1. In the name of GOD

2. Myoma in pregnancy Sedigheh Borna,MD perinatologist
Medical university of Tehran
Vali_asr Hospital
Obstetrics/Gynecology Department

3. کدام میوم ها باید قبل بارداری جراحی شوند؟
آیا زنان دارای میوم می توانند باردار شوند؟
اثر بارداری بر فیبروم
کدام میوم ها باید قبل بارداری جراحی شوند؟

4. Myomas are the most frequently recorded benign smooth muscle tumor of the uterus, affecting 20%–60% of women of reproductive age and may negatively affect fertility and outcome of pregnancy
As most fibroids are asymptomatic, the true prevalence of fibroids may be greatly higher
The incidence of fibroids in pregnancy reported ranges from 0.1 to 10.7% of all pregnancies and increases as the female chooses to postpone pregnancy later on
It was found that 10%–40% of prepartum complications which happened in pregnancy with fibroid have been associated with the presence of it

5. EFFECTS OF PREGNANCY ON FIBROID
Changes in size – increases
Fibroid is an estrogen dependant tumor. Increased vascularity , Edema , Hypertrophy and hyperplasia of the fibromuscular tissues.
Pregnancy is a progesterone predominant state.
Actually, most fibroids do not increase in size during pregnancy.
69% - had no increase in fibroid volume throughout pregnancy
31% - noted increase in fibroid volume, greatest increase before 10th week of gestation and a reduction to baseline value 4 weeks after delivery
Larger fibroids (>5cm) more likely to grow Smaller fibroids More likely to remain stable. The mean increase in fibroid volume during pregnancy 
12% very few fibroids increase by >25%.
Changes in position
Changes in shape - becomes flattened
Degenerative changes specially, red degeneration
Torsion of pedunculated subserous fibroid %
Infection and polypoidal changes are more in puerperium.

6. Treatment: ACOG
Certain signs and symptoms may signal the need for treatment:
Heavy or painful menstrual periods that cause anemia or that disrupt a woman’s normal activities
Bleeding between periods
Uncertainty whether the growth is a fibroid or another type of tumor, such as an ovarian tumor
Rapid increase in growth of the fibroid
Infertility
Pelvic pain

7. Management of uterine fibroids should be tailored to and location of fibroids;
the patient's age, symptoms,
desire to preserve fertility,
and access to therapy;
and the physician's experience.

10. Medical therapy
Most medical therapies for uterine leiomyomas preclude conception, cause adverse effects when employed long-term, and result in rapid symptom rebound when discontinued.
Therefore, medical treatment of leiomyomas in infertile patients attempting to become pregnant is usually unsuccessful
One medical treatment of uterine leiomyoma is a selective progesterone modulator, ulipristal.
It is associated with rapid decrease in uterine bleeding, slight reduction in myoma size, and minimal menopausal symptoms .
If needed ,ulipristal can be administered for another three months after two menstrual periods.
use 5 mg orally per day for three months, and the longest treatment has been four courses.

11. Miscellaneous techniques
Myoma coagulation or myolysis is associated with adhesion formation and may increase the risk of uterine rupture in pregnancy.
The efficacy and safety of other procedures, especially in young women who wish to conceive, have not been proven.
These techniques include occlusion of uterine vessels either via laparoscopy or a vaginally-placed clamp, High intensity focused ultrasound (HIFU), cryomyolysis, radiofrequency ablation, and magnetic resonance imaging-directed
cryotherapy

12. Myomectomy versus embolization
We prefer myomectomy over uterine artery embolization (UAE) for treatment of most women with uterine leiomyomas who wish to conceive
However, we suggest UAE in women at high surgical risk, such as those with previous multiple laparotomies or diffuse uterine leiomyomas where myomectomy might not be technically feasible
We generally avoid UAE in women who wish to conceive because the safety of the procedure with respect to
subsequent pregnancy outcome has not been established.

13. MANAGEMENT BEFORE PREGNANCY
Indications for preconception myomectomy
Made on a case-by-case basis
Age
Reproductive history
Severity of symptoms
Size
Site.
No good data that preconception myomectomy will improve pregnancy success or the take-home baby

14. What types of surgery may be done to treat fibroids?
Treatment should be efficient with the maximum efficacy and the minimum risk and cost.
it is not necessary to emphasize that asymptomatic UFs do not require treatment regardless of their size.
However, the bigger the size, the more probable it is that they cause symptomatology.

17. . Myomectomy can be considered in selected patients with a history of obstetrical complications that appear related to the presence of leiomyomas.
Prior to pregnancy, myomectomy can be considered in women with unexplained infertility or recurrent pregnancy loss, although whether such surgical interventions actually improve fertility rates and perinatal outcome remains unclear.
In general, perform myomectomy before pregnancy if it is symptomatic.

18. PRECONCEPTIONAL PLANNING
women with leiomyomas not postpone pregnancy for a prolonged period of time, if possible.
Our rationale is that fertility naturally declines with age, especially after age 35 years, and
leiomyomas may impair fertility and adversely affect pregnancy outcome

19. INFERTILITY AND MISCARRIAGE
Leiomyomas are estimated to account for 1 to 2 percent of infertility .
Fibroids, particularly those that impinge upon the endometrium, may affect fertility by interfering with implantation over the
myoma site, rapidly distending the uterus in early pregnancy, or impairing uterine contractility .

20. INFERTILITY AND MISCARRIAGE
The location of a fibroid, and not its size, is the key factor regarding fertility.
Leiomyomas that distort the uterine cavity (submucosal or intramural with an intracavitary component) result in difficulty conceiving a pregnancy and an increased risk of miscarriage .
In contrast, subserosal fibroids do not impact fertility. The role of intramural fibroids in infertility is controversial .
Couples should complete a full infertility evaluation before addressing the role of leiomyomas in their infertility

21. Preparing for in vitro fertilization
The effect of leiomyomas on IVF is dependent upon their location:
submucosal myomas decrease the chance of success, whereas subserosal myomas do not appear to have any effect.
Observational data suggest that intramural myomas may also have a negative impact on IVF outcomes

22. Preconception/Prenatal counseling:
the risks of obstetrical complications are increased with the presence of fibroids in pregnancy, but neither size or location adequately predict additional adverse outcomes.
Most fibroid growth occurs in the first trimester. Throughout pregnancy approximately 60% of fibroids will increase or decrease by greater than 10% of their original size.