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Myomas of the uterus in pregnancy: Ultrasonographic follow-up
Myqmas of the uterus in pregnancy: Ultrasonographic follow-up DAVID
MURAM,
MARTIN JACK Ottawa,
M.D.
GILLIESON, H.
WALTERS,
Ontario,
M.B.,
F.R.C.S.(C.)
M.D.
Canada
A review was made of the medical records of pregnant patients who had myomas that were documented by ultrasonographic studies. Only 42% of the myomas were diagnosed by physical examination. In most instances the clinical diagnosis was made when the neoplasm was large. However. when the myoma was 3 cm to 5 cm in diameter, the rate of detection on physical examination was only 12.5%. The relationship between the location of the myomas and the placental site emerged as a significant prognostic clue to the outcome of the pregnancy. Ten of 13 patients in whom there was contact between the two presented with complications of pregnancy, mainly antepartum bleeding and premature rupture of membranes. A prospective study is currently in progress. (AM. J. OBSTET. GYNECOL. 138:16, 1980.)
AccoRDr~c to reports of‘ several iarge series,‘+ the incidence of myomas of the uterus in pregnancy ranges between 0.3% and 2.6%. The low figure suggests that the majority of myomas are asymptomatic, even in pregnancy, and hence, escape detection. The finding of uterine myomas in 50% of autopsies5 emphasized the common occurrence of these neoplasms. The clinical evaluation of small, symptom-free myomas of the uterus is often subjective and not always simple. Because of the pregnancy, the physician tends to avoid an invasive investigation. Among the complications of pregnancy ascribed to myomas are a decreased fertility,’ increased incidence of abortions,’ ectopic pregnancy,“, i red degeneration, disseminated intravascular coagulation, H.f, hemoperitoneum,‘” premature rupture of membranes,” dystocia secondary to cervical myoma,” extrusion of the myoma,’ inversion of the uterus,” *’ and postpartum hemorrhage.”
Material and methods The introduction of ultrasonography to the field of obstetrics gave the physician an opportunity to docuand Gynecology,and of Ottawa. January 22, 1980.
From the Department of Obstetrics the Ultrasound Section, University Received for publication Revised
April
Accepted April
7, 1980. 14, 1980.
Reprint requests: Martin Gillieson, Hospital, 43 Bruyere St., Ottawa,
5CR.
16
M.B.,
Ottawa
General
Ontario, Canada KIN
ment the presence of myomas in the uterus, to measure them, and to follow them throughout pregnancy. In a retrospective study, we reviewed the medical records of about 5,000 obstetric patients who had undergone at least one ultrasonographic examination at the Ottawa General Hospital over a period of 2% years between 1976 and 1978. All ultrasonographic screening was performed by the same examiner, with the use of a Picker Echoview XI with EDC gray scale adaptation. Man) patients were also studied by means of an Advanced Diagnostic Research real-time machine, but the size of the myomas and the placental site were always diagnosed by means of the storage gray-scale technique. Diagnosis of myomas was made when the following criteria were fulfilled: (I) A mass greater than 3 cm in diameter was observed. (2) The mass was spherical. (3) The myometrial contour was distorted by the mass, either externally or by impingement on the gestation sac. (4) The mass was of different acoustical structure than the myometrium. All masses fulfilling these first four criteria were subjected to further study at varying ultrasound sensitivities in order to bring out their structure. Internal echoes were studied carefully in order to differentiate them from reverberation artifacts. Two more criteria were added after this detailed study: (I) The mass showed a speckled pattern of internal echoes, increasing in density with an increased ultrasound sensitivity. (2) No enhancement of echoes was noticed behind the mass, which would have suggested a cystic nature. 0002-9378/80/170016+04$00.40/0
0
1980
The
C. V. Mosby
Co.
Volume Number
Table I. Relationship between and their clinical detection
location
of myomas
No. of Location Isthmus Corpus Corpus
17
Myomas of uterus in pregnancy
158 I
uteri uteri,
of myoma.3
anterior
patients
surface
uteri, posterior surface Fundus uteri Cornua uteri
1 21 14
Table II. Relationship method of delivery
between
Vaginal delivery Cesarean section Spontaneous abortion
12 1 3
size of mvomas and
Clinically detected 1 8
2
6 2
3
3
The placenta was localized by means of the usual well-established criteria.“’ Patients were rescanned at varying intervals for indications, such as estimation of growth patterns, etc., to evaluate growth of the myomas. If more than one myoma was diagnosed, the largest one was considered to be representative. There were 3 1 patients in whom a definite diagnosis of myomas of the uteruc was made, and 41 of them were followed until the termination of the pregnancy. Of the other 10 patients, six moved to other cities and four had therapeutic abortions. In I Y of the patients the ultrasonographic diagnosis was confirmed by pathologic examination. In six patients the myomas were seen at the time of cesarean section, and in one of them a myomectomy was performed at that time. Four of the remaining 13 patients underwent abdominal hysterectomy, and the presence of myomas was confirmed by the pathologist. In the other three patients, the myomas were visualized at the time of laparotomy. The indications for laparotomy were adnexal disease in two patients and tubal ligation in one.
Results Age, parity, and race of the patients. The patients ranged in age between 24 and 41 years, with an average of 3 1 years. Sixteen of the patients were under the age of 30 years, and only one patient was older than 39 years. There were 25 primigravidas and 16 multiparas. Only live of 41 patients were not Caucasians. Three were Blacks, and two were Indians. Clinical detection of myomas of the uterus during pregnancy. In 17 of 41 patients (41%), the myomas were diagnosed by the referring physician. Small myomas escaped clinical detection frequently, whereas large ones were detected with relative ease. Sixteen patients had small myomas, 3 cm to 5 cm in diameter. only two of which (12.5%) were diagnosed clinically. Twenty patients had a medium-sized myomas, between 5 cm and 10 cm in diameter, 11 of which were diagnosed on physical examination. Five patients had large myomas, more than 10 cm in diameter, four
Table III. Relationship placental site
between
14
‘3
3 2
2
myoma
29 7 5
and
Partial or cowsplete overlapping
j 1
I
3 to5cm 5 to 10 cm >lO cm Total
10 15 3 28
L
6 3 -. 1 10
2 I 3
of which (80%) were diagnosed prior to the ultrasonographic examination. Location of the myomas and clinical detection of them. Thirty-five of 41 patients had a mvoma on the corpus uteri. In 21 of these patients the neoplasm was on the anterior surface of the uterus. and in 14 it was on the posterior surface. The myoma was on the cornua in three patients, on the fundus in two, and on the isthmus in one. In the latter six patient5 the diagnoses were made on physical examination. The rate of detection was lower when the neoplasm was on the corpus uteri. In only eight of 21 patients with the myoma on the anterior surface of the uterus, and in six of 14 patients with the myoma on the posterior surf&e were the tumors found by phvsical examination (Table I). Changes in size of myomas during pregnancy. In 38 of 41 patients there was no demonstrable change in size of the myoma. In two patients the size of the mvoma increased by 20% and 25%. In one paciellr the neoplasm diminished in size by 20%,. Abortion. Five patients aborted spontaneously: four of them in the first trimester, and one patient at 16 weeks’ gestation. The overall incidence of abortion was 12%. The abortion rate appears not to have been increased. Fetal growth. The incidence of small-for-dates infants was similar to the general figures. ‘Three infants were below the tenth percentile for- gestational age, 17 were in the tenth to fiftieth percentile for gestational
18 Muram, Gillieson, and Walters
Table Patient
H. J. M. L. P. I. A. S. R. I. N. R. G. L. R. B. M. L. s. L. H. C. c. L. D. A.
IV. Course Sire of myoma
Small Small Small Medium Medium Medium Small Medium Large Small Medium Small Large
of pregnancy
in patients
Relatiovskip between myomu and phcental site
Contact Contact Contact Overlapping Overlapping Contact Contact Contact Contact Contact Contact Contact Overlapping
in whom
there was contact
Week of gestatiwn 8 10 11 11 16 26 33 33 38
Postpartum 40 40 40
age, and 16 were in the fiftieth to ninetieth percentile for gestational age. Fetal growth appears not to have been affected by the presence of myomas. Method of delivery. Twenty-nine of 36 patients who carried to viability had a vaginal delivery. The other seven patients were delivered of infants by cesarean section, an incidence of 17%. The indications for abdominal delivery were as follows: previous cesarean section in two cases, and one each because of extensive myomectomy, breech presentation in a primigravida, placenta previa, fetal distress, and cephalopelvic disproportion. The size of the myoma did not appear to affect the method of delivery (Table II). Relationship between size of myoma and placental site. In 28 of 41 patients, there was no contact between the margin of the placenta and the myoma. In these patients the placenta was impIanted on the opposite wall of the uterus. In IO of 41 patients the placenta was implanted on the same uterine wall as the myoma, and the placental margin was in contact with the myoma. In three patients the placenta was located directly over a myoma (Table III). In 13 patients there was contact between the myoma and the placenta. A signihcant observation was that 10 of these patients had complicated pregnancies. The complications included premature rupture of membranes, bleeding during pregnancy, and postpartum hemorrhage; the three patients with these complications had no problems during gestation and labor, even though in one case the myoma was large and the placenta was situated directly over the myoma (Table IV).
Comment The problems of ultrasonic diagnosis of myomas which complicate pregnancy are considerable. In the first trimester they may be confused with a corpus luteum, cystic teratoma of the ovary, other benign or
between
Complication
myoma
of pregnancy
Bleeding Bleeding Bleeding Bleeding Bleeding Premature rupture of membranes Premature rupture of membranes Premature rupture of membranes Bleeding Hemorrhage
-
and placenta Pregnancy
outcome
Abortion Normal vaginal delivery Abortion Abortion Abortion Delivery Delivery Delivery Cesarean section Normal Normal Normal
vaginal vaginal vaginal
delivery delivery delivery
malignant tumors of the ovary, and, more rarely, the nonpregnant cornua of a bicornuate uterus.” In view of this, no patient was included in this study on the basis of a first-trimester scan alone. Myomas often show bizarre internal structure, and may be more or less transonic than the myometrium. Nevertheless, solid tumors of the ovary or uterus which might be confused with myomas are rare, and we doubt that any have been inadvertently included in the study. In the last 2 years, we were able to confirm pathologically or anatomically the presence of myomas in 13 patients. This confirmation emphasizes the accuracy ofthe ultrasonographic diagnosis. In this series, the incidence of myomas complicating pregnancy was less than 1%. Clinical detection of the myomas depended on their size and location. Only two of the 16 myomas that were 3 cm to 5 cm in size were found by physical examination, whereas there was a pick-up rate of 80% when the myoma was larger than 10 cm in diameter. All the fundal, cornual, and isthmic myomas were detected clinically. Myomas that were situated on the corpus uteri often escaped detection. The overall rate of clinical diagnosis was 42%. It is interesting to note that most of the patients were Caucasians. The average age and parity in this series were not different from those in other series.‘, ’ Fetal growth and method of delivery were not affected by the presence of myomas. We were able to correlate not only the size of the myomas with the outcome of pregnancy, but also the relationship between the placental site and the myoma. This latter association appears to be significant in view of the multiple complications in the patients in whom the placental site was in contact with a myoma. Even though the number of patients was small, the findings suggest that patients in whom the placental site is near a myoma form a special subgroup which is
Volume Number
Myomas of uterus in pregnancy
Is-4 I
at risk for complications, such as premature rupture of membranes, antepartum bleeding, and postpartum hemorrhage. This study indicates that the location of the myoma, especially its relationship to the placental site, is more significant than its actual size in predicting pregnancy outcome. The ultrasonic technique enables one to visualize myomas, measure them accurately, and follow them throughout pregnancy without harming the mother or the fetus. Patients in whom there is a close
proximity between myoma and placental site seem to be at greater risk and should be followed more carefully. Since only ultrasonographic study can determine the relationship between the myoma and the placental site, every pregnant patient with suspected myoma should be scanned. We are now conducting a prospective study to assess our findings. We wish to thank encouragement.
REFERENCES 1. Chassar Moir, J., and Myerscough, P. R.: Fibromyomata of the uterus, in Kerr, M., editor: Operative Obstetrics, London, 1971, Bailiere, Tindall Cassell, Ltd., chap. 18, pp. 398-42 I. 2. Davids, A. M.: Fibromyomas, in Rovinski, J. J., and Gutmarche, A. F., Medical, Surgical and Gynecologic Complications of Pregnancy. Baltimore, 1965, The Williams & Wilkins Co., chap. 28, pp. 366-382. 3. Douglas, R. G., and Stromme, W. B.: Operative Obstetrics. New York, 1976, Appleton-Century-Crofts, p. 413. 4. Tisne, L., and Anselmo, J.: Contribution al estudio sobre mioma y esrado gravido puerperal, Bol. Sot. Chile Obstet. Ginecol. 20: 178, 1955. 5. Mattingly, R. F.: In Te Linde, R., editor: Operative Gynecology, Philadelphia, 1977, J. B. Lippincott, Co., p. 187. 6. Dees, H. C.: Cervical pregnancy associated with uterine leiomyomas, South. Med. J. 59:900, 1966. 7. Hepperlen, H. M.: Ectopic pregnancy associated with fibromyoma. Nebr. Med. I. 55:428. 1970. 8. Hnat, R. F., Anderson. G:‘G., and klonzo, D. R.: Diffuse
19
9.
10.
11.
12.
13.
Dr. H. Oxorn
for his advice and
intravascular coagulation associated with a degenerating myoma during pregnancy, Obstet. Gynrcol. 29:207, 1967. Moore, J. B.. and Morton, D. G.: Leiomyomas of the uterus, in Sciarra, J. J., and McElin, T. W., editors: Gynecology and Obstetrics, Hagerstown, 1979, Harper & Row, Publishers, vol. I, chap. 26, pp. 1-l 1. Buttery. B. W.: Spontaneous haempoeritoneum complicating uterine libromyoma, Aust. N. %. J. Obstet. Gynaecol. 12:210, 1972. Von Mickey, L. I.: Sonographic study of uterine fibromyomata in the non-pregnant state and during gestations. in Saunders, R. D., and James, A. E., editors: Ultrasonography in Obstetrics and Gynecology, New York. 1977, Appleton-Century-Crofts, chap. 26, pp. 297-331. Telko, M., Powlony, M., and Pawlicka, H.: Diagnosis and therapy of puerperal eversion of myomatous uterus, Ginekol. Pol. 44:699, 1973. Kobayashi, M., Hellman, L. M., and Fillisti, L.: Placental localization by ultrasound. AM. J. ORSTLT. GYNECOL. 106:279, 1970.
MURAM,
MARTIN JACK Ottawa,
M.D.
GILLIESON, H.
WALTERS,
Ontario,
M.B.,
F.R.C.S.(C.)
M.D.
Canada
A review was made of the medical records of pregnant patients who had myomas that were documented by ultrasonographic studies. Only 42% of the myomas were diagnosed by physical examination. In most instances the clinical diagnosis was made when the neoplasm was large. However. when the myoma was 3 cm to 5 cm in diameter, the rate of detection on physical examination was only 12.5%. The relationship between the location of the myomas and the placental site emerged as a significant prognostic clue to the outcome of the pregnancy. Ten of 13 patients in whom there was contact between the two presented with complications of pregnancy, mainly antepartum bleeding and premature rupture of membranes. A prospective study is currently in progress. (AM. J. OBSTET. GYNECOL. 138:16, 1980.)
AccoRDr~c to reports of‘ several iarge series,‘+ the incidence of myomas of the uterus in pregnancy ranges between 0.3% and 2.6%. The low figure suggests that the majority of myomas are asymptomatic, even in pregnancy, and hence, escape detection. The finding of uterine myomas in 50% of autopsies5 emphasized the common occurrence of these neoplasms. The clinical evaluation of small, symptom-free myomas of the uterus is often subjective and not always simple. Because of the pregnancy, the physician tends to avoid an invasive investigation. Among the complications of pregnancy ascribed to myomas are a decreased fertility,’ increased incidence of abortions,’ ectopic pregnancy,“, i red degeneration, disseminated intravascular coagulation, H.f, hemoperitoneum,‘” premature rupture of membranes,” dystocia secondary to cervical myoma,” extrusion of the myoma,’ inversion of the uterus,” *’ and postpartum hemorrhage.”
Material and methods The introduction of ultrasonography to the field of obstetrics gave the physician an opportunity to docuand Gynecology,and of Ottawa. January 22, 1980.
From the Department of Obstetrics the Ultrasound Section, University Received for publication Revised
April
Accepted April
7, 1980. 14, 1980.
Reprint requests: Martin Gillieson, Hospital, 43 Bruyere St., Ottawa,
5CR.
16
M.B.,
Ottawa
General
Ontario, Canada KIN
ment the presence of myomas in the uterus, to measure them, and to follow them throughout pregnancy. In a retrospective study, we reviewed the medical records of about 5,000 obstetric patients who had undergone at least one ultrasonographic examination at the Ottawa General Hospital over a period of 2% years between 1976 and 1978. All ultrasonographic screening was performed by the same examiner, with the use of a Picker Echoview XI with EDC gray scale adaptation. Man) patients were also studied by means of an Advanced Diagnostic Research real-time machine, but the size of the myomas and the placental site were always diagnosed by means of the storage gray-scale technique. Diagnosis of myomas was made when the following criteria were fulfilled: (I) A mass greater than 3 cm in diameter was observed. (2) The mass was spherical. (3) The myometrial contour was distorted by the mass, either externally or by impingement on the gestation sac. (4) The mass was of different acoustical structure than the myometrium. All masses fulfilling these first four criteria were subjected to further study at varying ultrasound sensitivities in order to bring out their structure. Internal echoes were studied carefully in order to differentiate them from reverberation artifacts. Two more criteria were added after this detailed study: (I) The mass showed a speckled pattern of internal echoes, increasing in density with an increased ultrasound sensitivity. (2) No enhancement of echoes was noticed behind the mass, which would have suggested a cystic nature. 0002-9378/80/170016+04$00.40/0
0
1980
The
C. V. Mosby
Co.
Volume Number
Table I. Relationship between and their clinical detection
location
of myomas
No. of Location Isthmus Corpus Corpus
17
Myomas of uterus in pregnancy
158 I
uteri uteri,
of myoma.3
anterior
patients
surface
uteri, posterior surface Fundus uteri Cornua uteri
1 21 14
Table II. Relationship method of delivery
between
Vaginal delivery Cesarean section Spontaneous abortion
12 1 3
size of mvomas and
Clinically detected 1 8
2
6 2
3
3
The placenta was localized by means of the usual well-established criteria.“’ Patients were rescanned at varying intervals for indications, such as estimation of growth patterns, etc., to evaluate growth of the myomas. If more than one myoma was diagnosed, the largest one was considered to be representative. There were 3 1 patients in whom a definite diagnosis of myomas of the uteruc was made, and 41 of them were followed until the termination of the pregnancy. Of the other 10 patients, six moved to other cities and four had therapeutic abortions. In I Y of the patients the ultrasonographic diagnosis was confirmed by pathologic examination. In six patients the myomas were seen at the time of cesarean section, and in one of them a myomectomy was performed at that time. Four of the remaining 13 patients underwent abdominal hysterectomy, and the presence of myomas was confirmed by the pathologist. In the other three patients, the myomas were visualized at the time of laparotomy. The indications for laparotomy were adnexal disease in two patients and tubal ligation in one.
Results Age, parity, and race of the patients. The patients ranged in age between 24 and 41 years, with an average of 3 1 years. Sixteen of the patients were under the age of 30 years, and only one patient was older than 39 years. There were 25 primigravidas and 16 multiparas. Only live of 41 patients were not Caucasians. Three were Blacks, and two were Indians. Clinical detection of myomas of the uterus during pregnancy. In 17 of 41 patients (41%), the myomas were diagnosed by the referring physician. Small myomas escaped clinical detection frequently, whereas large ones were detected with relative ease. Sixteen patients had small myomas, 3 cm to 5 cm in diameter. only two of which (12.5%) were diagnosed clinically. Twenty patients had a medium-sized myomas, between 5 cm and 10 cm in diameter, 11 of which were diagnosed on physical examination. Five patients had large myomas, more than 10 cm in diameter, four
Table III. Relationship placental site
between
14
‘3
3 2
2
myoma
29 7 5
and
Partial or cowsplete overlapping
j 1
I
3 to5cm 5 to 10 cm >lO cm Total
10 15 3 28
L
6 3 -. 1 10
2 I 3
of which (80%) were diagnosed prior to the ultrasonographic examination. Location of the myomas and clinical detection of them. Thirty-five of 41 patients had a mvoma on the corpus uteri. In 21 of these patients the neoplasm was on the anterior surface of the uterus. and in 14 it was on the posterior surface. The myoma was on the cornua in three patients, on the fundus in two, and on the isthmus in one. In the latter six patient5 the diagnoses were made on physical examination. The rate of detection was lower when the neoplasm was on the corpus uteri. In only eight of 21 patients with the myoma on the anterior surface of the uterus, and in six of 14 patients with the myoma on the posterior surf&e were the tumors found by phvsical examination (Table I). Changes in size of myomas during pregnancy. In 38 of 41 patients there was no demonstrable change in size of the myoma. In two patients the size of the mvoma increased by 20% and 25%. In one paciellr the neoplasm diminished in size by 20%,. Abortion. Five patients aborted spontaneously: four of them in the first trimester, and one patient at 16 weeks’ gestation. The overall incidence of abortion was 12%. The abortion rate appears not to have been increased. Fetal growth. The incidence of small-for-dates infants was similar to the general figures. ‘Three infants were below the tenth percentile for- gestational age, 17 were in the tenth to fiftieth percentile for gestational
18 Muram, Gillieson, and Walters
Table Patient
H. J. M. L. P. I. A. S. R. I. N. R. G. L. R. B. M. L. s. L. H. C. c. L. D. A.
IV. Course Sire of myoma
Small Small Small Medium Medium Medium Small Medium Large Small Medium Small Large
of pregnancy
in patients
Relatiovskip between myomu and phcental site
Contact Contact Contact Overlapping Overlapping Contact Contact Contact Contact Contact Contact Contact Overlapping
in whom
there was contact
Week of gestatiwn 8 10 11 11 16 26 33 33 38
Postpartum 40 40 40
age, and 16 were in the fiftieth to ninetieth percentile for gestational age. Fetal growth appears not to have been affected by the presence of myomas. Method of delivery. Twenty-nine of 36 patients who carried to viability had a vaginal delivery. The other seven patients were delivered of infants by cesarean section, an incidence of 17%. The indications for abdominal delivery were as follows: previous cesarean section in two cases, and one each because of extensive myomectomy, breech presentation in a primigravida, placenta previa, fetal distress, and cephalopelvic disproportion. The size of the myoma did not appear to affect the method of delivery (Table II). Relationship between size of myoma and placental site. In 28 of 41 patients, there was no contact between the margin of the placenta and the myoma. In these patients the placenta was impIanted on the opposite wall of the uterus. In IO of 41 patients the placenta was implanted on the same uterine wall as the myoma, and the placental margin was in contact with the myoma. In three patients the placenta was located directly over a myoma (Table III). In 13 patients there was contact between the myoma and the placenta. A signihcant observation was that 10 of these patients had complicated pregnancies. The complications included premature rupture of membranes, bleeding during pregnancy, and postpartum hemorrhage; the three patients with these complications had no problems during gestation and labor, even though in one case the myoma was large and the placenta was situated directly over the myoma (Table IV).
Comment The problems of ultrasonic diagnosis of myomas which complicate pregnancy are considerable. In the first trimester they may be confused with a corpus luteum, cystic teratoma of the ovary, other benign or
between
Complication
myoma
of pregnancy
Bleeding Bleeding Bleeding Bleeding Bleeding Premature rupture of membranes Premature rupture of membranes Premature rupture of membranes Bleeding Hemorrhage
-
and placenta Pregnancy
outcome
Abortion Normal vaginal delivery Abortion Abortion Abortion Delivery Delivery Delivery Cesarean section Normal Normal Normal
vaginal vaginal vaginal
delivery delivery delivery
malignant tumors of the ovary, and, more rarely, the nonpregnant cornua of a bicornuate uterus.” In view of this, no patient was included in this study on the basis of a first-trimester scan alone. Myomas often show bizarre internal structure, and may be more or less transonic than the myometrium. Nevertheless, solid tumors of the ovary or uterus which might be confused with myomas are rare, and we doubt that any have been inadvertently included in the study. In the last 2 years, we were able to confirm pathologically or anatomically the presence of myomas in 13 patients. This confirmation emphasizes the accuracy ofthe ultrasonographic diagnosis. In this series, the incidence of myomas complicating pregnancy was less than 1%. Clinical detection of the myomas depended on their size and location. Only two of the 16 myomas that were 3 cm to 5 cm in size were found by physical examination, whereas there was a pick-up rate of 80% when the myoma was larger than 10 cm in diameter. All the fundal, cornual, and isthmic myomas were detected clinically. Myomas that were situated on the corpus uteri often escaped detection. The overall rate of clinical diagnosis was 42%. It is interesting to note that most of the patients were Caucasians. The average age and parity in this series were not different from those in other series.‘, ’ Fetal growth and method of delivery were not affected by the presence of myomas. We were able to correlate not only the size of the myomas with the outcome of pregnancy, but also the relationship between the placental site and the myoma. This latter association appears to be significant in view of the multiple complications in the patients in whom the placental site was in contact with a myoma. Even though the number of patients was small, the findings suggest that patients in whom the placental site is near a myoma form a special subgroup which is
Volume Number
Myomas of uterus in pregnancy
Is-4 I
at risk for complications, such as premature rupture of membranes, antepartum bleeding, and postpartum hemorrhage. This study indicates that the location of the myoma, especially its relationship to the placental site, is more significant than its actual size in predicting pregnancy outcome. The ultrasonic technique enables one to visualize myomas, measure them accurately, and follow them throughout pregnancy without harming the mother or the fetus. Patients in whom there is a close
proximity between myoma and placental site seem to be at greater risk and should be followed more carefully. Since only ultrasonographic study can determine the relationship between the myoma and the placental site, every pregnant patient with suspected myoma should be scanned. We are now conducting a prospective study to assess our findings. We wish to thank encouragement.
REFERENCES 1. Chassar Moir, J., and Myerscough, P. R.: Fibromyomata of the uterus, in Kerr, M., editor: Operative Obstetrics, London, 1971, Bailiere, Tindall Cassell, Ltd., chap. 18, pp. 398-42 I. 2. Davids, A. M.: Fibromyomas, in Rovinski, J. J., and Gutmarche, A. F., Medical, Surgical and Gynecologic Complications of Pregnancy. Baltimore, 1965, The Williams & Wilkins Co., chap. 28, pp. 366-382. 3. Douglas, R. G., and Stromme, W. B.: Operative Obstetrics. New York, 1976, Appleton-Century-Crofts, p. 413. 4. Tisne, L., and Anselmo, J.: Contribution al estudio sobre mioma y esrado gravido puerperal, Bol. Sot. Chile Obstet. Ginecol. 20: 178, 1955. 5. Mattingly, R. F.: In Te Linde, R., editor: Operative Gynecology, Philadelphia, 1977, J. B. Lippincott, Co., p. 187. 6. Dees, H. C.: Cervical pregnancy associated with uterine leiomyomas, South. Med. J. 59:900, 1966. 7. Hepperlen, H. M.: Ectopic pregnancy associated with fibromyoma. Nebr. Med. I. 55:428. 1970. 8. Hnat, R. F., Anderson. G:‘G., and klonzo, D. R.: Diffuse
19
9.
10.
11.
12.
13.
Dr. H. Oxorn
for his advice and
intravascular coagulation associated with a degenerating myoma during pregnancy, Obstet. Gynrcol. 29:207, 1967. Moore, J. B.. and Morton, D. G.: Leiomyomas of the uterus, in Sciarra, J. J., and McElin, T. W., editors: Gynecology and Obstetrics, Hagerstown, 1979, Harper & Row, Publishers, vol. I, chap. 26, pp. 1-l 1. Buttery. B. W.: Spontaneous haempoeritoneum complicating uterine libromyoma, Aust. N. %. J. Obstet. Gynaecol. 12:210, 1972. Von Mickey, L. I.: Sonographic study of uterine fibromyomata in the non-pregnant state and during gestations. in Saunders, R. D., and James, A. E., editors: Ultrasonography in Obstetrics and Gynecology, New York. 1977, Appleton-Century-Crofts, chap. 26, pp. 297-331. Telko, M., Powlony, M., and Pawlicka, H.: Diagnosis and therapy of puerperal eversion of myomatous uterus, Ginekol. Pol. 44:699, 1973. Kobayashi, M., Hellman, L. M., and Fillisti, L.: Placental localization by ultrasound. AM. J. ORSTLT. GYNECOL. 106:279, 1970.