How does uterine fibroid affect pregnancy? Can a doctor remove fibroids during a caesarean section? General information about the disease

Uterine fibroids are a benign tumor of the myometrium (the muscular layer of the uterus). Other names for this pathology are leiomyoma, fibromyoma, fibroma. Is pregnancy possible against the background of such a disease? What are the dangers of fibroids discovered during pregnancy?

Causes

According to statistics, uterine fibroids occur in 30% of all women who consult a gynecologist about a particular disease. During pregnancy, pathology is detected in 0.5-1% of expectant mothers. Uterine fibroids occur predominantly in women over 25 years of age. With age, the likelihood of developing pathology increases significantly.

The exact causes of fibroids have not yet been studied. According to one theory, uterine fibroids are considered a hereditary disease. It is assumed that during intrauterine development there is a failure in the formation of smooth muscle cells of the organ, which subsequently leads to the development of the disease. This theory is not without meaning, although it has never received reliable confirmation.

Most experts are of the opinion that fibroids develop throughout a woman’s life. The tumor is considered hormone dependent. An increase in the amount of estrogen leads to the appearance of fibroids and its gradual growth in the muscle layer of the uterus. Under the influence of hormones, the number of changed cells increases with each menstrual cycle. The larger the fibroid, the less susceptible it is to estrogen and progesterone, and the more difficult it can be to stop its growth without surgery.

Risk factors for developing fibroids:

• heredity;
• age over 25 years;
• early onset of menstruation (before 12 years);
• late menopause (after 45 years);
• abortions and miscarriages;
• complicated childbirth;
• any interventions in the uterine cavity (therapeutic and diagnostic).

During pregnancy, hormonal levels change and blood flow in the uterus increases. During this period, there is a natural growth of fibroids and an increase in tumor size. Active growth of nodes occurs until the 8th obstetric week. From the end of the first trimester until childbirth, the death of atypical cells is activated, which can provoke tumor necrosis and other serious complications of this condition.

Symptoms

Manifestations of uterine fibroids during pregnancy depend on the location and size of the tumor. The most common symptoms that occur are:

• pain in the lower abdomen and lower back;
• bleeding of varying intensity;
• frequent urination;
• constipation

Pain in the lower abdomen is often regarded as a sign of a threatened miscarriage. With such a diagnosis, a woman is often admitted to a hospital, where appropriate therapy is carried out. The abdominal pain does not subside, which frightens the expectant mother. A routine ultrasound examination will help to understand the situation and identify fibroids.

Bleeding during pregnancy - alarming symptom. If any bloody discharge from the genital tract, a woman urgently needs to see a doctor. After an ultrasound, it will be possible to find out whether the bleeding is associated with detachment of the ovum (placenta) or is explained by the presence of a benign tumor. Bleeding may recur several times throughout the pregnancy.

Frequent urination and constipation are rarely perceived as a symptom of fibroids. Similar signs also occur in healthy women during pregnancy, so they have no diagnostic value.

Due to the rapid growth of fibroids in the first 8 weeks, the main manifestations of the disease are observed during this period. In the future, the tumor may not make itself felt. In some expectant mothers, the disease is asymptomatic and is not accompanied by complications.

Outside of pregnancy, fibroids make themselves felt with the following symptoms:

• intermenstrual bleeding;
• heavy and painful menstruation;
• chronic abdominal pain;
• constipation;
• frequent urination.

The pathology is often combined with endometrial hyperplasticity, adenomyosis and ovarian tumors.

Uterine fibroids and conception

Uterine fibroids are one of the factors causing infertility. A tumor located in the uterine cavity mechanically interferes with the attachment of the fertilized egg. The embryo, which has not found a place for itself, dies, and a miscarriage occurs in the early stages. If the embryo dies before 2 weeks, the woman may never know that she was pregnant.

The location of the tumor near the fallopian tubes also interferes with the normal conception of a child. If the lumen of both fallopian tubes is blocked, sperm cannot penetrate to the egg, and fertilization does not occur. This pathology is quite rare and is easily detected during hysteroscopy.

Myoma is a tumor that occurs when there is an altered hormonal background. In this situation, the conception of a child may be prevented by an imbalance of hormones in female body. The combination of fibroids with adenomyosis and other gynecological diseases significantly reduces the likelihood of pregnancy.

Complications of pregnancy

Pregnancy that occurs against the background of uterine fibroids does not always proceed well. The following women are at high risk:

• age over 35 years;
• presence of accompanying gynecological diseases;
• the size of myomatous nodes is more than 5 cm;
• multiple nodes;
• the location of the tumor is close to the mucous layer of the uterus;
• node necrosis;
• the duration of the disease is more than 5 years.

Frequent complications of pregnancy due to uterine fibroids:

• miscarriage;
• premature birth;
• placental insufficiency;
• fetal hypoxia;
• delayed fetal development;
• incorrect placement of the fetus in the uterus;
• placental abruption;
• thrombosis of the pelvic veins.

The threat of miscarriage persists throughout pregnancy. Most often, miscarriage occurs in the early stages due to malnutrition of the endometrium. It happens that the embryo cannot find a convenient place of attachment and is located in the cervix. Cervical pregnancy develops, in which pregnancy is impossible. Uterine fibroids also increase the risk of tubal pregnancy.

Many women with uterine fibroids experience premature birth. The likelihood of such a complication increases with concomitant endometrial pathology and large size nodes. Increased uterine tone persists throughout gestation.

ICI (isthmic-cervical insufficiency) develops when the tumor is localized in the cervix. In this case, painless dilatation of the cervix occurs before the onset of labor. In the early stages, this condition can lead to miscarriage. After 22 weeks, ICI threatens the development of premature birth.

A tumor located in the muscle layer of the uterus interferes with the normal functioning of the placenta. The supply of oxygen is disrupted and nutrients to the fruit. Hypoxia develops - a condition in which the baby suffers from oxygen deficiency. There is a delay in the development of the fetus, a lag in its weight and height. All this further affects the health of the baby after his birth, including his mental and physical development.

With large fibroids, the baby rarely takes the correct longitudinal position in the uterus. The proximity to the tumor leads to the fact that the fetus is located obliquely or transversely. In this situation, natural childbirth is not possible. Incorrect position of the fetus is a reason for a caesarean section.

Tight attachment of the placenta is another danger that awaits expectant mothers. Changes in the endometrium due to the growth of fibroids lead to the fact that after childbirth the placenta does not come out on its own. With this condition, heavy bleeding develops. If the placenta is firmly attached, a manual examination of the uterus is performed and the placenta is removed under general anesthesia.

Diagnostics

Fibroids can be detected already in the early stages of pregnancy during an ultrasound scan. In the future, the expectant mother is recommended to regularly undergo all ultrasound screenings. During the examination, the doctor will pay attention not only to the condition of the fetus, but also to the size of the fibroids. This approach makes it possible to detect in time fast growth nodes and identify associated complications. It is recommended to undergo an additional ultrasound before childbirth to clarify the location and size of myomatous nodes.

Planning pregnancy with uterine fibroids

Uterine fibroids can become a serious obstacle to conceiving and bearing a child. All women suffering from this pathology should visit a doctor before planning a pregnancy. An ultrasound is performed to assess the condition and size of the nodes. Further tactics will depend on the severity of the detected pathology.

Conservative therapy is prescribed for small fibroids, when they are in a stable condition or when they are growing slightly. Priority is given to drugs from the group of gonadotropin-releasing hormone agonists and combined oral contraceptives. The course of treatment lasts up to 6 months. While taking hormonal medications, the size of fibroids decreases, which allows a woman to conceive and carry a child without complications.

Surgical treatment is performed for large fibroids, rapid tumor growth and complications. The operations are carried out primarily through laparoscopic access, which significantly reduces rehabilitation time and speeds up the patient’s recovery.

Pregnancy should be planned during the first months after completion of therapy. You should not put off conceiving a child indefinitely. Uterine fibroids often recur. After discontinuation of hormonal drugs, rapid re-growth of fibroids is possible, and then the onset of pregnancy will be a big question.

Management of pregnancy with uterine fibroids

During pregnancy, specific treatment is not carried out. If complications develop, the following drugs are prescribed:

• antispasmodics for threatened miscarriage in the first trimester;
• tocolytics (drugs that reduce uterine tone) after 16 weeks;
• antiplatelet agents for impaired uterine blood flow;
• Antibacterial therapy for necrosis of myomatous node.

Indications for fibroid removal during pregnancy:

• inability to maintain pregnancy with the original size of the tumor;
• rapid growth of fibroids;
• node power failure;
• location of fibroids in the cervix;
• compression of the pelvic organs by a tumor.

The optimal time for surgical treatment is 16-19 weeks of pregnancy. After surgery, conservation therapy is carried out, tocolytics and other drugs are prescribed as indicated. Throughout pregnancy, the condition of the fetus is constantly monitored using ultrasound and CTG.

Childbirth with uterine fibroids

Prenatal hospitalization is carried out at 37-39 weeks. Independent childbirth is allowed if the fibroids are small and the condition of the fetus is satisfactory. Complications may develop during childbirth:

• premature rupture of water;
• anomalies of labor;
• perineal injuries;
• premature detachment placenta;
• tight attachment of the placenta;
• bleeding in the postpartum period.

Caesarean section is performed in the following situations:

• multiple myomatous nodes;
• large tumor size;
• location of fibroids in the cervix;
• a scar on the uterus after a previous myomectomy (tumor removal);
• node necrosis;
• suspicion of malignancy of fibroids (development of a malignant tumor);
• combination of uterine fibroids with other complications of pregnancy;

Uterine fibroids during pregnancy are a serious problem faced by pregnant women. The development of pregnancy in the presence of this pathology is fraught with the risk of complications, as a result of which a woman may lose not only her unborn child, but also her entire reproductive organ.

Is pregnancy possible with uterine fibroids? The probability of conception and successful gestation is influenced by the number and size of myomatous nodes, as well as their location. If the lesions are small in size and located in the wall of the uterus, then the possibility of conceiving and bearing a child is quite high.

With multiple myomatous nodes, large tumors located near the fallopian tubes, the chance of conception is minimal. If it does occur, then there is a high risk of developing complications and pathologies of the embryo.

Uterine fibroids and pregnancy directly influence each other's development. As a result of the growth and development of the fetus, changes in the cells of myomatous tissue occur, and as a result of the progression of fibroids, the normal functioning of the placenta is disrupted.

As pregnancy progresses, as a rule, the blood supply and nutrition of the tumor are disrupted. If a woman has subserous fibroids, there is a fairly high risk of torsion of the leg, especially if the pregnant woman has gestosis, accompanied by edema and increased pressure, or uterine hypertonicity.

If the placenta is located above a large myomatous node, its blood supply is disrupted. The structure of the blood vessels of the placenta changes, and blood clots may form in them. As a result, placental insufficiency develops.

The maximum severity of circulatory disorders of the placenta is observed when labor approaches. For this reason, women have a caesarean section at 38 or 39 weeks.

Tumor diagnosis

When a woman is registered for pregnancy, an examination is carried out to determine the woman’s health status.

If fibroids were not diagnosed before conception, then the diagnosis can be made during a gynecological examination already during a developing pregnancy. Most often this happens through an ultrasound examination.

During an ultrasound, the doctor determines the location of myomatous nodes, their number and size, structure, and location relative to the placenta.

How does uterine fibroid affect pregnancy, is it dangerous, what is the risk of combining the disease with bearing a child - these and other questions worry pregnant women.

If a pregnant woman is diagnosed, cause the development pathological process The following factors may:

• the size of the largest myomatous node is more than 7-8 cm;
• multiple fibroids (total number of nodes – more than 5);
• location of the placenta directly above the tumor;
• direction of the node into the uterine cavity, which leads to deformation of the organ;
• necrotic or dystrophic changes in the myomatous lesion;
• the presence of scars on the uterus due to operations;
• diagnosis of infertility in the past;
• other diseases of the pelvic organs;
• varicose veins of the pelvis;
• The woman is over 30 years old.

So, young women under 30 have every chance of successfully bearing a child, without other gynecological diseases and operations on the uterus in the past, with less than 5 myomatous nodes, the size of which is less than 8 cm. The tumor foci should be located on the anterior or back wall and grow outward relative to the uterine cavity, located away from the placenta. In this case, the development of the embryo proceeds, as a rule, without any complications.

Other options are considered high risk, a woman can have an early or late pregnancy termination.

What complications may arise?

Patients who are at high risk may develop the following complications:

• fetoplacental insufficiency;
• isthmic-cervical insufficiency, as a consequence of the localization of the tumor on the cervix or isthmus of the uterus;
• proliferating tumor (i.e. rapidly growing);
• disruption of the blood supply to the neoplasm;
• uterine rupture along a scar (if there are scars and there is a history of operations);
• gestosis;
• development of anemia;
• placental abruption;
• spontaneous termination of pregnancy;
• premature birth.

Video about the effect of uterine fibroids on pregnancy

Treatment

Is treatment required if there are uterine fibroids during pregnancy? Therapy is prescribed when there is a high risk of complications and the threat of interruption.

In this case, the doctor prescribes the following to the woman:

• , vitamin complexes, antispasmodics;
• semi-bed or bed rest;
• complete renunciation of intimate life;
• prohibition on any physical activity.

Other complications and prescribed treatment:

• Rapid growth neoplasm. Antiplatelet agents are prescribed (for example, Curantil tablets), which improves the nutrition of the tumor. It is possible to prescribe antispasmodics and hepatoprotectors.
• Isthmic-placental insufficiency. Bed rest is recommended. Ginipral is administered. Suturing the cervix is ​​not possible due to the high risk of damage to the nodes.
• Placental insufficiency. Therapy is carried out only in a hospital setting. Curantil, Actovegin, Magne B6 and other drugs are prescribed.
• Node power failure. In this case, the woman’s well-being worsens, abdominal pain occurs, the general body temperature rises, and the threat of miscarriage develops. Therapy involves prescribing antibacterial drugs, antispasmodics, desensitizing drugs. If drug therapy does not have an effect, surgery is performed to remove the node.

Other indications for emergency surgery for uterine fibroids and pregnancy:

• infringement of the uterus in the pelvic cavity;
• rupture of myomatous node;
• development of peritonitis;
• neoplasm necrosis;
• transition of fibroids to a malignant form.

Pregnancy management tactics

Maintaining pregnancy is a priority in the following situations:

• the woman’s desire to keep the child;
• period of more than 24 obstetric weeks;
• pregnancy after prolonged infertility.

Indications for termination of pregnancy with fibroids are as follows:

• development of neoplasm necrosis;
• localization of the myomatous node in the cervix and the resulting development of isthmic-cervical insufficiency, miscarriage, bleeding, intrauterine infection of the embryo;
• multiple fibroids with more than 15 cm;
• severe concomitant diseases of the pelvic organs;
• the woman’s age is over 45 years and the presence of high risk factors.

How is childbirth?

Hospitalization of a pregnant woman with diagnosed uterine fibroids occurs at 37-38 weeks. An examination is carried out to determine the condition of the fetus and placenta, and the dilatation of the cervix. Based on the results of the examination, the doctor makes a choice of labor management tactics.

In the presence of low risk factors, natural childbirth is allowed; in difficult cases, a cesarean section is indicated.

Caesarean section is mandatory in the following cases:

• presence of a scar on the uterus;
• multiple fibroids;
• large sizes of nodes;
• localization of the tumor in the lower sections, which will prevent natural movement fetus;
• breech presentation of the fetus;
• suspicion of tumor malignancy;
• suspicion of necrosis of the myomatous node;
• presence of concomitant diseases.

Performing a hysterectomy during a cesarean section, that is, removal of the uterus, is possible if the following indications exist:

• the presence of multiple nodes in a woman giving birth over the age of 40;
• re-development of the tumor after surgery to remove it - myectomy;
• necrosis of a tumor located in the wall of the uterus.

After pregnancy and childbirth, in most cases there is a tendency for fibroids to stop growing, which is the result of hormonal changes in the body, lactation, and the use of hormonal contraceptives.

Uterine fibroids during pregnancy have different risk factors. Much depends on the type of tumor, its size and location, and progression. In some cases, no treatment is required; in other situations, drug therapy and surgical intervention are performed if indicated. Natural birth or caesarean section is possible.

Are fibroids and pregnancy compatible? According to gynecologists, every fifth woman aged 18 to 50 years has a history of a tumor-like node on the uterus of a benign nature. By changing the organ cavity, the tumor causes infertility and recurrent miscarriage, and also provokes complications during gestation and childbirth. However, a myomatous node cannot be considered absolute contraindication for pregnancy. Is it possible to conceive and carry a baby to term with this disease? How to behave if uterine fibroids appear during pregnancy?

what is fibroid and why does it occur?

Myoma is hormonally dependent benign neoplasm, growing from the smooth muscle elements of the uterus.

Its main causes are considered to be an increase in the level of ovarian hormones and metabolic disorders. This condition can occur when:

• Physiological fluctuations in the synthesis of ovarian hormones: pregnancy, perimenopause.
• Diseases endocrine glands: hormonally active tumors and ovarian cysts, pathologies of the adrenal glands, thyroid gland.
• Lesions of the central nervous system affecting the hypothalamus and pituitary gland.
• Obesity.
• Smoking and alcoholism.
• Chronic stress.
• Long-term use of hormonal drugs.

Under the influence of unfavorable conditions, atypical cells appear in the muscle layer of the uterus, which begin to divide randomly, forming a node. It can grow in the thickness of the myometrium (interstitial), extend to the surface of the organ (subserous) or protrude into the cavity (submucosal).

For a long time, the disease is asymptomatic and is detected when the node reaches 30 mm or more in diameter. The main manifestations of fibroids are:

• Long, heavy periods.
• Pain and discomfort in the lower abdomen.
• Compression of the adjacent intestines and bladder by the tumor, causing problems with defecation and urination.
• Acute painful sensations and signs of inflammation of the peritoneum due to malnutrition in the nodes.

If these symptoms occur, a uterine tumor requires mandatory elimination.

Are fibroids and pregnancy compatible?

Myomatous nodes, located among the muscle fibers of the uterus, disrupt its architecture. The uterus prevents the flow of sperm into the organ cavity and fallopian tubes, where the process of fertilization of the egg should take place. Also, conception is impossible if the node grows, blocking the lumen of the fallopian tubes.

The tumor, complicating the contractility of the uterine muscles, disrupts the normal menstrual cycle. Moreover, it is often accompanied by endometriosis - the growth of the uterine epithelium outside its inner layer. This minimizes the chances of successfully combining pregnancy with fibroids without drug treatment.

If fertilization does occur, nodes having a submucosal location may prevent complete attachment of the blastocyst, from which the embryo and its location are formed. This is the cause of miscarriages different dates and disorders of intrauterine development of the child.

How does fibroid affect pregnancy?

It is not always possible to detect fibroids at the stage of preconception preparation. And if a woman who has this pathology, pregnancy has already begun, myomatous nodes can complicate its course.

And changes in the uterus during pregnancy

The gestation period is accompanied by changes throughout the body. The uterus undergoes significant changes: its epithelial lining thickens, muscle fibers elongate and hypertrophy, allowing the organ to greatly stretch as the size of the fetus increases.

These changes are controlled by hormones that are actively produced by the ovaries, and after 12 weeks of gestation, by the placenta. And often this provokes intensive growth of a hormonally dependent pathological structure.

About the complications of pregnancy against the background of fibroids

The percentage of spontaneous abortions during early pregnancy in women with this pathology is significantly higher than in women without myometrial nodes. At the same time, the risk of miscarriage increases significantly with numerous myomatous tumors.

When the placenta is adjacent to areas of fibroids, there are frequent cases of its detachment, which is accompanied by pain, heavy bleeding and subsequent death of the fetus.

For the same reason, delays and abnormalities in fetal development are often observed. Large nodes in the uterine cavity can put pressure on the baby, leading to various deformities.

The second third of the gestational age may be complicated by placental insufficiency, which provokes insufficient oxygen supply to the fetus (hypoxia). Placenta previa to the cervical canal contributes to frequent bleeding and the threat of spontaneous abortion. Also, with further development of pregnancy, preeclampsia may occur. This pathological condition, characterized by:

• High blood pressure.
• The appearance of protein in the urine.
• Swelling of the face and limbs.
• Neurological disorders.

During development hypertensive crisis and convulsions (eclampsia), urgent delivery is required, regardless of gestational age.

In the third trimester of pregnancy, fibroids can cause abnormal positioning of the baby. Large nodes prevent him from taking a head position towards the entrance to the pelvis. The baby is positioned transversely or feet first, which will significantly complicate the birth process. This may be an indication for cesarean section for fibroids.

Is it possible to confuse fibroids with pregnancy?

Often myomatous nodes are symptomatically similar to the gestation period. They can be confused with pregnancy due to the following symptoms:

• Delay of the next menstruation.
• Bloody discharge during the intermenstrual period.
• Enlarged belly.

If these signs occur, you should definitely consult a doctor to make a correct diagnosis.

Diagnosis of a tumor during pregnancy

Most accurately, a uterine tumor can be detected by examining the uterine cavity with ultrasound. Confusion on ultrasound can only occur if the pedunculated submucous fibroid has a small volume.

It can be mistaken for an embryo. In such cases, it is necessary to determine the concentration of hCG (human chorionic gonadotropin) in the urine or blood. This hormone is a marker of pregnancy and with fibroids its concentration is close to zero.

How to distinguish

Pregnancy can be distinguished from myomatous tumor by the following features:

• Weekly increase in the concentration of hCG in the blood and urine.
• The appearance of a bluish tint of the vagina and cervix, softening of the tissues of the organ when palpated.
• Ultrasound: detection of fetal heartbeat from 6-12 weeks, movements from 16 weeks of gestation.

Important! Delayed menstruation, bloody spotting from the genital tract, pain and discomfort in the abdomen, as well as an increase in its size are reasons for mandatory visit obstetrician-gynecologist. Only a doctor can determine whether a patient has fibroids or pregnancy.

Can fibroids resolve on their own during pregnancy?

In the practice of some obstetricians and gynecologists, cases have arisen when a pregnant woman’s fibroids resolve. However, such situations are extremely rare.

As a rule, pregnancy gives impetus to more intensive growth of the uterine nodes due to changes in hormonal levels.

Therefore, all women with a history of this pathology should plan pregnancy and, if necessary, treat the pathology at the stage of preconception preparation.

Recommendations for maintaining pregnancy

About the main dangers during pregnancy

The most common complications of a tumor during gestation are:

• Bleeding.
• Low attachment and placenta previa.
• Threats of miscarriage.
• Underdevelopment of the placenta.
• Compression of the fetus by tumor-like nodes, leading to deformities.
• Development of preeclampsia.
• Incorrect (transverse, leg) position of the fetus towards the entrance to the pelvis, complicating the birth process.

How to behave correctly during pregnancy

Pregnant women with fibroid tumors should not panic. The main thing a woman can do to prevent the development of complications is to follow all the recommendations of the obstetrician-gynecologist.

To prevent tumor growth, it is necessary to undergo an ultrasound of the pelvic organs and fetus within the time prescribed by the doctor.

If any disturbing symptoms occur (blood from the genital tract, abdominal pain, deterioration in general health), you should definitely visit a gynecologist.

Women with tumors, especially pregnant women, are not recommended to stay in the sun for a long time or carry out warming procedures on the lower abdomen and lower back. Should be adhered to proper nutrition and give up bad habits. And you should definitely avoid stress and unnecessary worries.

Treatment of pathology during pregnancy

Hormonal therapy prescribed to eliminate uterine nodules is not possible during pregnancy. Therefore, tumor treatment is carried out only symptomatically when clinical manifestations occur.

Important! Any drug therapy during pregnancy must be agreed upon with an obstetrician-gynecologist. Many medications should not be taken during gestation.

In what cases is surgery to remove a tumor performed?

During pregnancy, uterine nodes are removed for the following indications:

• Nodes of significant volumes and their intensive growth.
• Twisting of the base of the myomatous formation, accompanied by tissue death.
• Lack of results from drug therapy.
• Strong pain syndrome.

The optimal and safest time for myomectomy for the mother and fetus is 15-19 weeks of gestation. The operation requires a wide incision (laparotomy). The tumor is isolated and excised, and immediately after the intervention an ultrasound is performed to assess the viability of the fetus. During pregnancy, natural childbirth is contraindicated.

Is it possible to give birth with uterine fibroids?

A node on the uterus can complicate the process of childbirth. It disrupts the contractility of the organ, makes it difficult for the child to pass through the birth canal; with cervical fibroids, its mobility and transformation for a successful birth are impaired.

Complications

The main complications caused by uterine neoplasms during childbirth are:

• Weakness or absence of contractions and pushing.
• Discoordinated labor activity.
• Bleeding.
• High risk of uterine rupture.
• Creating an obstacle to the birth of a fetus.
• Delayed separation of placenta.

E vaginal birth or caesarean section

Childbirth with fibroids can occur naturally with a small diameter of the node, its localization near the fundus of the uterus and the absence of mechanical barriers to the birth of the fetus.

Delivery of fibroids by cesarean section is carried out when large nodes are located in the lower segment, complications occur, and after myomectomy.

Childbirth and the postpartum period

It is possible to give birth safely with fibroids. The birth process must be supervised by qualified medical personnel. At the same time, contractions and fetal heartbeat are constantly monitored. If complications occur, emergency surgical delivery is used. After childbirth, uterine bleeding and retained placenta are more common. Therefore, it also requires constant medical supervision.

Consequences for the child

The main one for the fetus is compression by large nodes, causing deformations and deformities. And also when the placenta is adjacent to pathological tissues Possible disruption of blood circulation between the uterus and placenta, leading to delayed fetal development and oxygen starvation of varying severity.

However, with medical supervision over the course of the gestation period, such complications are extremely rare. Despite all the scary possible consequences, fibroids and childbirth are compatible if the woman is under the supervision of doctors and follows all their instructions.

Myoma causes infertility

The greatest adverse effect on reproductive function are caused by tumor-like nodes of submucosal and intermuscular localization. They prevent the blastocyst from fully attaching to the uterine wall, causing infertility. At the same time, myomectomy and hormonal therapy carried out before pregnancy increase the chances of a successful conception and pregnancy.

Uterine fibroids are in first place among benign tumors that occur in women. reproductive system. A special feature of this cancer is the high frequency of development at a young age.

If a woman of reproductive age with the presence of a myomatous node develops pregnancy, then its management and childbirth in this case become more complicated.

Uterine fibroids are a benign neoplasm that tissue composition has a high similarity with muscle layer uterus - myometrium. It has a round shape and does not have infiltrative and invasive growth; the boundaries between atypical cells and healthy myometrium are clearly visible.

A common cause of tumor development is a violation hormonal balance female sex hormones with a predominance of estrogen, which leads to active division of uterine muscle cells and tumor development.

Effect on the fetus

How does fibroid manifest itself, and what effect does the tumor have on the fetus in the first trimester of pregnancy? The first trimester is considered the early stages of pregnancy, i.e. time from the moment the child is conceived until the end of the 12th week of pregnancy. It is in the first trimester up to 12 weeks that the risk of miscarriage when conceiving a child is highest and directly depends on the volume of the neoplasm.

The issue of progression of tumor growth during pregnancy, associated with hormonal changes in a pregnant woman, is also important. In 70% of cases, tumor growth activity does not increase during pregnancy.

The location and number of nodes in the body of the uterus also play an important role in the development of the fetus. With the submucosal or submucosal form, the risk of early pregnancy loss is higher than with other forms.

With fibroids in pregnant women in the early stages, it is noted increased amount bleeding, although during pregnancy there is no menstrual cycle. Miscarriage before 12 weeks can occur if the tumor is large and destroyed.

As a result of the destruction of the tumor, substances - prostaglandins, responsible for the inflammatory process - enter the uterine bloodstream; they increase the contractility of the uterus, which leads to miscarriage. Also, neuroendocrine disorders, which caused the formation of nodes, can have a negative impact on pregnancy.

Complications of pregnancy with uterine fibroids can occur in any trimester. Each period has its own problems:

• In 1st trimester there is the highest risk of threatened miscarriage due to increased myometrial tone.
• In the 2nd trimester the risk of twisting of the leg of the node increases, with disruption of its trophism and subsequent necrosis.
• In the 3rd trimester Pregnancy significantly increases the risk of bleeding, especially if the node has a submucosal location close to the placenta insertion. Also, if the tumor volume is large, deformation of parts of the child’s body may occur.

The most dangerous types of tumors

Most dangerous form fibroids are submucosal or submucosal, especially localized in the fundus of the uterus.

Submucosal nodes often form thin legs, and the node itself is located in the uterine cavity - this leads to constant mechanical impact on the inner layer of the uterus - the endometrium.

Photo from ultrasound monitor: tumor and 8 weeks of pregnancy

Submucosal fibroids, unlike other forms, have intensive growth and more often than others undergo malignancy - malignancy.

Subserous node is more prone to bleeding than others, this is especially true in the later stages of pregnancy, when the child is already large.

Relatively safe species fibroids are: interstitial fibroid, which is located directly in the thickness of the myometrium and subserous fibroid, which is located on the outside of the uterus under the parametrium (uterine peritoneum).

The submucosal and interstitial forms of the nodes grow more slowly than the submucosal ones and to a lesser extent increase the tone of the uterine muscles. The risk of bleeding with them in the later stages of pregnancy is significantly lower than with the submucosal form.

Diagnostics

Expectant management and constant patronage of the pregnant woman from the very beginning early dates is prerequisite to minimize the risks of miscarriage and other pregnancy complications. Mandatory diagnostic examination women is carried out at the following stages.

• In the first trimester at 6 and 10 weeks pregnancy;
• In the second trimester at 15 and 23 weeks;
• In the third trimester at 33 and 38 weeks.

In addition to assessing the development of the fetus, the dynamics of the development of the myomatous node is also determined. In the later stages with a normal course in the process ultrasound diagnostics the number, location and size of tumors are clarified, as well as the distance from the placenta insertion site.

An ultrasound examination assesses the degree of feto-placental blood flow and the presence of disturbances in the nutrition of the uterine nodes. Routine ultrasound diagnostics of the pelvic organs helps prevent the most serious complications associated with the shape and location of tumor nodes.

In addition to ultrasound diagnostics, in the third trimester, cardiofetotocography is required to determine the activity of the child’s cardiovascular activity, and the frequency of cardiofetotocography is several times higher than during standard pregnancy. Cardiofetotocography is performed every 5-6 days starting from the 32nd week of pregnancy.

Doctors' actions

When pregnancy develops in a woman with uterine fibroids, treatment of the tumor itself is not carried out, except in cases of disruption of the trophism of the node. All treatment tactics boil down to constant monitoring of the condition of the pregnant woman and her fetus, as well as the neoplasm.

Prevention of possible complications is carried out. To reduce their risk, the following measures are required:

• Waiting tactics– constant monitoring of all parameters of pregnancy development and manifestations of fibroids allows as soon as possible prevent any complication.
• Decreased muscle tone of the uterus to reduce the risk of miscarriage.
• Maximum preservation of the safe condition of the pregnant woman and the baby to reach full term.
• Reducing the risk of premature birth.

Because when the placenta is located in close proximity to the myomatous node If feto-placental blood flow is disrupted and fetal hypoxia occurs, then treatment is primarily aimed at eliminating these conditions.

Due to the presence of fibroids, early prevention of placental insufficiency is carried out. Starting from the 15th week of pregnancy, tumor growth is monitored, the formation and attachment of the placenta to the endometrium is monitored, and the physiological development of the fetus is monitored.

Treatment can only be carried out if blood flow in it is disrupted, which leads to severe pain and increased muscle tone of the uterus. Conservative therapy consists of prescribing a pregnant woman a special protein diet, ferric iron supplements and vitamin therapy.

People try not to prescribe hormonal therapy during pregnancy so that the child’s development is physiological.

In case of serious disturbance of the trophism of the myomatous node and the impossibility of correction using conservative therapy, surgical treatment is prescribed. A myomectomy is performed - an operation to resect a tumor while preserving the uterus and pregnancy.

This surgical intervention is prescribed extremely rarely and only if there is a serious threat to the health of the pregnant woman.

For the safest possible delivery, a pregnant woman is hospitalized 1-2 weeks before the expected birth. If the tumor is small in volume and does not have high activity, then delivery can be done through natural birth canal.

If the tumor is voluminous and blocks the birth canal, then delivery is performed to minimize the risk operationally using a cesarean section.

After childbirth, the woman must be administered oxytocin to maximize the active contraction of the uterine myometrium and eliminate bleeding. After discharge from the maternity hospital, the patient undergoes conservative hormonal therapy according to a standard regimen, for example, progesterone.

Forecast

The prognosis of pregnancy with uterine fibroids largely depends on the shape of the fibroid, its location, the number of nodes and the volume of the tumor. As described above, the most unfavorable option for the course of pregnancy and subsequent childbirth is the submucous form of the node, since it develops quickly, increases in volume and increases the tone of the uterine muscles.

However, with constant monitoring and rational correction of the condition, even with a submucosal form of the tumor, it is possible to bear a healthy child.

The most favorable option is considered to be a form with a subserous location, since the external localization of the node has a lesser effect on the tone of the uterine myometrium and does not mechanically affect the fetus and placenta.

To summarize, we can conclude that the smaller the size of the myomatous node and the further from the uterine cavity it is localized, the higher the chance of favorable development of pregnancy and physiological childbirth.

For example, this video shows successful case, when at 33 weeks the fetus is fine, in the presence of fibroids:

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The causes of severe complications of pregnancy and childbirth can be not only the fibroid itself (its large size, unfavorable localization, malnutrition of the tumor node), but also the reasons that caused its occurrence, growth and development. Uterine fibroids do not occur in healthy women.

Somatic cell mutations lead to tumor transformation of immature myocytes after undergoing and concomitant hormonal disorders, neuroendocrine-metabolic and inflammatory diseases, as well as hypoxic, dystrophic and traumatic damage to the uterus as a result of intrauterine interventions (abortion, curettage, inflammatory processes).

Complicating factors are the consequences of myomectomies, which are almost always accompanied by adhesions and scar formation on the uterus.

Inflammatory processes and ovarian tumors, dishormonal diseases of the mammary glands, hypofunction of the thyroid gland and adrenal cortex are often combined with uterine fibroids.

IN last years The presence of uterine fibroids in young women (22-29 years old) is noteworthy. As a rule, these are hereditary uterine fibroids. If the patient’s mother was diagnosed with uterine fibroids at a late reproductive or even premenopausal age, then her daughter’s uterine fibroids are diagnosed 10-15 years earlier. Moreover, in young women, uterine fibroids are often active (growing rapidly, accompanied by pronounced clinical signs).

Most often, uterine fibroids occur in primiparas of late reproductive age with a burdened obstetric, gynecological and somatic history. For these women, it often takes 15-20 years from the onset of sexual activity to their first pregnancy. And during these years, the woman, as if avoiding pregnancy, uses long-term contraception, suffers many urogenital infections, has at least three to five somatic chronic diseases. This common uterine tumor is also characterized by infertility or repeated abortions, stressful situations, mental stress and shocks that deplete the function of the thyroid gland and adrenal cortex.

It should be emphasized once again that the premorbid background for the development of uterine fibroids at any age is a somatic mutation of cells, as a consequence of burdened heredity, previous somatic and gynecological diseases, as well as a violation of integrative relationships in the endocrine, immune, nervous and hemostatic systems.

Pathogenesis (what happens?) during uterine fibroids during pregnancy

Changes in myomatous nodes. The most common complications during pregnancy are secondary changes in myomatous nodes. Most often this concerns simple fibroids, which have few vessels, are located subperitoneally, sometimes on a thin stalk that can twist. Malnutrition of myomatous nodes can occur with a prolonged increase in uterine tone, excessive physical activity, increased blood pressure, edema during pregnancy. In this case, the outflow of venous blood is disrupted.

If there is a malnutrition of myomatous nodes during pregnancy, degenerative changes: red, hyaline and cystic.

Acute malnutrition in the tumor nodes causes red degeneration, which is expressed in many hemorrhages in the fibroid tissue. With the rapid growth of myomatous nodes, when the increase in their size outstrips the blood supply, hyaline degeneration occurs and cavities filled with hemorrhagic contents are formed.

Changes in the placental bed. The most pronounced disturbances in the physiological course of pregnancy are observed when the placenta is located in the projection of a large intermuscular myomatous node (“placenta on a node”).
The anatomical coincidence of the placental bed with a large intermuscular myomatous node causes a number of pathological changes in the uterus and placenta.
- The angioarchitecture of the vessels of the subplacental zone of the myometrium is disrupted. Spiral vessels become less convoluted and short. The number of anastomoses is reduced. Thrombosis and hemorrhages are observed in certain areas of the placental bed.
- In the presence of risk factors, placental hypoplasia often occurs, which is clinically manifested as placental insufficiency.

The following morphological changes in the placenta are observed:
- There is an increase in the volume of intervillous fibrinoid, a partial stop in the development of villi.
- Pathological immaturity and randomness of sclerotic villi predominate.
- Areas of pseudoinfarction with fibrinoid deposition are formed. Along with this, signs of compensatory reactions increase, angiomatosis of terminal villi increases, and the number of syncytial buds increases.

Significant changes occur in the subplacental zone (placental bed) of the uterus: complete gestational transformations of the uteroplacental arteries of the myometrial segments as a result of the second wave of cytotrophoblast invasion were noted in only 44% of the vessels. In 56%, only partial gestational restructuring of arterial vessels occurs. The degree of their severity depends on the size of the fibroids. The larger the node, the less pronounced the necessary gestational transformations of the uteroplacental arteries.

With centripetal growth of the myomatous node, thinning of the muscular membrane between the decidua and the fibroid is observed. True ingrowth of chorionic villi into the myometrium is possible.

It has been established that the most severe rheological disturbances in the placenta develop immediately before childbirth, when the tone and excitability of the uterus increase. In this regard, in pregnant women considered to be at high risk, the optimal time for delivery by cesarean section is 38-39 weeks of gestation.

Degrees of risk of complicated pregnancy and contraindications to preserving it in case of uterine fibroids

Initially, we will focus on risk factors, which are then summarized into a degree of low or high risk.
- Features of the anamnesis. Aggravated obstetric and gynecological history (infertility, induced pregnancy, birth of a sick or non-viable child).
- The presence of scars on the uterus after conservative myomectomy, cesarean section, conservative plastic surgery.
- Concomitant diseases and their characteristics (neuroendocrine, chronic inflammatory, vascular, varicose veins veins, including pelvic veins).
- Localization and location of myomatous nodes. Subperitoneal, intermuscular, centripetal growth, location in the fundus, body of the uterus or in the cervical-isthmus region, lower segment of the uterus.
- Dimensions of the largest myomatous node. Up to 4 cm in diameter, fibroids are classified as small, 5-6 cm - medium, 7-8 cm or more - large.
- The severity of myomatous changes in the uterus, which is determined by the number of myomatous nodes. The presence of 1-4 myomatous nodes refers to a moderate degree of severity, 5 fibroids or more - to a pronounced degree of myomatous changes in the uterus.
- Form of growth of uterine fibroids. The most unfavorable is centripetal growth of the tumor or the presence of a submucous myomatous node, deforming the uterine cavity, which relates to the risk of impaired fetal condition.
- The location of the placenta in relation to the large intermuscular myomatous node. Localization of the placenta in the projection of the intermuscular myomatous node is a risk factor for the development of placental insufficiency.
- The presence of secondary changes in the tumor nodes (edema, hyaline or red degeneration, necrosis), in which the tone of the uterus increases, microcirculation is disrupted, and venous outflow is obstructed. All this contributes to the threat of premature termination of pregnancy. The presence of pronounced myomatous changes in the uterus, the presence of large tumor sizes can cause fetal “stealing” syndrome, when a significant part of the blood is consumed to supply the uterine fibroids.
- Tumor histotype (simple and proliferating uterine fibroids).
- Age of the patient. In accordance with age-related general changes, in primiparous women 30-35 years old and older, processes of “myocyte aging” occur. Some of the so-called normal “average” myocytes, which are mature, have typical morphofunctional properties (the ability to stretch and contract), are replaced by more fragile and rigid myocytes of large sizes. Large myocytes are the final cells of muscle differentiation and are sensitive to damaging factors. They are not fully capable of adaptation (extension, contraction). These cells are inherent in the myometrium of women aged 40-50 years. If a woman has not had a pregnancy or childbirth before the age of 30-35, the uterus has not undergone changes due to the gestational process (it has not stretched or contracted), large myocytes appear earlier, at the age of 30-35, which indicates premature processes of “aging” of the uterus . Most often this is observed in “elderly” primiparous women, since the organization of the smooth muscle structure is determined primarily by the functional activity and contractile (motor) activity of the uterus. Obstetricians identify late age (30-35 years or more) in primiparous women as a risk factor functional disability uterus, in which frequent complications during childbirth are weakness of labor, uterine hypotension and other complications caused by decreased contractile activity of the uterus.
- Heredity for tumor diseases. Hereditary uterine fibroids occur in daughters 10-15 years earlier than in their mothers. Most often, such fibroids belong to the proliferating histotype. Pregnancy with simple uterine fibroids proceeds without any particular complications, since this variant of fibroid development is asymptomatic, calm and is characterized by the least number of disturbances in regulatory systems, including at the level of molecular biological cell-intercellular relationships.

It is recommended to continue pregnancy in patients with low-risk uterine fibroids. If there is a high risk of complicated pregnancy and childbirth, the issue of continuing pregnancy should be approached individually.

The following factors are taken into account:
- A woman’s persistent desire to have a child, when no doctor’s arguments about a certain degree of risk of pregnancy for the patient matter.
- Late admission under medical supervision after 22-24 weeks of pregnancy, when the fetus is viable.
- Prolonged infertility and unexpected onset of real pregnancy.
- Inability to terminate pregnancy through the natural birth canal, except for a minor cesarean section (cervical-isthmus location of the myomatous node, full presentation placenta, centripetal growth of low-lying fibroids, etc.).
- Extremely late reproductive age (39-42 years) of a primiparous patient with uterine fibroids. At late age a real pregnancy may be the only one in the patient’s life, which places a special responsibility on the doctor.

Contraindications to continuing pregnancy in patients with high-risk uterine fibroids are as follows.
- Suspicion of sarcoma, malignant tumor of any location.
- Submucosal localization of the myomatous node, disrupting the condition and growth of the fetus. Pregnancy with submucosal uterine fibroids can occur, but rarely persists.
- Necrosis of the myomatous node (spread inflammatory process throughout the uterus).
- Cervical-isthmus localization of a large myomatous node (organic ICN, real threat miscarriage, IUI of the fetus, bleeding).
- The presence of very large myomatous nodes (more than 15 cm in diameter), their low location and multiple numbers.
- Large size of the myomatous uterus: in the first trimester, the size of the uterus corresponds to its size at 20-22 weeks of pregnancy.
- Very late age of a primigravida (over 43-45 years old) in combination with high-risk factors.
- Poor health of the patient.

Symptoms of uterine fibroids during pregnancy

Heavy, prolonged menstruation.
- Pain or feeling of pressure in the lower abdomen, in the pelvic area.
- Pain in the lower abdomen, radiating to the area back surface legs
- Pain during sexual intercourse.
- Feeling of pressure on bladder. Frequent urination, urinary incontinence, or inability to empty the bladder.
- Intestinal dysfunction (constipation and/or flatulence).
- An increase in the size of the abdomen, which may be mistakenly attributed to weight gain or pregnancy.

Diagnosis of uterine fibroids during pregnancy

First of all, careful history taking. It is important to find out the possibility of hereditary uterine fibroids, which most often refers to the proliferating variant of development. Assess the number and outcome of previous pregnancies and births. Unfavorable history factors include: infertility, induced pregnancy, non-developing pregnancy, birth of a sick child, stillbirth, and premature termination of pregnancy.

During a general clinical examination, one should evaluate the general state of health, signs of neuroendocrine and inflammatory diseases, including the urinary system (pyelonephritis, colpitis).

At abdominal-vaginal and rectal examination it is necessary to clarify the size, location and size of myomatous nodes, including low-lying ones, in which ICI may occur (risk of premature termination of pregnancy and infection of the fetus).

A mandatory research method is Ultrasound, allowing you to detect:
- number of myomatous nodes;
- their localization (including along the posterior wall of the uterus);
- nature and direction of growth (intermuscular, subperitoneal, submucosal, centripetal growth, deforming the uterine cavity);
- dimensions (by largest diameter in centimeters);
- structure (dense knot, softening, indicating the presence of cavities).
- location of the placenta in relation to intermuscular myomatous nodes.

Sonographic examination in the first trimester allows you to timely detect pregnancy, clarify its duration, correspondence of the size of the embryo (fetus) to gestational age, detect multiple pregnancies, determine the site of implantation of the fertilized egg and the localization of the villous chorion, examine the ultrasound anatomy of the fetus, detect signs of a complicated pregnancy (chorionic detachment, local hypertonicity uterus, expansion of the internal os). All this must be assessed at the first ultrasound.

Ultrasound is performed using transabdominal and transvaginal methods.

The presence and frequency of fetal cardiac activity should be assessed (normal fetal heart rate is 110-130 beats/min). A decrease in fetal heart rate is an unfavorable sign indicating a violation of its development.

It is important to timely diagnose birth defects and hereditary diseases of the fetus, which, according to us, occur 2 times more often in patients with uterine fibroids than in the general population. The cause is mutations of somatic cells as a consequence of many previous and concomitant diseases, so characteristic of patients with uterine fibroids, late age of primiparous women, as well as so-called random mutations.

For this purpose, assessment of the width of the collar zone and biochemical screening (AFP, hCG, unconjugated E3) are used.

The most effective markers of Down syndrome in the first trimester are PAPP-A and the free fraction of β-CG. The optimal period for biochemical screening is 12-14 weeks of pregnancy.

During pregnancy, three mandatory ultrasounds are performed:
- at 10-14 weeks;
- at 20-24 weeks;
- at 32-34 weeks.

The purpose of the second screening ultrasound is to diagnose fetal development disorders (20-24 weeks of pregnancy), which includes assessment of the anatomy of the fetus, visualization of its internal organs, and the state of the BMD. The second wave of cytotrophoblast invasion ends by 16-18 weeks, when a vascular uteroplacental network with low-resistant blood flow is formed. Delay or failure of the second wave of trophoblast invasion causes decreased blood flow in the uteroplacental arteries (one or both sides).

The consequence of disruption of these processes is placental insufficiency.

Thus, at 20-24 weeks it is necessary to study the spectrum of blood flow in the uterine arteries. The sensitivity of the method does not exceed 25-30%, but the specificity is high - 94-96%.

The third ultrasound at 32-34 weeks allows to identify intrauterine fetal malformations with late manifestation (anomalies urinary tract, gastrointestinal tract, skeletal dysplasia).

From 32 weeks, CTG monitoring of the fetal condition is performed.

It should be emphasized that the presented biochemical and ultrasound parameters indicate only the risk of chromosomal abnormalities and the possibility of intrauterine malformations of the fetus.

Placenta examination includes an assessment of its location, thickness, structure and degree of maturity. Ultrasonic stages of maturation:
O stage - detected in pregnancy up to 30 weeks;
Stage I - 31-34 weeks (options 27-26 weeks);
Stage II - 35-37 weeks (options 34-39 weeks);
Stage III - 38-40 weeks (after 37 weeks, i.e. with full-term pregnancy).

The discrepancy between the degree of maturity of the placenta and the gestational age does not in all cases indicate a violation of its function, but requires a more thorough assessment of the condition of the fetus.

Treatment of uterine fibroids during pregnancy

Treatment of patients with uterine fibroids depends on the manifestation of a number of specific and nonspecific complications characteristic of uterine fibroids.

The first, specific complications are as follows.
- Malnutrition and secondary changes in the myomatous nodes, as well as necrosis of the myomatous node, which is extremely rare when the pedicle of the subperitoneal myoma is twisted (more often typical for simple fibroids).
- Isthmic-cervical insufficiency, which occurs with cervical-isthmus myomatous nodes that prevent the closure of the cervix.
- A rapid increase in the size of fibroids, the formation of a conglomerate of myomatous nodes, which is characteristic of a proliferating variant of tumor development.
- Fetoplacental insufficiency as a consequence of the location of the placenta in the projection of a large intermuscular myomatous node, with centripetal growth of fibroids or in the presence of a conglomerate of fibroids.
- Thrombosis of the pelvic veins due to compression by large myomatous nodes.
- Rupture of the uterus along the scar after myomectomy (performed laparoscopically). IN in this case We are talking about the removal of several nodes, a conglomerate of nodes, as well as situations when diathermocoagulation is used for hemostasis.

Nonspecific complications that often accompany uterine fibroids are:
- premature termination of pregnancy (miscarriage, premature birth);
- low placentation;
- premature placental abruption;
- tight attachment and true ingrowth of chorionic villi;
- gestosis;
- chronic anemia.

Let's look at some of the complications that occur most often.

- Premature termination of pregnancy
The frequency of threatened miscarriage in patients with uterine fibroids in the first half of pregnancy is 42-58%. It is especially pronounced in patients with high risk, as well as in proliferating tumor development. The risk of premature birth is 12-25%.

If there is a threat of premature termination of pregnancy in patients with uterine fibroids, the same drugs are used as in patients without fibroids. It is necessary, if possible, to find out the cause of this complication. On the part of uterine fibroids, this may be increased myometrial tone as a result of malnutrition of one of the nodes, a rapid increase in the size of fibroids, low placentation, partial chorionic detachment in patients at high risk, insufficiency of progesterone production - the main hormone that maintains pregnancy.

In all these cases, with preventive and therapeutic purpose it is necessary to prescribe drugs with antispasmodic, antiplatelet and metabolic effects. These include:
- Magne B6: prescribe 2 tablets 2-3 times a day for 3-4 weeks;
- chimes: 25 mg 2 times a day - 4 weeks;
- Actovegin: 1 tablet 2 times a day - 10-14 days.

For hormonal insufficiency (progesterone deficiency), duphaston 30 mg/day and tocopherol acetate 150 mg/day are used during clinical signs of threatened miscarriage.

Maintaining the pregnancy “at all costs” is hardly justified. The concept of “happy motherhood” lies, first of all, in having a healthy, full-fledged child. Pregnant women with large uterine fibroids, centripetal growth and low location of tumor nodes have risk factors for normal development pregnancy, therefore it is important to prevent iatrogenic complications. It is important to maintain a gentle bed or semi-bed rest and avoid sexual and physical activity. Staying in a warm bed improves uteroplacental and renal blood flow to a certain extent, even without medications.

- Isthmic-cervical insufficiency
In case of ICI caused by low location of myomatous nodes, suturing the cervix is ​​not recommended due to the risk of necrosis of myomas. Treatment is carried out according to the generally accepted method:
- bed rest;
- tocolytic drugs: ginipral 1/4 tablet 4-6 times a day (1 tablet contains 0.5 mg of the substance) or intravenous drip at a dose of 0.075 mcg/min. Dosage calculation: 1 ampoule of ginipral (5 ml - 25 mcg) is diluted in 500 ml of isotonic sodium chloride solution or 5% glucose solution and administered at a rate of 15 drops/min. The drug is administered using an automatic infusion pump. Before administering ginipral, it is necessary to do an ECG, and during treatment, monitor the mother’s pulse and the fetus’s heartbeat.

To prevent tachycardia, finoptin, a calcium ion blocker, is prescribed at the same time, 40 mg 2-3 times a day.

- Rapid growth of myomatous nodes
With a rapid increase in myomatous nodes, it is necessary to prescribe antiplatelet drugs that improve uterine microcirculation (Curantil, Actovegin).

In the presence of large myomatous nodes or a conglomerate of nodes, multiple myomatous changes in the uterus, the phenomenon of “stealing the fetus” may occur. The formation of additional vessels feeding rapidly growing myomatous nodes is sometimes insufficient. A reduction in the volume of arterial blood flowing from the mouths of the uteroplacental arteries into the intervillous space of the placenta is formed.

To improve BMD and myometrial microcirculation in these difficult cases, hospitalization and infusion therapy are necessary. The drugs used must have a targeted effect:
- reduction of uterine hypertonicity (spasmolytics and tocolytics);
- elimination of hypovolemia and hypoproteinemia (introduction of fresh frozen plasma, glucose solutions with vitamins);
- optimization of metabolic and metabolic processes (hepatoprotectors and membrane stabilizers).

- Placental insufficiency
Placental insufficiency is primarily a decrease in blood supply to the placenta and blood flow in the intervillous space, spiral vessels of the uterus and umbilical cord. The functional reserves of the placenta, its hormonal and metabolic functions are reduced, and the selective selectivity of the placental barrier is disrupted.

Prevention of placental insufficiency is carried out from 14-16 weeks of pregnancy in the group of patients with uterine fibroids at high risk. If the risk is low, use any medications without specific justification is undesirable.

For prevention in high-risk groups, the following drugs are prescribed.
- Acetylsalicylic acid 50 mg 1 time per day from the 16th to the 37th week of pregnancy.
- Dipyridamole (chimes) 25 mg 2 times after meals. This drug should be used with caution, as individual intolerance is possible in case of cardiopathy, bronchopulmonary diseases, and arterial hypotension.
- If necessary (malnutrition, chronic gastritis), additionally prescribe multivitamins with microelements for pregnant women: tocopherol acetate (vitamin E) 100-300 mg/day; vitamin C 3 ml of 5% solution 3 times ( daily dose no more than 1 g); folic acid 4 mg/day (0.001 g tablets 3-4 times).

Treatment of placental insufficiency:
-. Hospitalization. In-depth examination of the condition of the mother and fetus. Assessment of the condition of myomatous nodes (exclude node necrosis!).
- Infusion therapy: rheopolyglucin at a dose of 5 mg/kg intravenously 1-2 times a week No. 2-3; fresh frozen plasma 100-150 ml 1-2 times a week under the control of the hemostasis system, protein content in the blood plasma. Prescribed for hypoproteinemia; pentoxifylline (trental) 0.1 g (2% solution - 5.0 ml), diluted in 200-400 ml of 0.9% sodium chloride solution; Actovegin solution 5.0 ml or carnitine chloride 1% solution 5 ml in 200 ml isotonic sodium chloride solution, intravenously every other day 3 times. The above drugs are administered 2-3 times a week, combining or alternating them with each other; aminophylline 2.4% solution 5.0 ml in 200 ml 5% glucose solution 2-3 times a week intravenously. It is advisable to use suppositories with aminophylline (0.15 g) rectally at night. After 2-3 weeks of treatment, they switch to taking medications orally: Magne B6, 2 tablets (1 tablet contains 470 mg of magnesium lactate and 5 mg of pyridoxine hydrochloride) per day; chimes 25 mg 2-3 times a day; Actovegin 1 tablet 2 times a day. The course of treatment is 3-4 weeks.

It is very important to prevent fetal hypoxia. It has now been revealed that hypoxia, even short-term, can lead to disruption of the development of the fetal brain (delayed maturation of neurons, focal damage such as focal cellular devastation, inhibition of the biosynthesis of neurospecific proteins, metabolic changes).

During ultrasound, attention should be paid to the tone, movement, and behavioral reactions of the fetus, because the centripetal nodes of the tumor can affect the neurological status of the fetus.

In the presence of large myomatous nodes, deformation of the uterine cavity, and oligohydramnios, fetal movements may be limited, which may have adverse consequences for the development of the child.

By 38 weeks of intrauterine ontogenesis, all organs and regulatory systems are practically formed and actively functioning in the fetus. In the placenta, from this period the physiological reduction of chorionic villi begins (physiological involution of the placenta).

By the end of pregnancy, the placental-fetal coefficient, reflecting the ratio of the amount of placental mass to a unit of fetal mass, decreases by more than 70 times (from 9.3 at 8 weeks to 0.13 at 40 weeks).

The differences between the physiological involution of the placenta (38-41 weeks of pregnancy) and the aging of the placenta are:
- satisfactory condition of the fetus and normal biophysical characteristics; fetal heart rate within 120-130 beats/min;
- normal utero-placental-fetal blood flow;
- preservation of the proliferative potential of the trophoblast (presence of individual cambial Langhans cells and immature intermediate villi).

With aging of the placenta, a decrease in BMD occurs (obliteration of stem villi, opening of arteriovenous shunts, a decrease in the number of functioning capillaries in the terminal chorionic villi), signs of fetal hypoxia appear and intensify, and the amount of amniotic fluid decreases.

In patients with uterine fibroids, who are at high risk, the processes of premature aging, and not just physiological involution of the placenta, begin from 37 weeks. Therefore, it is advisable to carry out delivery by cesarean section at 38-39 weeks of pregnancy, which to a certain extent helps to avoid fetal hypoxia. Calcareous deposits, microthrombosis and microhemorrhages are often found in the placenta. Further growth of the fetus is limited by rationally reducing blood flow through the uterine arteries and in the intervillous space of the placenta.

Many factors that affect the developing fetal brain can delay brain maturation. In the future, this can cause disruption of the child’s neuropsychic development. These factors primarily include hypoxia as a consequence of insufficient blood supply to the fetus in patients with uterine fibroids who are at high risk. Acidosis, accumulation of cytotoxic amino acids and free radicals are also damaging factors. Increasing anaerobic glycolysis leads to the accumulation of lactic acid in the blood and brain tissue of the fetus, which is most unfavorable for the child’s health.

- Malnutrition in myomatous nodes
The clinical picture is very characteristic. Pain syndrome appears (at rest or upon palpation). Painful sensations can vary in location, intensity and nature (aching, constant, periodic). Signs of peritoneal irritation, increased heart rate, increased body temperature, leukocytosis, and a noticeable increase in tumor size (nodal edema) may be observed. The general condition of the woman changes. Symptoms of threatening miscarriage appear.

The nature and irradiation of pain depend on the location of the tumor. When the nodes are located on the anterior wall of the uterus, the pain is local in nature or radiates to the lower abdomen; when located on the posterior wall of the uterus and inaccessibility to palpation, pain of a different, unclear nature occurs in the sacrum and lower back.

Differential diagnosis must be carried out with acute appendicitis. With appendicitis, an increase in pulse rate (100-120 beats/min) does not correspond to body temperature, which may be slightly elevated (37.1 °C) or even normal. Also differentiated from acute pyelonephritis, which is characterized by severe intoxication, clinical and bacteriological signs of urinary infection.

Treatment of malnutrition of uterine fibroid nodes is carried out with antispasmodic drugs in combination with antibacterial, detoxifying and desensitizing agents. Treatment is monitored taking into account clinical symptoms, thermometry data (every 3 hours), general blood test over time.

If there is no effect from the therapy within 3-5 days, an increase in pain symptom and intoxication, surgical treatment is indicated - enucleation of the node.

Basically, only subperitoneal nodes are subject to removal. An attempt to enucleate intermuscular nodes during pregnancy is accompanied by a high risk of its interruption.

Indications for removal of the uterus during pregnancy are: necrosis of the node, peritonitis, suspicion of malignant degeneration of uterine fibroids, entrapment of the uterus in the pelvis, rupture of the capsule of the node, as well as the presence of contraindications to maintaining pregnancy.

Necrosis of the myomatous node is accompanied by a clinical picture of an “acute” abdomen and intoxication: acute local pain, nausea, vomiting, tension in the anterior abdominal wall, increased body temperature, malaise, and sometimes there may be retention of urination and stool.

If there is a malnutrition of the myomatous node, it is necessary to eliminate the hypertonicity of the uterus (prescription of tocolytic and antispasmodic drugs). Antibacterial and detoxification therapy should be carried out. In a few days Clinical signs this pathology gradually disappears. Need for surgical treatment rarely occurs. In case of necrosis of the myomatous node (as a rule, this is a torsion of the pedicle of the subperitoneal tumor node), myomectomy is indicated. You should avoid the temptation to remove other myomatous nodes, since if the scope of the operation is expanded, termination of pregnancy is highly likely.

It is interesting to note that myomatous nodes during pregnancy can change localization. As the volume of the uterine cavity increases, the layers of the myometrium shift relative to each other, the lower segment stretches, and the uterus naturally rotates to the right. The tumor nodes seem to move relative to the axis of the uterus to the side, up, or, conversely, towards the center. This depends on the displacement of the myometrial layer (outer, middle, inner) in which the fibroid is located. Intermuscular nodes may become more subperitoneal or take a centripetal direction, causing deformation of the uterine cavity.

Cervical and cervical-isthmus myomatous nodes can lead to severe complications. As the uterus grows and increases in size during pregnancy, strangulation may occur. large fibroids in the small pelvis. Prolonged pressure of the tumor on the walls of the pelvis can cause thrombosis of the pelvic veins and cause thrombotic complications.

- Myomectomy during pregnancy
Myomectomy during pregnancy is a very unsafe operation due to the real possibility of termination of pregnancy. It is performed only in case of torsion of the leg of the subperitoneal node and the phenomena of “acute abdomen”. Very rarely, a rupture of a vessel on the surface of one of the fibroid nodes is possible with symptoms of acute intra-abdominal bleeding.

The surgical technology of conservative myomectomy during pregnancy differs significantly from that performed outside of pregnancy. This is due to the need to comply with the following conditions for the operation.
- Minimal invasiveness of the operation (longitudinal incision of the anterior abdominal wall).
- Selection of a rational incision on the uterus, in accordance with the direction of the smooth muscle bundles of the uterus at a certain localization of the myomatous node.
- Good suture material, having minimal allergenicity and strength.
- Careful comparison of the myometrial surface of the removed myomatous node and reliable hemostasis.
- Peritonization of the myomectomy site. After the operation, for 3-5 days, patients undergo infusion-transfusion therapy, including plasma-substituting, crystalloid solutions and agents that improve microcirculation and tissue regeneration. For the purpose of prevention infectious complications a course of antibiotics is prescribed. Also used are drugs aimed at prolonging pregnancy: antispasmodics, tocolytics, magnesium sulfate.

The absolute indication for myomectomy during pregnancy is only node necrosis (fever, tachycardia, local pain, nausea, vomiting, increasing leukocytosis, increased ESR.

According to our data, the rapid growth of a myomatous node during pregnancy is not an indication for myomectomy, including large fibroids (more than 10 cm in diameter).

- Management of childbirth and the postpartum period in patients with uterine fibroids
Pregnant women with uterine fibroids should be hospitalized at 37-38 weeks for examination, preparation for childbirth and selection of a rational method of delivery.

Due to the fact that the presence of myomatous nodes on the posterior wall of the uterus and their centripetal growth may not be recognized in a timely manner, surgical delivery is not excluded in every patient with this pathology.

Features of the management of childbirth through the natural birth canal in patients with uterine fibroids who are at low risk are the following:
- The use of antispasmodic drugs during the active phase of the first stage of labor (opening of the uterine pharynx 5-8 cm).
- Limit the use of labor stimulation with oxytocin. If it is necessary to enhance labor, it is advisable to prescribe prostaglandin E2 drugs (Prostin E2), which have an optimal effect on the myomatous uterus and do not disrupt the microcirculation of the myometrium and the hemostasis system.
- Prophylaxis of fetal hypoxia during childbirth.
- Prevention of bleeding in the afterbirth and early postpartum periods with the help of methylergometrine. To do this, 1.0 ml of methylergometrine is diluted in 20.0 ml of 40% glucose solution and administered simultaneously intravenously immediately after the birth of the placenta.

Indications for elective caesarean section are:
- Low-lying myomatous nodes (cervix, isthmus, lower segment of the uterus), which can be an obstacle to the dilation of the cervix and the advancement of the fetus.
- The presence of multiple intermuscular nodes or large fibroids(diameter 10 cm or more).
- A scar on the uterus after myomectomy, the consistency of which is difficult to assess. This is due to the fact that, firstly, a whole conglomerate of nodes is often removed, and secondly, diathermocoagulation is used for hemostasis. This is especially true for myomectomy using laparoscopic access. All these features are rarely reflected in the discharge summary after myomectomy.
- Malnutrition, leading to secondary changes in tumor nodes, which after delivery through the vaginal birth canal can undergo necrotic changes. In this case, necrotic inflammatory and dystrophic changes spread to unchanged areas of the uterus (metritis).
- Breech presentation of the fetus, which may be a consequence of a myomatous node with centripetal growth.
- Suspicion of malignancy or necrosis of fibroids (rapid growth, large size, soft consistency, local pain, anemia).
- The combination of uterine fibroids with other diseases and complications of pregnancy that worsen the prognosis for the mother and fetus (ovarian tumor, endometriosis, late age of the woman, data indicating a proliferating variant of the fibroid morphotype, placental insufficiency).

Indications for myomectomy during cesarean section:
- Subperitoneal nodes on a leg (all must be removed in any accessible place).
- Dominant intermuscular myomatous node of medium and large size. You can delete no more than one or two nodes. Synthetic threads are used to suture the myomectomy site. Careful hemostasis is necessary, especially at the site where the node is cut off, where the vessels always change.
- Single nodes.
- Secondary changes in one of the nodes.

Myomectomy is not advisable in cases of multiple myomatous changes in the uterus, or in cases of late age of the woman in labor (39-40 years or more).

Indications for subsequent removal of the uterus during cesarean section:
- Multiple uterine fibroids with various options location of myomatous nodes in women of late reproductive age (39-40 years or more).
- Necrosis of the intermuscular node.
- Relapse (further growth of myomatous nodes) after a previously performed myomectomy (most often this is a proliferating variant of the tumor).
- Location of myomatous nodes in the area of ​​vascular bundles, the lower segment of the uterus, interligamentous localization, centripetal growth and submucosal nodes.

In case of low location of fibroids emanating from the lower segment, isthmus, cervix, with malignancy (established by urgent histological examination), hysterectomy is necessary.

In the postpartum period, patients with uterine fibroids should be prescribed antispasmodic drugs. If there are signs of subinvolution, oxytocin is prescribed 0.5-1.0 ml 2-3 times a day along with 2-4 ml of no-shpa intramuscularly.

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