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Uterine myoma in pregnancy: ultrasound study
Int. J. Gynecol. Obstet., 1989,28: 109-117 International Federation of Gynecology and Obstetrics
109
Uterine myoma in pregnancy: ultrasound P. Rosati, U. Bellati, C. Exacoustos,
P. Angelozzi
study
and S. Mancuso
Department of Obstetrics and Gynaecology, Catholic University, Rome (Italy) (Received July 21st, 1987) (Revised and accepted March 7th, 1988)
Abstract
In many cases the presence of a myomatous formation in pregnancy begins its effect in a symptomless way and is revealed only by a regular sonographic control or at the time of delivery. In other cases, however, it could represent the cause of several complications, such as increased incidence of abortion extrauterine pregnancy premature breaking of the membranes, premature delivery distocia during delivery or it could itself be the site of necrotic processes. The attitude towards this type of pathology during pregnancy has often varied. The authors report their experiences regarding 408 cases of pregnancies complicated by myoma that were followed with accurate sonographic monitoring and they evaluate the incidence of the principal complications during pregnancy at the time of delivery and the eventual influence on the fetal weight at the time of birth. Keywords:
Myoma;
Ultrasound
evaluation;
Pregnancy. Introduction
The incidence of myomas in pregnancy varies, depending on the author, from 0.3% to 2.6% [3,4,6]. Frequently, especially when of smaller dimensions, they do not present any symptomatology and they are identified through regular sonographic controls or at 002s7292/89/$03.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
the time of delivery [ 111. Other authors have pointed out, however, especially for myomas of larger dimensions, the high incidence of complications both during pregnancy and at the time of delivery [2,4,10,14,19]. Myomas of large dimensions seem to be associated, in the first two trimesters of pregnancy, with an increased percentage of spontaneous abortions and extrauterine pregnancies [3,5,8,14]. In the second half of pregnancy there is an association with premature delivery, premature breaking of membranes [19], hemoperitoneum [2] and distocia during delivery 161.The attitude towards this kind of pathology during pregnancy varies, to this day, ranging from excessive and sometimes unjustified intervention [ 141 to a state of relative tranquility [l 11. In a previous study [ 131 we pointed out how adequate obstetrical assistance, along with accurate ultrasound monitoring, enormously reduced maternal and fetal complications relating to the presence of myoma. Only in the case of large myomatous formations, with size exceeding 10 cm in diameter, did we verify an increased percentage in the incidence of cesarian section and a negative influence on the normal fetal growth. We wanted to verify, in a large case study, the incidence of the principal maternal and fetal complications in pregnancies complicated by myomas and the outcome of the pregnancy, in relation not only to the dimension of the myomatous formation, but also to its location, development and its relationship with the placental area. Clinical and CIinical Research
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Rosati et al.
Table 1. Evaluation of the principal ultrasound parameters in pregnancies with the presence of a myomatous formation.
Table III.
Abortion. Abortion (no. 33)
Ultrasound parameters (408 myomas) No.
%
3-5 6-10 > 10
16 (228) 14 (151) 3 (29)
7.02 9.27 10.34
Position MY Back Isthmus
24 (292) 6 (66) 3 (50)
8.22 9.09 6.00
Location Intramural Subserous Submucosa
25 (281) 5 (75) 3 (52)
8.90 6.67 5.77
Relation to theplacenta Non-contact Contact Superimposition
18 (237) 9(111) 6 (60)
7.59
Diameter (cm)
3-5 228 55.88
6-10 151 37.01
> 10 29 7.11
Size (cm)
Location
Body 292 71.57
Back 66 16.18
Isthmus 50 12.25
Position
Intramural 281 68.87
Subserous 75 18.38
Submucosa 52 12.74
Non-contact 237 58.09
Superimposition 60 14.70
Relation Contact 111 27.21 to the placenta
Materials and methods At the Obstetric Day Hospital of the Obstetrics and Gynaecological Department of the Catholic University in Rome, 408 pregnancies complicated by uterine myoma were observed through 13 18 sonographic examinations and documented. Gestational age ranged from 11 to 40 weeks. The ultrasound surveys were carried out with equipment in real time Aloka 256, Toshiba Sal 30A and General Electric RT 3600. The pregnancy outcome is not known in all cases, either because of missed ascertainment or because pregnancy is still in course. The parameters used in the evaluation of the myomatous formations were the following: the size, the
Table II.
Complications in pregnancy.
Complications in pregnancy
Abortion Threats of abortion Premature delivery Threats of premature delivery
Int J Gynecol Obstet 28
Uterine myoma
Normal group
No.
Total
Vo
33 87 21 47
349 349 162 249
9.46 24.92 12.% 18.87
%
8.11 10.00
location, the tendency to appear on the uterine wall, internal or external and the relationship with the placental area. All those formations which were less than 3 cm in diameter were excluded. In 56 patients (69.13%) the ultrasound diagnosis was confirmed at the time of the cesarian section. Preterm deliveries were defined as births occurring at 26-37 weeks gestation. We have considered as threatened preterm deliveries all those pregnancies under tocolytic treatment at 26-37 weeks. Our data were analyzed using a chi-square test. Results Age and equalities Patient age varies from a minimum of 23 to a maximum of 43 years of age, with an average of 31. In 62% of the cases, the age was less than or equal to 30 and only 5 cases were over 40. Two hundred thirty-five patients (57.59%) were at their first pregnancy and 162 (42.4lVo) were at least at their second.
Uterine myoma in pregnancy
Ultrasound evaluations The ultrasound parameters account are shown in Table I.
taken
into
Complications in pregnancy The complications in pregnancy are shown
Table N.
111
in Table II and compared with those obtained in our clinic in a normal population. The percentage of such complications was determined for abortions and abortion threats out of the total number of pregnancies complicated by myoma in which we had carried out
Percentage of abortive events in relation to the same ultrasound parameters. Abortion (no. 33)
Size (cm) 3-S (16) 6-10 (14) > 10 (3)
Body Back Isthmus Body Back Isthmus Body Back Isthmus
10 (146) 3 (30) 3 (18) 11 (83) 3 (18) 0(26) 3 (18) O(8) O(2)
6.85 10.00 16.67 13.25 16.67 00.00 16.67 00.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
9 (120) 3 (51) 4 (23) 8 (71) 5 (31) 1(25) l(8) 1(16) l(4)
7.50 5.88 17.39 11.23 16.13 4.00 12.50 6.25 25.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
15 (149) 0 (26) 1(19) 7 (78) 5 (29) 2 (20) 3 (20) 0 (8) 0 (0)
10.07 00.00 5.26 8.97 17.24 10.00 15.00 00.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
13 (135) 6 (68) 5 (44) 2 (31) 3 (20) l(5) 3 (33) O(l0) O(3)
9.63 8.82 11.36 6.45 15.00 20.00 9.09 00.00 00.00
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 >lO
10 (146) 11 (83) 3 (18) 3 (30) 3 (18) 0 (8) 3 (18) 0 (26) 0 (2)
6.85 13.25 16.67 10.00 16.67 00.00 16.67 00.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
17 (187) 5 (28) 2 (32) 5 (29) 0 (23) l(4) 3 (31) 0 (12) 0 (3)
9.09 17.86 6.25 17.24 00.00 25.00 9.68 00.00 00.00
Body Back Isthmus Body Back Isthmus Body Back Isthmus
17 (187) 5 (29) 3 (31) 5 (28) 0(23) O(l2) 2 (32) l(4) O(3)
9.09 17.24 9.68 17.86 00.00 00.00 6.25 25.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
13 (146) 8 (68) 4 (33) 5 (43) 0(18) 0 (2) 0 (10) 1(12) 2 (17)
8.90 11.76 12.12 11.63 00.00 00.00 00.00 8.33 11.76
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
15 (149) 7 (78) 3 (20) 0 (26) 5 (29) 0 (8) 1(19) 2 (20) 0 (0)
10.07 8.97 15.00 00.00 17.24 00.00 5.26 10.00 00.00
13 (135) 2(31) 3 (33) 6 (68) 3 (20) O(l0) 5 (44) 1 (5) O(3)
9.63 6.45 9.09 8.82 15.00 00.00 11.36 20.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
13 (146) 5 (43) 0 (10) 8 (68) 0(18) 1(12) 4 (33) 0 (2) 2 (17)
8.90 11.63 00.00 11.76 00.00 8.33 12.12 00.00 11.76
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
9 (120) 8 (71) l(8) 3 (51) 5(31)
7.50 11.27 12.50 5.88 16.13 6.25 17.39 4.00 25.08
Position Body (24) Back (6) Isthmus (3) Location Intramural (25) Subserous (5) Submucosa (3) Relation to the Non-contact (18) Contact (9) Superimposition (6)
placenta
BUY Back Isthmus Body Back Isthmus Body Back Isthmus
1W 4 (23) 1(25) l(4)
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Rosati et al.
observations until the 27th week of gestation. The threat of premature delivery and the premature deliveries were evaluated in all cases followed, at least until the 37th week of pregnancy. In Table III we report the percentage of abortions in relation to the ultrasound parameters considered. There are no significant variations in the statistical analysis between the abortive event and the dimension of the myomatous formation, the location and the position in relation to the placenta. In a more accurate analysis which considers more variables in pointing out the risk of abortion, even by breaking down the data, there is no evident significance in a statistical analysis (Table IV). The number and percentage of abortion threats observed, are shown in Table V. An increase in such pathology with increased size of the myoma is evident. There is also an increased incidence, significant in a statistical evaluation (P < O.OOl), in cases where the myoma is in relation to the placenta and in cases where the myoma lies outside the submucosa as compared to those that develop on the inside of the uterine wall or in a subserous location. An analysis of several associated variables basically confirm the above statements (Table VI). As far as threats of premature delivery are concerned, there is a greater percentage incidence, especially in cases of myomatous formations developing in submucosa areas, in isthmian areas and in those overlapping the placenta. Instead, the dimensions seem to have scant influence on this type of complication (Table VII). An analysis which of contemplates a number variables associated amongst themselves (Table VIII) seems to confirm only part of the data obtained individually analyzing each variable. The dimensions of the myoma, in case of it not contacting the placental area, seem to noticeably affect this kind of complication in pregnancy, varying from 13.5 1% in cases of small myomas (3-5 cm in diameter) to 62.50% in cases of myomas having a diameter Int J Gynecol Obstet 28
Table V.
Threats of abortion. Threats of abortion (no. 87) No.
%
Size(cm) 3-5 6-10 > 10
45 (228) 32 (151) 10 (29)
19.74 21.19 34.48
Position Body Back Isthmus
58 (292) 18 (66) 11 (SO)
19.86 27.27 22.00
Location Intramural Subserous Submucosa
63 (281) 9 (75) 15 (52)
22.42 12.00 28.85
Relation to theplacenta Non-contact Contact Superimposition
38 (237) 36(111) 13 (60)
16.03 32.43 21.67
greater than 10 cm (P < 0.001). On the other hand, the manifestation of the myomatous formation at the interior of the uterine cavity (submucosa) or on the uterine wall (intramural), in cases of myomas in contact with the placental area, does not particularly appear to influence anticipated delivery, in respect to the same cases in which there is no placental contact. Fetal growth Fetal weight at birth is shown in Fig. 1, expressed in percentiles, according to the curve of standard Italian newborn weight elaborated by Gagliardi [7], and in function of the gestation time, in relation to the dimension of the myomatous formation. We can see how in cases of larger dimension fibromas (diameter greater than 10 cm) the weight distribution is towards low values. This fact confirms what we had already pointed out in a previous study [ 131.
Uterine myoma in pregnancy
Delivery procedures The percentage of operative deliveries in the patients we studied is shown in Table IX. The cases considered (162 cases = 39.71%) are those surveyed until the end of pregnancy, of which the events related to delivery are Table VI.
113
known. Often the indicator of surgery was tied to other co-existing maternal and/or fetal pathologic events. Keeping trace of those cases in which the indication for surgery was ‘given either primarily or exclusively by the presence of the myomatous formation, the
Percentage of threats of abortion in relation to the same ultrasound parameters. Threats of abortion (no. 87)
Location Body Back Isthmus Body Back Isthmus Body Back Isthmus
40(187) 13 (29) lO(31) 6 (28) 2 (23) 1(12) 12 (32) 3 (4) 0 (3)
21.39 44.83 32.26 21.43 8.70 8.33 37.50 75.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
26 (146) 31 (63) 6 (33) 9 (43) 0(18) 0 (2) 3 (10) 5 (12) 7 (17)
17.81 45.59 18.18 20.93 00.00 00.00 30.00 41.67 41.18
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
38 (149) 16 (78) 9 (20) 2 (26) 6 (29)
10 (20) 0 (0)
25.50 20.51 45.00 7.69 20.69 12.50 26.32 50.00 00.00
Relation to theplacenta Body Non-contact Back Isthmus (38) Body Contact Back Isthmus (36) Body Superimposition Back Isthmus (13)
28 (135) 4 (31) 6 (33) 21 (68) 10 (20) 5 (10) 9 (44) 4 (5) 0 (3)
20.74 12.90 18.18 30.88 50.00 50.00 20.45 80.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
26 (146) 3 (10) 9 (43) 3 1 (68) 5 (12) 0(18) 6 (33) 7 (17) 0 (2)
17.81 30.00 20.93 45.59 41.67 00.00 18.18 41.18 00.00
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
20 (120) 15 (71) 3 (8) 17 (51) 13 (31) 6 (16) 6 (23) 4 (25) 1(4)
16.67 21.13 37.50 33.33 41.94 37.50 34.78 16.00 25.00
Body Back Isthmus Body Back Isthmus Body Back Isthmus
31(146) 9 (30) 5 (18) 21(83) 6(18) 5 (26) 6 (18) 3 (8)
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
20 (120) 17 (51) 8 (23) 15 (71) 13 (31) 4 (25) 3 (8) 6 (16) 1(4)
16.67 33.33 34.78 21.13 41.94 16.00 37.50 37.50 25.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
38 (149) 2 (26) 5 (19) 16 (78) 6 (29) 10 (20) 9 (20)
1(2)
21.23 30.00 21.78 25.30 33.33 19.23 33.33 37.50 50.00
1(8) 0 (0)
25.50 7.69 26.32 20.51 20.69 50.00 45.00 12.50 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
28 (135) 21(68) 9 (44) 4(31) 12 (20) 4 (5) 6 (33) 5 (10) 0 (3)
20.74 30.88 20.45 12.90 50.00 80.00 18.18 50.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
40(187) 6 (28) 12 (32) 13 (29) 2 (23) 3 (4) lO(31) 1(12) O(3)
21.39 21.43 37.50 44.83 8.70 75.00 32.26 8.33 00.00
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
10 (146) 11 (83) 3 (18) 3 (30) 3 (18) 0 (8) 3 (18) 0 (26) 0 (2)
6.85 13.25 16.67 10.00 16.67 00.00 16.67 00.00 00.00
Intramural
Subserous (9) Submucosa (15)
1(8) 5 (19)
Size (cm) 3-5 (45) 6-10 (32) > 10 (10) Position Body (58) Back (18) Isthmus (11)
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Rosati et al.
3-scm. Fig. 1.
6 -10
a.
10 cm.
Fetal weight at birth in relation to the dimension of the myomatous formation.
Table VII.
Threats of premature delivery. Threats of premature delivery (no. 47) No.
%
Size (cm) 3-5 6-10 > 10
19 (130) 23 (94) 5 (25)
14.62 24.47 20.00
Position Body Back Isthmus
25 (169) 12 (45) 10 (35)
14.79 26.67 28.57
Location IDtMnllUal Subserous Submucosa
34 (183) 9 (53) 4 (13)
18.58 16.98 30.77
Relation to theplacenta Non-contact Contact Superimposition
25 (133) 10 (74) 12 (42)
18.80 13.51 28.57
Znt J Gynecol Obstet 28
percentage of operative delivery seems to be only slightly lower than the general one surveyed in our clinic (approx. 20%). This percentage is, in our opinion, underestimated, because a myomatous formation can have an indirect role in the choice of abdominal delivery. Conclusions The presence of myomatous nodules undoubtedly represents a condition of increased fetal risk. The evaluation of such risks, case by case, can only be carried out through accurate sonographic surveillance [11,11,17-191. Ultrasound permits us to accurately evaluate the myomatous formations, from a volumetrical point of view and in relation to its site, to its tendency to develop in the precinct of the uterine wall or towards the interior or the exterior of the cavity and to its relation to the placenta. Myomatous formations with size inferior to 3 cm
Uterine myoma in pregnancy
were eliminated in accordance with the literature [11,12] regarding the fact that in these cases it appears difficult to differentiate local contractions of the myometrium from a myomatous formation. We wanted to corre-
Table VIII.
115
late not only the dimensions of the myoma, its location and its eventual contact with the placental area, with the principal complications in pregnancy, but several variables were correlated amongst themselves. In
Percentage of threats of premature delivery in relation to the same ultrasound parameters. Threats of premature delivery (no. 47)
Size (cm) 3-5 (19) 6-10 (23) > 10 (5)
Body Back Isthmus Body Back Isthmus Body Back Isthmus
12 (94) 4 (26) 3 (IO) ll(60) 5(11) 7 (23) 2 (15) 3 (8) O(2)
12.77 15.38 30.00 18.33 45.45 30.43 13.33 37.50 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
109 (74) 3 (38) 6(17) 10 (51) 7 (22) 6 (22) 5 (8) 0 (14) 0 (0)
13.51 7.89 35.29 19.61 31.82 27.27 62.50 00.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
14 (104) 2 (20) 3 (6) 17 (61) 5 (17) 3 (17) 2 (8) O(0)
13.46 10.00 50.00 27.81 29.41 16.67 17.65 25.00 00.00
9 (84) 7 (50) 9 (35) 8 (27) 1(14) 3 (4) 8 (22) 2 (10) O(3)
10.71 14.00 25.71 29.63 7.14 75.00 36.36 20.00 00.00
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
12 (94) ll(60) 2 (15) 4 (26) 5 (11) 3 (8) 3 (10) 7 (23) 0 (2)
12.77 18.33 13.33 15.38 45.45 37.50 30.00 30.43 00.00
Intramural Subserous Intramural Subserous Submucosa Intramural Subserous Submucosa
19 (133) 2 (24) 4 (12) 7 (24) 5 (20) O(1) 8 (26) 2 (9) O(0)
14.29 8.33 33.33 29.17 25.00 00.00 30.77 22.22 00.00
19 (133) 7 (24) 8 (26) 2 (24) 5 (20) 2 (9) 4 (12) O(1) O(0)
14.29 29.17 30.77 8.33 25.00 22.22 33.33 00.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
16 (100) 9 (56) 9 (26) 9 (30) 0 (10) 0 (0) 0 (3)
3-5 6-10 > 10 3-5 6-10 > 10 3-S 6-10 > 10
14 (104) 17 (61) 3 (17) 2 (20) 5 (17) 2 (8) 3 (6)
3 (16)
16.00 16.07 34.62 30.00 00.00 00.00 00.00 12.50 18.75
O(0)
13.46 21.87 17.65 10.00 29.41 25.00 50.00 16.67 00.00
9 (84) 8 (27) 8 (22) 7 (50) 1(14) 2 (10) 9 (35) 3 (4) 0 (3)
10.71 29.63 36.36 14.00 7.14 20.00 25.71 75.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
16 (100) 9 (30) 0 (3) 9 (56) 0 (10) l(8) 9 (26) 0 (0) 3 (16)
16.00 30.00 00.00 16.07 00.00 12.50 34.62 00.00 18.75
3-S 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
10 (74) 10 (51) 5 (8) 3 (38) 7 (22) 0(14) 6 (17) 6 (22) 0 (3)
13.51 19.61 62.50 7.89 31.82 00.00 35.29 27.27 00.00
1(6)
Position Body (25) Back (12) Isthmus (10)
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
Location Intramural (34) Subserous (9) Submucosa (4)
Body Back Isthmus Body Back Isthmus Body Back Isthmus
Relation to the placenta Body Non-contact Back Isthmus (25) Body Contact Back Isthmus (10) Body Superimposition Back Isthmus (12)
1(8)
1(6)
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Rosati et al.
Table IX.
Percentage of operative deliveries. Total cases
Operative deliveries
Operative deliveries for myoma
No.
No.
%
No.
Size (cm) 3-S 6-10 > 10
38 97 27
25 41 15
65.19 42.27 55.56
6 7 3
15.79 7.16 11.11
Position Body Back Isthmus
110 33 19
55 16 10
5o.ocl 48.48 52.63
10 4 2
9.09 12.12 10.53
Location Intramural Subserous Submucosa
99 41 22
50 19 12
50.50 46.34 54.54
12 3 1
12.12 1.32 4.45
Relation to theplacenta Non-contact Contact Superimposition
97 38 21
41 25 15
42.27 65.79 55.56
7 6 3
7.16 15.79 11.11
%
ception. An anomalous uterine activity, tied to the presence of a myomatous formation, could thus be the cause of major complications, both outside of pregnancy (diminished fertility) [3] and during pregnancy. In our experience, we noticed a greater negative influence on fetal weight in cases of rather large myomatous formations and an increase in operative delivery. Ultrasound evaluation could in some pathologies represent not only the means for recognition of myomatous formations, which would otherwise only have been noticed at the time of delivery or which more frequently would have gone unnoticed, but it permits an accurate monitoring of such pathologies in time, thus noticeably reducing the incidence of complications during pregnancy. In addition, it represents a useful tool for orientating the obstetrician towards the type of delivery and its eventual anticipation. References 1
particular, in cases in which the myomatous formation is located in contact with the placental area, there appears to be frequent association with a large part of pregnancy complications, especially with the threat of abortion and the threat of premature delivery. These data have previously been pointed out by other authors [ 111. It is interesting to see how, in our experience, in the case of superimposition or contact of the myoma with the placental area, there is no percentage difference in the incidence of abortion threats with the varying dimensions of the myoma (Table VI). Evaluations carried out in non-pregnant patients, showed greater uterine activity in patients carrying myomas compared to a control group [9]. In normal circumstances, uterine activity seems to play an important role in transporting spermatozoa from the experior of the cervix to the fallopian tubes [16] and in transporting and nesting the product of conInt J Gynecol Obstet 28
2
3
4
8 9 10
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Muram D, Gillieson M, Walters JH: Myomas of the uterus in pregnancy: ultrasonographic follow-up. Am J Obstet GynecolI28(1): 16, 1980. Muram-Winer HT, Muram D, Gillieson MS, Ivey BJ, Muggah HF: Uterine myomas in pregnancy. Can Med Assoc J 128: 949, 1983. Noia G, Masini L, Mazzei R, Pompa G, De Luca P, Rosati P, Guariglia L: Ultrasonografia nella gravidanza complicata da fibromi uterini. VII Riunione Gruppo di Studio e di Ricerca in medicina fetale, p 187, 1982. Ottolenghi-Preti GF: Fibromiomi dell’utero in gravidanza. Ann Ostet Ginecol5.92: 303,197O. Palatynski A, Zdziennicki A: Two cases of uterine myoma necrosis in early pregnancy. Wiad Lek 12: 963, 1984. Settlage DSF, Motoshima M, Bengtsson LP: Sperm transport from the external cervical as to the fallopian tubes in women: a time and quantitation study. Fertil Steril24: 655, 1973. Sidorowa IS: Assessment of the state of the fetus in patients with a uterine myoma by using complex ultrasonic scanning. Vopr Okhr Materin Det 24,4: 50, 1979.
18
19 20
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Sidorowa IS: State of the fetoplacental system and the characteristics of fetal intrauterine development in uterine myoma patients. Akush Gineko15: 31, 1980. Tisne 1955. Von Mickey LI: Sonographic study of uterine fibromyomata in the non pregnant state and during gestation. In Ultrasonography in Obstetrics and Gynecology (ed RD Saunders, AE Jamers) p 297. Appleton-Century-Crofts, New York, 1977.
Address for reprints: P. Rosnti Department of Obstetrics and Gyaaecology Catholic University L. go A. Gemelli, 8 00168 Roma Italy
Clinical and Clinical Research
109
Uterine myoma in pregnancy: ultrasound P. Rosati, U. Bellati, C. Exacoustos,
P. Angelozzi
study
and S. Mancuso
Department of Obstetrics and Gynaecology, Catholic University, Rome (Italy) (Received July 21st, 1987) (Revised and accepted March 7th, 1988)
Abstract
In many cases the presence of a myomatous formation in pregnancy begins its effect in a symptomless way and is revealed only by a regular sonographic control or at the time of delivery. In other cases, however, it could represent the cause of several complications, such as increased incidence of abortion extrauterine pregnancy premature breaking of the membranes, premature delivery distocia during delivery or it could itself be the site of necrotic processes. The attitude towards this type of pathology during pregnancy has often varied. The authors report their experiences regarding 408 cases of pregnancies complicated by myoma that were followed with accurate sonographic monitoring and they evaluate the incidence of the principal complications during pregnancy at the time of delivery and the eventual influence on the fetal weight at the time of birth. Keywords:
Myoma;
Ultrasound
evaluation;
Pregnancy. Introduction
The incidence of myomas in pregnancy varies, depending on the author, from 0.3% to 2.6% [3,4,6]. Frequently, especially when of smaller dimensions, they do not present any symptomatology and they are identified through regular sonographic controls or at 002s7292/89/$03.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
the time of delivery [ 111. Other authors have pointed out, however, especially for myomas of larger dimensions, the high incidence of complications both during pregnancy and at the time of delivery [2,4,10,14,19]. Myomas of large dimensions seem to be associated, in the first two trimesters of pregnancy, with an increased percentage of spontaneous abortions and extrauterine pregnancies [3,5,8,14]. In the second half of pregnancy there is an association with premature delivery, premature breaking of membranes [19], hemoperitoneum [2] and distocia during delivery 161.The attitude towards this kind of pathology during pregnancy varies, to this day, ranging from excessive and sometimes unjustified intervention [ 141 to a state of relative tranquility [l 11. In a previous study [ 131 we pointed out how adequate obstetrical assistance, along with accurate ultrasound monitoring, enormously reduced maternal and fetal complications relating to the presence of myoma. Only in the case of large myomatous formations, with size exceeding 10 cm in diameter, did we verify an increased percentage in the incidence of cesarian section and a negative influence on the normal fetal growth. We wanted to verify, in a large case study, the incidence of the principal maternal and fetal complications in pregnancies complicated by myomas and the outcome of the pregnancy, in relation not only to the dimension of the myomatous formation, but also to its location, development and its relationship with the placental area. Clinical and CIinical Research
110
Rosati et al.
Table 1. Evaluation of the principal ultrasound parameters in pregnancies with the presence of a myomatous formation.
Table III.
Abortion. Abortion (no. 33)
Ultrasound parameters (408 myomas) No.
%
3-5 6-10 > 10
16 (228) 14 (151) 3 (29)
7.02 9.27 10.34
Position MY Back Isthmus
24 (292) 6 (66) 3 (50)
8.22 9.09 6.00
Location Intramural Subserous Submucosa
25 (281) 5 (75) 3 (52)
8.90 6.67 5.77
Relation to theplacenta Non-contact Contact Superimposition
18 (237) 9(111) 6 (60)
7.59
Diameter (cm)
3-5 228 55.88
6-10 151 37.01
> 10 29 7.11
Size (cm)
Location
Body 292 71.57
Back 66 16.18
Isthmus 50 12.25
Position
Intramural 281 68.87
Subserous 75 18.38
Submucosa 52 12.74
Non-contact 237 58.09
Superimposition 60 14.70
Relation Contact 111 27.21 to the placenta
Materials and methods At the Obstetric Day Hospital of the Obstetrics and Gynaecological Department of the Catholic University in Rome, 408 pregnancies complicated by uterine myoma were observed through 13 18 sonographic examinations and documented. Gestational age ranged from 11 to 40 weeks. The ultrasound surveys were carried out with equipment in real time Aloka 256, Toshiba Sal 30A and General Electric RT 3600. The pregnancy outcome is not known in all cases, either because of missed ascertainment or because pregnancy is still in course. The parameters used in the evaluation of the myomatous formations were the following: the size, the
Table II.
Complications in pregnancy.
Complications in pregnancy
Abortion Threats of abortion Premature delivery Threats of premature delivery
Int J Gynecol Obstet 28
Uterine myoma
Normal group
No.
Total
Vo
33 87 21 47
349 349 162 249
9.46 24.92 12.% 18.87
%
8.11 10.00
location, the tendency to appear on the uterine wall, internal or external and the relationship with the placental area. All those formations which were less than 3 cm in diameter were excluded. In 56 patients (69.13%) the ultrasound diagnosis was confirmed at the time of the cesarian section. Preterm deliveries were defined as births occurring at 26-37 weeks gestation. We have considered as threatened preterm deliveries all those pregnancies under tocolytic treatment at 26-37 weeks. Our data were analyzed using a chi-square test. Results Age and equalities Patient age varies from a minimum of 23 to a maximum of 43 years of age, with an average of 31. In 62% of the cases, the age was less than or equal to 30 and only 5 cases were over 40. Two hundred thirty-five patients (57.59%) were at their first pregnancy and 162 (42.4lVo) were at least at their second.
Uterine myoma in pregnancy
Ultrasound evaluations The ultrasound parameters account are shown in Table I.
taken
into
Complications in pregnancy The complications in pregnancy are shown
Table N.
111
in Table II and compared with those obtained in our clinic in a normal population. The percentage of such complications was determined for abortions and abortion threats out of the total number of pregnancies complicated by myoma in which we had carried out
Percentage of abortive events in relation to the same ultrasound parameters. Abortion (no. 33)
Size (cm) 3-S (16) 6-10 (14) > 10 (3)
Body Back Isthmus Body Back Isthmus Body Back Isthmus
10 (146) 3 (30) 3 (18) 11 (83) 3 (18) 0(26) 3 (18) O(8) O(2)
6.85 10.00 16.67 13.25 16.67 00.00 16.67 00.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
9 (120) 3 (51) 4 (23) 8 (71) 5 (31) 1(25) l(8) 1(16) l(4)
7.50 5.88 17.39 11.23 16.13 4.00 12.50 6.25 25.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
15 (149) 0 (26) 1(19) 7 (78) 5 (29) 2 (20) 3 (20) 0 (8) 0 (0)
10.07 00.00 5.26 8.97 17.24 10.00 15.00 00.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
13 (135) 6 (68) 5 (44) 2 (31) 3 (20) l(5) 3 (33) O(l0) O(3)
9.63 8.82 11.36 6.45 15.00 20.00 9.09 00.00 00.00
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 >lO
10 (146) 11 (83) 3 (18) 3 (30) 3 (18) 0 (8) 3 (18) 0 (26) 0 (2)
6.85 13.25 16.67 10.00 16.67 00.00 16.67 00.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
17 (187) 5 (28) 2 (32) 5 (29) 0 (23) l(4) 3 (31) 0 (12) 0 (3)
9.09 17.86 6.25 17.24 00.00 25.00 9.68 00.00 00.00
Body Back Isthmus Body Back Isthmus Body Back Isthmus
17 (187) 5 (29) 3 (31) 5 (28) 0(23) O(l2) 2 (32) l(4) O(3)
9.09 17.24 9.68 17.86 00.00 00.00 6.25 25.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
13 (146) 8 (68) 4 (33) 5 (43) 0(18) 0 (2) 0 (10) 1(12) 2 (17)
8.90 11.76 12.12 11.63 00.00 00.00 00.00 8.33 11.76
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
15 (149) 7 (78) 3 (20) 0 (26) 5 (29) 0 (8) 1(19) 2 (20) 0 (0)
10.07 8.97 15.00 00.00 17.24 00.00 5.26 10.00 00.00
13 (135) 2(31) 3 (33) 6 (68) 3 (20) O(l0) 5 (44) 1 (5) O(3)
9.63 6.45 9.09 8.82 15.00 00.00 11.36 20.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
13 (146) 5 (43) 0 (10) 8 (68) 0(18) 1(12) 4 (33) 0 (2) 2 (17)
8.90 11.63 00.00 11.76 00.00 8.33 12.12 00.00 11.76
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
9 (120) 8 (71) l(8) 3 (51) 5(31)
7.50 11.27 12.50 5.88 16.13 6.25 17.39 4.00 25.08
Position Body (24) Back (6) Isthmus (3) Location Intramural (25) Subserous (5) Submucosa (3) Relation to the Non-contact (18) Contact (9) Superimposition (6)
placenta
BUY Back Isthmus Body Back Isthmus Body Back Isthmus
1W 4 (23) 1(25) l(4)
Clinical and Clinical Research
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Rosati et al.
observations until the 27th week of gestation. The threat of premature delivery and the premature deliveries were evaluated in all cases followed, at least until the 37th week of pregnancy. In Table III we report the percentage of abortions in relation to the ultrasound parameters considered. There are no significant variations in the statistical analysis between the abortive event and the dimension of the myomatous formation, the location and the position in relation to the placenta. In a more accurate analysis which considers more variables in pointing out the risk of abortion, even by breaking down the data, there is no evident significance in a statistical analysis (Table IV). The number and percentage of abortion threats observed, are shown in Table V. An increase in such pathology with increased size of the myoma is evident. There is also an increased incidence, significant in a statistical evaluation (P < O.OOl), in cases where the myoma is in relation to the placenta and in cases where the myoma lies outside the submucosa as compared to those that develop on the inside of the uterine wall or in a subserous location. An analysis of several associated variables basically confirm the above statements (Table VI). As far as threats of premature delivery are concerned, there is a greater percentage incidence, especially in cases of myomatous formations developing in submucosa areas, in isthmian areas and in those overlapping the placenta. Instead, the dimensions seem to have scant influence on this type of complication (Table VII). An analysis which of contemplates a number variables associated amongst themselves (Table VIII) seems to confirm only part of the data obtained individually analyzing each variable. The dimensions of the myoma, in case of it not contacting the placental area, seem to noticeably affect this kind of complication in pregnancy, varying from 13.5 1% in cases of small myomas (3-5 cm in diameter) to 62.50% in cases of myomas having a diameter Int J Gynecol Obstet 28
Table V.
Threats of abortion. Threats of abortion (no. 87) No.
%
Size(cm) 3-5 6-10 > 10
45 (228) 32 (151) 10 (29)
19.74 21.19 34.48
Position Body Back Isthmus
58 (292) 18 (66) 11 (SO)
19.86 27.27 22.00
Location Intramural Subserous Submucosa
63 (281) 9 (75) 15 (52)
22.42 12.00 28.85
Relation to theplacenta Non-contact Contact Superimposition
38 (237) 36(111) 13 (60)
16.03 32.43 21.67
greater than 10 cm (P < 0.001). On the other hand, the manifestation of the myomatous formation at the interior of the uterine cavity (submucosa) or on the uterine wall (intramural), in cases of myomas in contact with the placental area, does not particularly appear to influence anticipated delivery, in respect to the same cases in which there is no placental contact. Fetal growth Fetal weight at birth is shown in Fig. 1, expressed in percentiles, according to the curve of standard Italian newborn weight elaborated by Gagliardi [7], and in function of the gestation time, in relation to the dimension of the myomatous formation. We can see how in cases of larger dimension fibromas (diameter greater than 10 cm) the weight distribution is towards low values. This fact confirms what we had already pointed out in a previous study [ 131.
Uterine myoma in pregnancy
Delivery procedures The percentage of operative deliveries in the patients we studied is shown in Table IX. The cases considered (162 cases = 39.71%) are those surveyed until the end of pregnancy, of which the events related to delivery are Table VI.
113
known. Often the indicator of surgery was tied to other co-existing maternal and/or fetal pathologic events. Keeping trace of those cases in which the indication for surgery was ‘given either primarily or exclusively by the presence of the myomatous formation, the
Percentage of threats of abortion in relation to the same ultrasound parameters. Threats of abortion (no. 87)
Location Body Back Isthmus Body Back Isthmus Body Back Isthmus
40(187) 13 (29) lO(31) 6 (28) 2 (23) 1(12) 12 (32) 3 (4) 0 (3)
21.39 44.83 32.26 21.43 8.70 8.33 37.50 75.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
26 (146) 31 (63) 6 (33) 9 (43) 0(18) 0 (2) 3 (10) 5 (12) 7 (17)
17.81 45.59 18.18 20.93 00.00 00.00 30.00 41.67 41.18
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
38 (149) 16 (78) 9 (20) 2 (26) 6 (29)
10 (20) 0 (0)
25.50 20.51 45.00 7.69 20.69 12.50 26.32 50.00 00.00
Relation to theplacenta Body Non-contact Back Isthmus (38) Body Contact Back Isthmus (36) Body Superimposition Back Isthmus (13)
28 (135) 4 (31) 6 (33) 21 (68) 10 (20) 5 (10) 9 (44) 4 (5) 0 (3)
20.74 12.90 18.18 30.88 50.00 50.00 20.45 80.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
26 (146) 3 (10) 9 (43) 3 1 (68) 5 (12) 0(18) 6 (33) 7 (17) 0 (2)
17.81 30.00 20.93 45.59 41.67 00.00 18.18 41.18 00.00
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
20 (120) 15 (71) 3 (8) 17 (51) 13 (31) 6 (16) 6 (23) 4 (25) 1(4)
16.67 21.13 37.50 33.33 41.94 37.50 34.78 16.00 25.00
Body Back Isthmus Body Back Isthmus Body Back Isthmus
31(146) 9 (30) 5 (18) 21(83) 6(18) 5 (26) 6 (18) 3 (8)
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
20 (120) 17 (51) 8 (23) 15 (71) 13 (31) 4 (25) 3 (8) 6 (16) 1(4)
16.67 33.33 34.78 21.13 41.94 16.00 37.50 37.50 25.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
38 (149) 2 (26) 5 (19) 16 (78) 6 (29) 10 (20) 9 (20)
1(2)
21.23 30.00 21.78 25.30 33.33 19.23 33.33 37.50 50.00
1(8) 0 (0)
25.50 7.69 26.32 20.51 20.69 50.00 45.00 12.50 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
28 (135) 21(68) 9 (44) 4(31) 12 (20) 4 (5) 6 (33) 5 (10) 0 (3)
20.74 30.88 20.45 12.90 50.00 80.00 18.18 50.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
40(187) 6 (28) 12 (32) 13 (29) 2 (23) 3 (4) lO(31) 1(12) O(3)
21.39 21.43 37.50 44.83 8.70 75.00 32.26 8.33 00.00
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
10 (146) 11 (83) 3 (18) 3 (30) 3 (18) 0 (8) 3 (18) 0 (26) 0 (2)
6.85 13.25 16.67 10.00 16.67 00.00 16.67 00.00 00.00
Intramural
Subserous (9) Submucosa (15)
1(8) 5 (19)
Size (cm) 3-5 (45) 6-10 (32) > 10 (10) Position Body (58) Back (18) Isthmus (11)
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Rosati et al.
3-scm. Fig. 1.
6 -10
a.
10 cm.
Fetal weight at birth in relation to the dimension of the myomatous formation.
Table VII.
Threats of premature delivery. Threats of premature delivery (no. 47) No.
%
Size (cm) 3-5 6-10 > 10
19 (130) 23 (94) 5 (25)
14.62 24.47 20.00
Position Body Back Isthmus
25 (169) 12 (45) 10 (35)
14.79 26.67 28.57
Location IDtMnllUal Subserous Submucosa
34 (183) 9 (53) 4 (13)
18.58 16.98 30.77
Relation to theplacenta Non-contact Contact Superimposition
25 (133) 10 (74) 12 (42)
18.80 13.51 28.57
Znt J Gynecol Obstet 28
percentage of operative delivery seems to be only slightly lower than the general one surveyed in our clinic (approx. 20%). This percentage is, in our opinion, underestimated, because a myomatous formation can have an indirect role in the choice of abdominal delivery. Conclusions The presence of myomatous nodules undoubtedly represents a condition of increased fetal risk. The evaluation of such risks, case by case, can only be carried out through accurate sonographic surveillance [11,11,17-191. Ultrasound permits us to accurately evaluate the myomatous formations, from a volumetrical point of view and in relation to its site, to its tendency to develop in the precinct of the uterine wall or towards the interior or the exterior of the cavity and to its relation to the placenta. Myomatous formations with size inferior to 3 cm
Uterine myoma in pregnancy
were eliminated in accordance with the literature [11,12] regarding the fact that in these cases it appears difficult to differentiate local contractions of the myometrium from a myomatous formation. We wanted to corre-
Table VIII.
115
late not only the dimensions of the myoma, its location and its eventual contact with the placental area, with the principal complications in pregnancy, but several variables were correlated amongst themselves. In
Percentage of threats of premature delivery in relation to the same ultrasound parameters. Threats of premature delivery (no. 47)
Size (cm) 3-5 (19) 6-10 (23) > 10 (5)
Body Back Isthmus Body Back Isthmus Body Back Isthmus
12 (94) 4 (26) 3 (IO) ll(60) 5(11) 7 (23) 2 (15) 3 (8) O(2)
12.77 15.38 30.00 18.33 45.45 30.43 13.33 37.50 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
109 (74) 3 (38) 6(17) 10 (51) 7 (22) 6 (22) 5 (8) 0 (14) 0 (0)
13.51 7.89 35.29 19.61 31.82 27.27 62.50 00.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
14 (104) 2 (20) 3 (6) 17 (61) 5 (17) 3 (17) 2 (8) O(0)
13.46 10.00 50.00 27.81 29.41 16.67 17.65 25.00 00.00
9 (84) 7 (50) 9 (35) 8 (27) 1(14) 3 (4) 8 (22) 2 (10) O(3)
10.71 14.00 25.71 29.63 7.14 75.00 36.36 20.00 00.00
3-5 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
12 (94) ll(60) 2 (15) 4 (26) 5 (11) 3 (8) 3 (10) 7 (23) 0 (2)
12.77 18.33 13.33 15.38 45.45 37.50 30.00 30.43 00.00
Intramural Subserous Intramural Subserous Submucosa Intramural Subserous Submucosa
19 (133) 2 (24) 4 (12) 7 (24) 5 (20) O(1) 8 (26) 2 (9) O(0)
14.29 8.33 33.33 29.17 25.00 00.00 30.77 22.22 00.00
19 (133) 7 (24) 8 (26) 2 (24) 5 (20) 2 (9) 4 (12) O(1) O(0)
14.29 29.17 30.77 8.33 25.00 22.22 33.33 00.00 00.00
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
16 (100) 9 (56) 9 (26) 9 (30) 0 (10) 0 (0) 0 (3)
3-5 6-10 > 10 3-5 6-10 > 10 3-S 6-10 > 10
14 (104) 17 (61) 3 (17) 2 (20) 5 (17) 2 (8) 3 (6)
3 (16)
16.00 16.07 34.62 30.00 00.00 00.00 00.00 12.50 18.75
O(0)
13.46 21.87 17.65 10.00 29.41 25.00 50.00 16.67 00.00
9 (84) 8 (27) 8 (22) 7 (50) 1(14) 2 (10) 9 (35) 3 (4) 0 (3)
10.71 29.63 36.36 14.00 7.14 20.00 25.71 75.00 00.00
Intramural Subserous Submucosa Intramural Subserous Submucosa Intramural Subserous Submucosa
16 (100) 9 (30) 0 (3) 9 (56) 0 (10) l(8) 9 (26) 0 (0) 3 (16)
16.00 30.00 00.00 16.07 00.00 12.50 34.62 00.00 18.75
3-S 6-10 > 10 3-5 6-10 > 10 3-5 6-10 > 10
10 (74) 10 (51) 5 (8) 3 (38) 7 (22) 0(14) 6 (17) 6 (22) 0 (3)
13.51 19.61 62.50 7.89 31.82 00.00 35.29 27.27 00.00
1(6)
Position Body (25) Back (12) Isthmus (10)
Non-contact Contact Superimposition Non-contact Contact Superimposition Non-contact Contact Superimposition
Location Intramural (34) Subserous (9) Submucosa (4)
Body Back Isthmus Body Back Isthmus Body Back Isthmus
Relation to the placenta Body Non-contact Back Isthmus (25) Body Contact Back Isthmus (10) Body Superimposition Back Isthmus (12)
1(8)
1(6)
Clinical and Clinical Rtsearch
116
Rosati et al.
Table IX.
Percentage of operative deliveries. Total cases
Operative deliveries
Operative deliveries for myoma
No.
No.
%
No.
Size (cm) 3-S 6-10 > 10
38 97 27
25 41 15
65.19 42.27 55.56
6 7 3
15.79 7.16 11.11
Position Body Back Isthmus
110 33 19
55 16 10
5o.ocl 48.48 52.63
10 4 2
9.09 12.12 10.53
Location Intramural Subserous Submucosa
99 41 22
50 19 12
50.50 46.34 54.54
12 3 1
12.12 1.32 4.45
Relation to theplacenta Non-contact Contact Superimposition
97 38 21
41 25 15
42.27 65.79 55.56
7 6 3
7.16 15.79 11.11
%
ception. An anomalous uterine activity, tied to the presence of a myomatous formation, could thus be the cause of major complications, both outside of pregnancy (diminished fertility) [3] and during pregnancy. In our experience, we noticed a greater negative influence on fetal weight in cases of rather large myomatous formations and an increase in operative delivery. Ultrasound evaluation could in some pathologies represent not only the means for recognition of myomatous formations, which would otherwise only have been noticed at the time of delivery or which more frequently would have gone unnoticed, but it permits an accurate monitoring of such pathologies in time, thus noticeably reducing the incidence of complications during pregnancy. In addition, it represents a useful tool for orientating the obstetrician towards the type of delivery and its eventual anticipation. References 1
particular, in cases in which the myomatous formation is located in contact with the placental area, there appears to be frequent association with a large part of pregnancy complications, especially with the threat of abortion and the threat of premature delivery. These data have previously been pointed out by other authors [ 111. It is interesting to see how, in our experience, in the case of superimposition or contact of the myoma with the placental area, there is no percentage difference in the incidence of abortion threats with the varying dimensions of the myoma (Table VI). Evaluations carried out in non-pregnant patients, showed greater uterine activity in patients carrying myomas compared to a control group [9]. In normal circumstances, uterine activity seems to play an important role in transporting spermatozoa from the experior of the cervix to the fallopian tubes [16] and in transporting and nesting the product of conInt J Gynecol Obstet 28
2
3
4
8 9 10
Bezjian AA: Ultrasonics evaluation of pelvic masses in pregnancy. Clin Obstet Gynecol2: 325, 1977. Buttery BW: Spontaneous haemoperitoneum complicating uterine fibromyoma. Aust NZJ Obstet Gynaecol 12: 210, 1972. Chassar-Moir J Myerscough PR: Fibromyomata of the uterus. In Operative Obstetrics (ed M Kerr) p 398. Bailiere, Tindall Cassel, Ltd., London, 1971. Davids AM: Fibromyomas. In Medical Surgical and Gynecologic Complications of Pregnancy (ed JJ Rovinski AF Gutmarche) p 366. Williams and Wilkins Co., Baltimore, 1965. Dees HC: Cervical pregnancy associated with uterine leiomyomas. South Med J 59: 900,1966. Douglas RG, Stromme WB: In Operative Obstetrics p 413. Appleton-Century-Crofts, New York 1976. Gagliardi L, Preve Cl-J, Corder0 di Montezemole C, Mattone GP, Piazza A: Accrescimento intrauterino ed eta’ gestazionale in un campione di 9774 casi. Ann Obstet Ginecol Med Perinat 96(3): 147,1975. Hepperlen HM: Ectopic pregnancy associated with fibromyoma. Nebr Med J 55: 428,197O. Iosif CS, Akerlund M: Fibromyomas and uterine activity. Acta Obstet Gynecol Stand 62: 165, 1983. Moore JB, Morton DG: Leiomyomas of the uterus. In Gynecology and Obstetrics (ed JJ Sciarra, TW MC Elin) Vol. 1, p 1. Harper and Row, Publishers Hagerston, 1979.
Uterine myoma in pregnancy 11
12
13
14 15
16
17
Muram D, Gillieson M, Walters JH: Myomas of the uterus in pregnancy: ultrasonographic follow-up. Am J Obstet GynecolI28(1): 16, 1980. Muram-Winer HT, Muram D, Gillieson MS, Ivey BJ, Muggah HF: Uterine myomas in pregnancy. Can Med Assoc J 128: 949, 1983. Noia G, Masini L, Mazzei R, Pompa G, De Luca P, Rosati P, Guariglia L: Ultrasonografia nella gravidanza complicata da fibromi uterini. VII Riunione Gruppo di Studio e di Ricerca in medicina fetale, p 187, 1982. Ottolenghi-Preti GF: Fibromiomi dell’utero in gravidanza. Ann Ostet Ginecol5.92: 303,197O. Palatynski A, Zdziennicki A: Two cases of uterine myoma necrosis in early pregnancy. Wiad Lek 12: 963, 1984. Settlage DSF, Motoshima M, Bengtsson LP: Sperm transport from the external cervical as to the fallopian tubes in women: a time and quantitation study. Fertil Steril24: 655, 1973. Sidorowa IS: Assessment of the state of the fetus in patients with a uterine myoma by using complex ultrasonic scanning. Vopr Okhr Materin Det 24,4: 50, 1979.
18
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Address for reprints: P. Rosnti Department of Obstetrics and Gyaaecology Catholic University L. go A. Gemelli, 8 00168 Roma Italy
Clinical and Clinical Research