4 см
The number of cicatrices on the uterus 1 2 3 and more

While studying the clinical cases, the frequency of complications of pregnancy and childbirth were analyzed, the risk factors for the occurrence of myoma, anamnesis, peculiarities of the course of pregnancy, childbirth and the postpartum period were studied to provide recommendations for the minimization of complications.

The statistical analysis was conducted using the software Statistica 13.0 (Dell Inc., USA).

Study results

The average age of the examined patients was 32.7±1.1 years. Intramural localization of myomatous nodes was the most common (228 cases or 60.6%). In 75 (19.9%) cases the sub-serous localization is determined, and in 73 (19.4%) – there was multiple localization. The average estimation of the prevalence of the pathological process in the scores was 6.7±0.2 points.

The main risk factors for the occurrence of uterine fibroids are the age of over 35 years old (odds ratio (OR) = 1.6), obesity and metabolic syndrome (OR = 1.4), burdened obstetric anamnesis (OR = 2.2), smoking (OR = 1.3) and prolonged use of hormonal contraception (OR = 1.8).

Further analysis showed that in 122 (32.4%) cases, myomatous nodes were located on the anterior wall of the uterus, in 35 (9.3%) -on the back, in 77 (20.5%) — in the region of the uterus, in 128 (34.0%) — in the area of ​​the body and the bottom of the uterus, in 14 (3.7%) pregnant women — in the area of ​​the isthmus.

Regarding the frequency of complications of pregnancy and childbirth, a retrospective analysis of medical records showed that in 338 (89.9%) women during the first trimester there was a threat of miscarriage. In 161 (42.8%) patients, this threat was sustained throughout pregnancy. Other common complications were makposition — 76 (20.2%), development of placenta dysfunction (254 or 67.6%), anemia of pregnancy (68 or 18.1%), preeclampsia (30 or 7.9%), syndrome of delayed fetal development (25 or 6.6%). Acute pain syndrome during pregnancy was registered in 166 (44.1%) cases.

In 10.9% of the puerperants, there was prenatal discharge of the amniotic fluid, in 7.4% there was weakness of the labor activity. In some cases, the cesarean section was combined with conservative myometectomy (4.0%), supra-cervical hysterectomy without appendages (3.1%) and one of the appendages (1.5%). Indications for expanding the scope of surgical intervention were mainly multiple myomatous nodes with signs of necrosis and atypical localization of nodes that prevented the delivery through natural delivery pathways.

Thus, the presence of myomatous nodes significantly influenced the course of pregnancy. Regarding the pain syndrome, which was often observed in women who had my uterus, its pathogenesis can be quite complicated. Firstly, with the rapid growth of myoma, there may occur ischemia as a result of developmental delay of the vascular network. This leads to anoxia and the formation of microinfarctions with subsequent inflammation of the perifocal zone. Secondly, during pregnancy, the myometrium architecture is changing, the phenomena of crowning, which exacerbate ischemia, are observed, even in the absence of tumor growth. Finally, pain is a consequence of secretion of prostaglandins by cells of an ischemic myomatous node. This partly explains the development of other complications of pregnancy against the background of fibroid carriage.

Conclusions:

1. The main risk factors for the occurrence of uterine myoma according to the analysis are age over 35 years old (OR = 1.6), obesity and metabolic syndrome (OR = 1.4), burdened obstetric anamnesis (OR = 2.2), smoking (OR = 1.3) and prolonged use of hormonal contraception (OR = 1.8)

2. The frequency of performing cesarean section against the background of myoma carriage is based on the data of the retrospective study of 1 case of 17 cases of operative delivery, which is significantly lower than the levels registered by other specialists.

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