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Fibroids, also known as myoma or leiomyoma, are benign pelvic tumours fairly prevalent in pregnancies, with about 10% of first-trimester pregnancies affected. They are more common in women of South Asian, African, and Middle Eastern descent and are linked with advancing maternal age. 

While many fibroids are harmless, some can significantly impact pregnancy outcomes. In pregnancy, fibroids may lead to placental abruption or premature detachment of the placenta. The 2015 MBRRACE report identified postpartum haemorrhage (PPH) related to fibroids as the second leading cause of direct maternal mortality, potentially leading to peripartum hysterectomy. They are also associated with malpresentation, preterm labour, and increased caesarean section rates.

In Singapore, where many mothers are above the age of 35 years old ( risk factor), understanding the implications of fibroids is particularly relevant. Given the fact that studies show they may increase during pregnancy and have varied effects in pregnancy, it’s crucial for expecting mothers to be informed.

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Fibroids Symptoms & Recurrence

Many women might not realise they have fibroids, as symptoms are only present in roughly one-third of cases. The common signs to watch for include:

  • Heavy or prolonged vaginal bleeding
  • General pelvic discomfort
  • Pelvic pain
  • Bladder issues, such as frequent urination
  • Pain in the lower back
  • Pressure in the rectal area, potentially leading to constipation
  • Discomfort or pain during sexual intercourse
  • An increase in the size of the abdomen

Fibroids Pregnancy Complications

About 10 to 30% of pregnant women with fibroids experience complications. Fibroids are likely to enlarge rapidly during pregnancy especially in the first trimester. . Large fibroids, especially those larger than 200 cm³ are more likely to cause complications. Those located low near the cervix, can migrate upwards as the uterus grows when the pregnancy progresses, altering their potential impact.

The mother may experience pain, often associated with fibroids larger than 5 cm. This pain can arise from red degeneration especially in the second or third trimester or the twisting of a fibroid on a stem (torsion in a pedunculated fibroid). Fibroids can also exert pressure, causing discomfort.

Studies note that women with fibroids face higher risks of preterm labour, placental abruption, retained placenta and caesarean sections. Large fibroids, or those in certain locations, can disrupt blood flow to the placenta, leading to ischaemic damage and doubling the risk of placenta praevia ( low lying placenta near the cervix). Post-delivery, fibroids can interfere with uterine contractility, leading to bleeding complications and hemorrhage. .

The fetus (foetus) is also impacted by fibroids, which increase the risk of first-trimester miscarriages. It is more common in women with fibroids within the uterine body than those with lower-located fibroids. Additionally, large or multiple fibroids, especially in the lower uterine, are risk factors for fetal malpresentation and rarely cause  structural anomalies like limb reduction defects, dolichocephaly, and torticollis due to compressive effects. 

Moreover, fibroids during pregnancy can affect where the pregnancy grows, where the placenta implants, and the baby’s position in the womb. In certain instances, fibroids can cause subfertility, especially if they are distorting the fallopian tubes or affect the entry of sperm into the uterine cavity. Submucosal and deep intramural fibroids protruding into the uterine cavity also have a higher risk of causing infertility due to difficulty with implantation due to mechanical causes or increased uterine contractility. Studies have shown that removing these fibroids can improve pregnancy rates.

The possibility of a normal delivery after fibroid removal depends on the fibroid’s size and location. Normal delivery may be possible if the fibroid is on the surface (subserosal and pedunculated where there was minimal disruption or stitching of the uterine wall. Vaginal delivery may also be possible when submucosal fibroids imbedded in the cavity are removed through a hysteroscopic procedure via the vaginal approach. However, if the fibroid is deeply embedded in the uterine wall (intramural) and requires a deep incision for removal, it’s essential to consult with your obstetrician-gynaecologist to determine if a natural delivery is still an option as usually a Caesarean section is preferred to reduce the risk of the uterine scar rupturing during labour. 

The Caesarean section may be more complicated if the location of fibroids is in the lower segment of the uterus where the uterine incision is typically performed for delivery of the baby. A modified incision above that area in a thickened part of the uterine wall predisposes to more blood loss during the procedure. It is generally not advisable to remove fibroids during the time of caesarean section unless they cause difficulty with the uterine closure or to facilitate safe delivery of the baby due to the risks of extensive hemorrhage necessitating the removal of the uterus. Most fibroids will regress in size post delivery and can be followed up or surgically removed subsequently. 

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Common Fibroids Treatments & Procedures

Managing fibroids entails several targeted procedures, each with specific indications and outcomes. Understanding these procedures is crucial for women making informed decisions about their health.

Hysterectomy is a definitive surgical procedure for fibroids, entailing the complete removal of the uterus. This approach is often considered when fibroids are large, symptomatic or if the woman is not planning future pregnancies. The procedure can sometimes be performed laparoscopically, involving smaller incisions and typically results in a quicker recovery compared to traditional open surgery. However, the feasibility of a laparoscopic approach depends on the size and location of the uterus and fibroids. A hysterectomy is a significant procedure with implications for fertility and hormonal balance. Hence, it’s usually reserved for more severe cases or when other treatments have failed.

Myomectomy is an alternative surgical procedure that aims to remove fibroids while preserving the uterus, making it a preferred option for women who wish to retain their fertility. This procedure can also be performed laparoscopically, known as laparoscopic myomectomy. In this approach, small and slender instruments are inserted through tiny incisions in the abdomen to excise the fibroids. Morcellation is sometimes used to break down the fibroids into smaller pieces, allowing for their removal through the same small incisions. The laparoscopic method is less invasive than traditional surgery, often resulting in shorter recovery time and less postoperative pain.

Uterine Artery Embolization (UAE) offers a non-surgical alternative to treat fibroids. This procedure involves cutting off the blood supply to the fibroids, causing them to shrink and eventually die. UAE is particularly suitable for older patients who may not be good candidates for surgery due to other health issues. It’s also an option for those with one or two large fibroids who do not wish to preserve their fertility. However, the availability of UAE in Singapore is limited, and it may not be the first-line treatment in all cases. There is a higher rate of miscarriage, placenta accreta, caesarean section and post delivery hemorrhage after UAE hence it is not recommended for patient still keen for future pregnancy.  

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Fibroids Medications & Contraindications

In managing fibroids, the suitability of medical treatments varies, especially during pregnancy and breastfeeding. Some medicines are not recommended due to potential risks, while the effects of others remain unclear. It’s often advised to stop certain medications before trying to conceive to avoid any complications.

Meanwhile, medications such as Gonadotropin-Releasing Hormone Agonists (GnRH Agonists) are known to shrink fibroids—these drugs lower estrogen (oestrogen) levels, leading to a medical menopause-like state. The smaller size of the fibroids then allows for less invasive surgical approaches, such as keyhole surgery. However, it does not have permanent effects although the temporary reduction can be beneficial in preparing for less invasive surgical procedures. One significant downside is the risk of osteoporosis with long-term use, typically making it inadvisable to use these drugs for more than six months.

Singapore Obstetrics & Gynaecology Specialist 

Whether or not a medical procedure is necessary depends on the woman’s unique conditions. It makes it imperative to have a thorough consultation with your doctor to understand the implications of each option, how they align with personal health goals and the impact they may have on future fertility and overall well-being.

Practising at the Thomson Medical Center (TLC Gynaecology Practice) in Singapore, Dr. Pamela Tan is an obstetrics and gynaecology specialist certified to perform Level 3 minimally invasive keyhole surgeries such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroid, and cyst removal). An in depth consultation is required to tailor advice and treatment to the individual circumstances. To schedule an appointment with us, please call +65 6254 2878 or send a message here.

SOURCES:

  1. SMG WOMEN’S HEALTH: 10 Things You Should Know About Fibroids and Pregnancy 
  2. THE OBSTETRICIAN AND GYNAECOLOGIST: Fibroids in pregnancy: management and outcomes

 

Dr Pamela Tan
About Dr Pamela Tan

Dr Pamela Tan is a board certified obstetrician and gynecologist in Singapore. She finished her undergraduate studies at the National University of Singapore and earned her post-graduate degree at the Royal College of Obstetricians and Gynaecologists in the UK. She is an accredited specialist by the Specialist Accreditation Board (Ministry of Health), and a fellow of the Academy of Medicine, Singapore. She subspecialises in colposcopy and is certified to perform Level 3 minimally invasive keyhole surgeries such as laparoscopic hysterectomy, myomectomy and cystectomy. Dr Pam also supports the natural birthing method and she strives to provide a personalised care and treatment for each patient.