home Audience 12 Caesarean section for uterine fibroids. Fibroids and pregnancy - all the nuances of childbirth and pregnancy

Caesarean section for uterine fibroids. Fibroids and pregnancy - all the nuances of childbirth and pregnancy

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. Therefore, in the hospital, an additional in-depth examination of the pregnant woman and the fetus is carried out, including an assessment of the hemostatic system, ECG data, the state of the uteroplacental-fetal blood flow, the position and presentation of the fetus, the proportionality of the fetal head and the mother’s pelvis, the state of cervical maturity and other indicators.

Uterine fibroids and pregnancy - preparation for childbirth

All risk factors for uterine fibroids (high - low) are also taken into account. As a rule, in patients with uterine fibroids who are at low risk, childbirth is carried out through the vaginal birth canal. In patients with high-risk factors, delivery by cesarean section is preferable, taking into account that there may be a single pregnancy.

As prenatal preparation, antispasmodic drugs are prescribed (in suppositories, tablets, intramuscularly, intravenously), since increased tone, excitability and contractile activity in the preparatory period can disrupt the nutrition of myomatous nodes, cause their swelling and hemorrhage.

It is also necessary to prepare the fetus for the stress of childbirth. For this purpose, 3-4 intravenous infusions of Actovegin are performed (20-50 ml of Actovegin are diluted in 300-500 ml of 5% glucose solution or 0.9% sodium chloride solution). A replacement for Actovegin is a solution domestic drug Carnitine chloride has the same effect.

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 necessary, reinforcement labor activity 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.

7. 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 women, data indicating a proliferating variant of the fibroid morphotype, placental insufficiency).

Indications for myomectomy during cesarean section:

1. Subperitoneal nodes on a leg (all must be removed in any accessible place).

2. Dominant intermuscular myomatous node of the middle and large sizes. 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 of cutting off the node, where the vessels always change.

3. Single nodes.

4. 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).

Despite the apparent simplicity of execution, myomectomy can be accompanied by severe complications. Firstly, the intermuscular myomatous node is well vascularized during pregnancy and myomectomy may be accompanied by bleeding and difficulty in hemostasis (the use of diathermocoagulation is undesirable). Secondly, when large fibroids are removed, deep cavities remain. Bleeding vessels can go deep into the myometrium, and after some time, bleeding in the tumor bed can resume. Therefore, it is very important to carefully ligate the vessels before removing the lower pole of the tumor, align the edges of the wound and close it with an 8-shaped or double-row suture. Peritonization should be performed using continuous or U-shaped sutures, covering the incision line with a piece of omentum or biofilm.

After myomectomy, it is advisable to drain the abdominal cavity. Antibiotics must be used in the postoperative period wide range actions. When two or three large nodes are removed, the uterus contracts poorly, and inflammatory complications often occur, requiring the prescription of two antibiotics, detoxifying agents, drugs that contract the uterus, in combination with antispasmodics (oxytocin, no-spa). On the 3-5th day, ultrasound control is required.

Indications for subsequent removal of the uterus during cesarean section:

1. Multiple uterine fibroids with different locations of myomatous nodes in women of late reproductive age (39-40 years or more).

2. Necrosis of the intermuscular node.

3. Relapse (further growth of myomatous nodes) after a previously performed myomectomy (most often this is a proliferating variant of the tumor).

4. Location of myomatous nodes in the area of vascular bundles, the lower segment of the uterus, interligamentous localization, centripetal growth and submucosal nodes.

With low location of fibroids emanating from the lower segment, isthmus, cervix, with malignancy (established during 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.

After myomectomy and complicated cesarean section, broad-spectrum antibiotics are used. Combinations of drugs with aerobic and anaerobic effects are used (cephalosporins + metronidazole, aminoglycosides + clindamycin, gentamicin + lincomycin).

Uterine fibroids and second pregnancy

Long-term results of monitoring women who have given birth indicate that the majority of those examined for 5-8 years do not experience further growth of uterine fibroids. Keeping it natural breastfeeding at least 6 months stabilizes the tumor size. The growth of nodes is observed in 10-15% in cases of failure various reasons from maintaining lactation, using hormonal drugs for the purpose of contraception or if there was an artificial termination of pregnancy by curettage of the uterus.

A differentiated approach to recommending continuation of pregnancy, management of pregnancy and childbirth in accordance with the degree of risk, conducting pathogenetically based prevention and treatment help reduce the frequency of complications and improve outcomes for the mother and fetus. Myomectomies should not be performed during pregnancy without strict and justified indications. If fibroids grow even to gigantic sizes, pregnancy can be maintained, while surgical removal large nodes almost always leads to premature termination of pregnancy and death of a non-viable fetus.

During cesarean section in patients with multiple nodes, large fibroids, a history of uterine scar after conservative myomectomy, either a longitudinal or transverse incision of the anterior abdominal wall, but good access to myomatous nodes is necessary, the possibility of their removal without violating the integrity of the wall (pseudocapsule), when the contents (necrotic masses) can penetrate into the abdominal cavity. The fetus should also be removed from the uterus freely and without obstacles, which may not be easy due to large fibroids located near the incision. Cosmetic problems in difficult cases should be of secondary importance, since a patient with uterine fibroids may have only one pregnancy. In all cases, the newborn must be born without birth trauma. The optimal outcome of pregnancy is birth healthy child, preservation reproductive organ - uterus - with the possibility subsequent treatment.

Uterine fibroids and its effect on pregnancy

Pregnancy affects fibroids positive action. First, the woman's body long time saturated with hormones, the ratio of which is most favorable for hormone-dependent organs and tissues, including the vascular system. Secondly, the changes that occur during pregnancy in the uterus (gradual stretching of smooth muscle bundles, natural processes hypertrophy, hyperplasia, increased blood supply and microcirculation), normalize the structure of the myometrium, its functional activity, and prevent the processes of premature “aging” of myocytes.

Prevention of further growth of fibroids consists in maintaining breastfeeding of the child, re-occurrence of pregnancy and childbirth after 2-3 years, healthy life, prevention of somatic and gynecological diseases.

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Questions and answers on: removal of fibroids by caesarean section

2008-03-04 17:01:55

Vladimir asks:

My wife is pregnant. At 8 weeks, an ultrasound revealed three fibroids. different sizes. They didn’t say anything about the type of fibroids then. At the 11th week, when undergoing an ultrasound to check for Down syndrome, the doctor discovered that there were five fibroids, not three. The most large fibroid 5x8cm, the smallest 2x3cm. Two fibroids are subserous, three are interstitial. After the second ultrasound, the doctor said that at the 18th week (4.5 months), after the fetus starts to beat, surgery is needed to remove fibroids. Questions: could two more fibroids of size 2x3cm and 5x6cm have grown in three weeks or were they simply not noticed at the first ultrasound, how is the operation to remove fibroids performed, what kind of rehabilitation does the wife need after this operation, how dangerous is this operation for the fetus? Is it possible to carry a fetus to term for up to 9 months and remove fibroids by caesarean section? How dangerous general anesthesia for the fetus in case of cesarean section and subsequent surgery to remove fibroids. I would be grateful for any recommendations on maintaining my wife’s health.

Answers Pivovarova Tatyana Pavlovna:

Indeed, all myomatous nodes might not have been seen. If now the wife is not in danger premature birth, she is not in the hospital, then it will be possible to observe the nodes, but if not, then we need to operate. The anesthesia for a caesarean section is very short, just to quickly deliver the fetus, so you don't have to worry about it.

2016-03-27 21:27:44

Natalya 75 asks:

Good afternoon? I am 41 years old. In 1989 - removal of the left uterine appendages - Grubopapillary cystoma.
The myomatous node was first discovered in 1999. during a caesarean section. Menstruation is very heavy and very painful. I am worried about pain in the lower abdomen between periods, sometimes quite severe.
Ultrasound result on the 17th day of MC: The body of the uterus is 70*57*81 mm, in anteflexion, shifted to the right. The contours are smooth, clear. The shape is irregular. The cervix is 25 mm long, with endocervical cysts up to 3 mm in diameter.
The myometrium is of a diffusely heterogeneous structure, in the area of the uterine fundus there is an intramural-subserosal node, 18 mm long; along the posterior column of the uterus in the lower third there is an intramural-subserous node, 30 mm long, of heterogeneous structure, along the left lateral column. uterus intramural-subserous node measuring 63*46 mm (consists of several nodes), heterogeneous structure, with EDC with the presence of blood flow, with the presence of anechoic inclusions, largest size: 10*8 mm - hyalinosis?
The endometrium is 14.0 mm, of heterogeneous structure, the uterine cavity is somewhat deformed.
The left ovary was surgically removed. The right ovary at the rib of the uterus measures 40*31 mm, with a fluid inclusion measuring 29*20 mm. There is no free fluid in the retrouterine space.
Conclusion: uterine fibroids. Endometrial hyperplasia. Ultrasound signs of adhesions in the pelvis.
I tested Tumor marker CA 125 - 85.1 U/ml when the norm is less than 35.
Please tell me what would be more effective in my situation: UAE or myomectamia? And what is the probability of saving the uterus with abdominal surgery? What is the probability of saving the ovary? What does this tumor marker result mean?

Answers Gerevich Yuri Iosifovich:

Good afternoon, CA-125 nonspecific marcur (not only ovarian cancer, but also gastrointestinal tract, breast, lung, cervical cancer, fallopian tubes) and can be increased slightly (up to 100) not only with oncological diseases, but also with endometriosis, fibroids, endometrial hyperplasia, so the cause is most likely fibroids, but it will be further examined and be sure to monitor the dynamics after treatment of fibroids (should return to normal). Considering this indicator (ca 125) it is probably better to undergo surgery (ovary, tubes - evaluate) laparoscopy is better, it is easier to tolerate than laparotomy, the ovary, if it is in order, should not be touched, this is not a problem, it is usually possible to save the uterus easily with normal qualifications. Judging by the ultrasound there shouldn't be any problems. But preserving the uterus means possible problems with dysfunctional bleeding, endometrial hyperplasia, so you will need to be observed and take care of yourself. You also need to do an endometrial biopsy (hysteroscopy or curettage).

2008-06-09 16:58:47

Yana asks:

Good afternoon. After removing the polyp from the uterine cavity and receiving the test results, the doctor prescribed the drug medroxyprogesterone. But the fact is that during a cesarean section 6 years ago, 2 fibroid nodes were discovered in me, which after childbirth are not visible with ultrasound. Will this drug affect the growth of fibroids? Thanks in advance for your answer

Answers Karapetyan Eliz Martinovna.

Article outline

Many women who are planning their pregnancy often face various obstacles in the form of benign tumors of the uterine muscles. If fibroids are detected and pregnancy has already been going on for several months, then there is no need to panic. There are enough examples that a woman learned about the presence of a tumor during pregnancy, but her child was born healthy. For the normal course of this period, it is necessary to know the danger of fibroids for the uterine cavity.

Expectant mothers begin to worry when they hear the diagnosis of uterine fibroids during pregnancy. Is it dangerous to have uterine fibroids when they are discovered while carrying a baby? This question still remains open. But despite this, doctors know how to act when such a diagnosis is discovered.

What is uterine fibroid and why does it occur?

This formation is considered benign; it is a tumor that grows on the muscles of the uterus. Experts have not yet been able to give specific answers as to why this is happening. But there are suggestions that this may be increased hormonal stimulation and increased secretion of estrogen. In other words, a tumor forms due to low level progesterone in the body and increases due to the excess balance of estrogen.

But if no hormonal imbalance is detected in the blood, this does not mean that a tumor cannot form. The level of estrogen in the uterus may increase slightly and not be reflected in a blood test. In almost all cases, the formation consists of several nodes in various sizes of seals. A tumor of this type is considered common, but it is extremely undesirable for an expectant mother.

Causes

This disease occurs as a result of hormone imbalance. The amount of estrogen increases, which contributes to rapid cell division and the formation of unwanted nodes. Nodes can grow in different places on the uterus in multiple quantities. If a tumor is detected and treated in time, then it does not pose any danger.

Reasons for the rapid production of estrogen by the ovaries:

genetics (if women had such a disease, then it is difficult for the next generation of women to avoid it);
infections that inflame the genitals;
intentional termination of pregnancy;
cyst on the ovaries;
birth control pills;
excess weight;
chemotherapy.

Uterine fibroids often cause infertility. But there are cases when pregnancy is still possible. Practice suggests that this disease affects each organism differently. Doctors cannot fully answer why some women give birth when fibroids form in the uterus, while others are unable to conceive a child with this benign multiple formation.

Symptoms

A formation on the uterus is accompanied by the following symptoms:

the menstrual cycle is very painful;
women very often feel slight pressure in the lower abdomen;
abdominal pain intensifies and has a pulling character;
sexual intercourse often becomes painful for a woman;
bladder often makes you want to go to the toilet;
the functioning of the gastrointestinal tract is disrupted;
belly growth.

To be able to give birth to a baby, you need to contact a specialist for examination at the first sign of these symptoms. He will order an ultrasound to detect fibroids on the muscle layer of the uterus. Ultrasound examination will help to detect tumor formations in time. Also, using this procedure, the doctor will find out:

the number of nodes that have formed on the uterus;
condition of myomatous nodes;
their place of growth;
exact size of fibroids;
exact location of lesions;
structure of tumors.

These characteristics are necessary to determine the answer to the question - whether a woman has the opportunity to give birth to a child. Conception can occur if nothing blocks the entry of sperm into the uterus and does not disrupt the ovulation process. For a successful pregnancy, the cervix should not be blocked by this tumor formation. As you can see, there is a possibility of pregnancy with this diagnosis.

Diagnostics

At the very beginning of the diagnosis, doctors ask the woman a number of questions. They find out how many times the woman was pregnant and how many times she terminated the pregnancy. Also, specialists need to find out whether there have been uterine surgeries or miscarriages. One of the questions may be about the birth of a non-living child. After clarification of all the nuances, the woman is sent for a study in which various methods diagnostics

General clinical examinations and tests are carried out. Doctors find out the main aspects of this disease. Diabetics and hypertensive patients are examined very carefully, because these diseases have big influence for the entire treatment process. In addition to general examinations, the woman is referred to a gynecologist.

The gynecologist must clarify through research all the sizes of the formed nodes and changes in the fibroids. Also, the exact location of fibroids. In addition, with the help of an ultrasound machine, a specialist monitors the development of the fetus if a pregnant woman is diagnosed. Ultrasound also determines where the tumors are located.

Treatment

At the very beginning of treatment for a woman who has been diagnosed with a tumor, doctors try to stop further growth of the tumor. All methods of stopping the development of a benign tumor depend on individual characteristics and fibroid structures. Also, the reason why the disease was diagnosed plays an important role. Pregnant women often experience iron deficiency in the body, and this can lead to tumor growth. Therefore, because of this factor, it is necessary to constantly take a blood test during pregnancy.

Prevention

Prevention involves taking iron, ascorbic acid And various vitamins. Proper nutrition, which includes food with big amount squirrel. Carbohydrates should be limited, and you should also stop eating animal fats. Fresh juices, vegetables and fruits have a beneficial effect on disease prevention. After giving birth by cesarean section, a woman may be prescribed a drug with progesterone. Thus, the process of cell division in the uterus is significantly reduced. The tumor does not grow under such conditions.

How fibroids affect pregnancy

It's no secret that such education has negative character during pregnancy. It can cause a miscarriage due to a lack of placenta, because the fetus must be surrounded by the placenta. Due to fibroids, the baby may receive little oxygen and all nutrients. The consequences may also cause heavy bleeding due to placental abruption. The worst thing is that all these processes can happen both in the early stages of pregnancy and in the last months. Therefore, uterine fibroids have a negative effect on pregnancy.

But if uterine fibroids are detected, you should not immediately terminate the pregnancy. After all, this disease and pregnancy are compatible. You just need to constantly be examined by a specialist. There are many examples where women carried a healthy child, and the pregnancy period was absolutely calm. But it’s better not to take risks, because the child may be born with a small weight or a deformed body. Bad influence fibroids in pregnancy cannot be ruled out at all, even despite many successful cases.

After 40 years, pregnancy is more difficult because at this age hormonal disbalance It has huge probability. Also, fast growth fibroids can significantly outpace the capillaries, which causes bleeding. If no disturbances were observed over the course of 12 weeks, this does not mean that after 20 weeks the same result will occur. The first trimester can pass without any symptoms. But complications can appear at any time. There is a high probability that blood circulation will be impaired in the later stages because myomatous nodes grow. Therefore, it is recommended to perform a caesarean section when the pregnancy is 39 weeks.

Nowadays, most women give birth after 30. At this age, hormonal imbalances begin to progress. Therefore, before conception, it is necessary for doctors to discover the location and size of the formation. If they reach 4 cm or 5 cm, then pregnancy is possible. But if the fibroid is 7 cm or 8 cm, then this significantly complicates the process of treatment and pregnancy.

How does the disease manifest itself in pregnant women?

A pregnant woman can have many symptoms. When the baby is pregnant, the tumor can disrupt the placenta and its functions. A woman may have a stomach ache. These pains in the lower abdomen are caused by poor circulation in the nodes. Also, there is an increased arterial pressure. Benign tumor can be easily recognized using echo signs of ultrasound examination.

Conception during illness

When a woman plans to conceive a baby, she needs to take into account all the characteristics of the tumor. It is important to know how it is located and where. Also, the size of the nodes and their predisposition to growth play an important role. If the uterus is deformed due to formation, then conception is impossible. In this case, it is necessary to remove the nodes. When planning pregnancy, fibroids should be carefully examined.

If the nodes are small and do not affect the uterus, then the likelihood of pregnancy becomes high. But during pregnancy, problems can arise. A woman may not be able to bear a child. Miscarriage or termination of pregnancy is highly likely.

Can a doctor remove fibroids during a caesarean section?

Removal of fibroids by a doctor during a cesarean section is possible:

in case of single education;
abdominal tumor, which has a stalk;
if there structural changes tumors;
large intermuscular formation.

But it happens that after a cesarean section, it is necessary to completely remove the uterus. This is necessary for women over forty years of age. Also, with necrosis of fibroids and recurrence of tumors. If during a cesarean section it was possible to remove the formation, then the woman can safely plan another conception of a child.

Natural birth or caesarean section

For each woman with a tumor, the choice of childbirth is individual. Natural childbirth can take place in the absence of contraindications. For example, the formation does not grow and will not interfere with the birth process. For such births, only pain medication is used. But often the doctor recommends a cesarean section to his patient. During a caesarean section, the fibroids can be removed by a doctor.

Caesarean section is necessary:

if the tumor is located low;
many nodes;
if there is a scar on the uterus after surgery;
the blood circulation of the tumor is impaired.

Contraindications

The growth of fibroids while carrying a child can lead to many complications. The development of all kinds of pathologies and diseases sometimes has to be stopped through emergency childbirth or termination of pregnancy. Therefore, pregnancy must be taken very seriously. Constant examination by specialists is necessary to avoid unpleasant unexpected situations.

For this disease, gynecological massage is contraindicated. Also, the lower abdomen should not be allowed to warm up in any way. That is, a bathhouse, solarium, sauna, etc. are contraindicated. Do not lift weights over 3 kg and drink a lot of water before bed. The latter can lead to swelling of the uterus.

Postpartum period

It is worth noting that tumors after childbirth may stop growing and developing. The uterus returns to its original position, and accordingly, fibroids and nodes also change. Uterine leiomyoma is found in almost every fifth woman, so the process of bearing a child and the postpartum period can be complicated by various processes.

Multiple uterine fibroids and pregnancy

In the uterus, fibroids often form with many nodes. After removing all the nodes, there may not be any left on the uterus healthy tissue, so planning conception and pregnancy can be accompanied by difficulties. But doctors can remove precisely the nodes that interfere with the development of the fetus, which will lead to various complications. Pregnancy with fibroids can proceed smoothly after removal of such nodes. And after the birth, the doctor will remove the remaining nodes that have formed.

Forecast

Pregnancy with a tumor can proceed calmly. But a tumor can reveal itself even on later. This will lead to premature labor or the need for a caesarean section. Also, a miscarriage may occur. Therefore, when planning a pregnancy with this disease, you need to think about all the consequences.

Complications

Why fibroids are dangerous:

Myoma during pregnancy threatens miscarriage. The risk is quite high. The percentage reaches the sixty mark. 25% of women give birth prematurely. To prevent the threat, patients take vitamins and special means. Doctors recommend staying in bed and limiting yourself to physical activity to prevent the occurrence of various complications.

Surgery to remove uterine fibroids during pregnancy

Used to treat fibroids operating method. Laparoscopy is an operation that is performed necessary tool and a camera for recording video in the abdominal cavity. This operation prevents the formation of adhesions and increases the patency of the tubes, so that a woman can become pregnant. This technique is safer than, for example, laparotomy.

The surgery to remove fibroids, called laparotomy, involves a manual process that may carry the risk of adhesions. This can lead to consequences such as infertility and even intestinal obstruction. But with the first type of operation, if the fibroid nodes are large, it will not be possible to stitch the uterus. This is solely due to the use of specific technology.

Therefore, women undergo laparoscopy and remove fibroids if the nodes are small - no more than six centimeters. An experienced surgeon is able to suture the uterus under such conditions. To sutured the uterus, which had large nodes, there is latest technology, but it also has some nuances. There is a risk that the uterine scar will simply rupture. Removing fibroids during pregnancy is not advisable because there is a risk of miscarriage. Often, fibroids are removed during childbirth during a cesarean section.

But is it necessary to remove fibroids before pregnancy? Yes, because then pregnancy can progress most in the usual way, without any interference. But this is provided that the nodes were small size. Also, before planning a conception, it is necessary to undergo a gynecological examination to ensure good condition scar. The age of the pregnant woman also plays an important role in this matter.

Treatment of infertility with fibroids

To cure infertility when a tumor is detected, surgery is necessary. If the size of the fibroids is large, then it can interfere with the process of conception. After its removal, there is a chance to conceive a child. But if the size was large, which led to deformation of the uterus, then perhaps the fibroids will be removed along with the uterus itself. It is necessary to detect the tumor in time so as not to lead to such consequences.

How pregnancy affects fibroids

Doctors cannot guarantee exactly how the formation on the uterus will change during pregnancy. We have not yet found out exactly why the formation decreases during pregnancy, which happens in most cases. But there is a small percentage that the tumor can almost double in size. However, it does not always interfere with pregnancy and childbirth. Perhaps progesterone increases and fibroid development decreases. But scientists cannot fully answer this question.

Childbirth with uterine fibroids poses a threat to the life of the expectant mother and her unborn child. Therefore, doctors carefully study everything possible indications. The decision that a cesarean section will be performed for uterine fibroids is made collectively or individually by a gynecologist, depending on the current circumstances. In most cases, fibroids and cesarean sections are inextricably linked, since a woman with a tumor will not be able to give birth naturally. Natural childbirth with fibroids is allowed only in the complete absence of any contraindications. You can read about how decisions are made and what parameters of the health of the mother and unborn child doctors pay attention to on this page. All indications for the use of cesarean section for fibroids as the main or only way to prevent a woman from becoming pregnant are described.

Is natural childbirth possible with large 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. But is it possible to have safe natural childbirth with fibroids, we will consider further in the article.

Features of the management of childbirth with large fibroids 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 by 5-8 cm).
Limit the use of labor stimulation with oxytocin. If it is necessary to enhance labor, it is advisable to prescribe prostaglandin preparations, which have an optimal effect on the myomatous uterus and do not disrupt the microcirculation of the myometrium and the hemostatic system.
Prophylaxis of fetal hypoxia during childbirth.
Prevention of bleeding during labor and the early postpartum period with the help of a strongly contracting agent for the uterus. It is administered simultaneously intravenously immediately after the birth of the fetal head.

Indications for caesarean section for uterine fibroids

Caesarean section for uterine fibroids to prevent pregnancy is used in most cases with a preliminary diagnosis of the tumor. Indications for cesarean section for fibroids in a planned manner 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 fetal head.
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 vaginal delivery can undergo necrotic changes. At the same time, 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).
Multiple uterine fibroids with different locations of myomatous nodes in women of late reproductive age (39-40 years or more).
Necrosis of the interstitial (intermuscular) node.
Relapse (further growth of myomatous nodes) after a previously performed myomectomy (most often this is an option active growth this muscular fibrous tumor).
The location of myomatous nodes in the area of vascular bundles, the lower segment of the uterus, interligamentous localization, centripetal growth and submucosal nodes.

These are the main indications for cesarean section for fibroids and the need for a planned abortion of a woman from a full-term pregnancy. In case of low location of fibroids emanating from the lower segment, isthmus, cervix, in case of 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 decreased contractility of the uterus, uterine contracting agents are injected into the muscle.

After myomectomy and complicated cesarean section, broad-spectrum antibiotics are used. Combinations of drugs that have an effect on aerobic and anaerobic microorganisms are used.

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Catad_tema Pathology of pregnancy - articles

Obstetric tactics in the management of pregnant women with uterine fibroids

The article is devoted to obstetric tactics in the management of pregnant women with uterine fibroids. 153 pregnant women with uterine tumors were examined. At 16-18 weeks of gestation, 25 pregnant women underwent myomectomy. After the operation, the pregnancy in 15 women was prolonged to full term and a caesarean section was performed. In 48 pregnant women, abdominal delivery was performed when uterine fibroids were combined with obstetric or extragenital pathology. 80 patients were delivered through the vaginal canal, also in the presence of a uterine tumor. Outcomes of both operative and spontaneous births were favorable for both mothers and their newborns. L.S. Logutova, S.N. Buyanova, I.I. Levashova, T.N. Senchakova, S.V. Novikova, T.N. Gorbunova, K.N. Akhvlediani
Moscow Regional Research Institute of Obstetrics and Gynecology of the Ministry of Health of Russia (director of the institute - corresponding member of the Russian Academy of Medical Sciences, Prof. V.I. Krasnopolsky).

IN last years Obstetricians increasingly have to decide on the possibility of prolonging pregnancy when it is combined with uterine fibroids. This is due to the fact that the number of women of fertile age suffering from uterine tumors is increasing from year to year. The course of pregnancy, obstetric tactics, as well as methods of delivery have their own characteristics. Features of the course of pregnancy when combined with uterine fibroids include the threat of miscarriage at various stages of gestation, fetoplacental insufficiency (FPI) and fetal growth restriction syndrome (FGR), rapid tumor growth, malnutrition and necrosis of the myomatous node, placental abruption, especially in those cases when it is partially located in the area of the myomatous node, incorrect positions and fetal presentation. Childbirth in pregnant women with uterine fibroids also occurs with complications (untimely rupture of water, abnormalities of uterine contractility, fetal distress, tight attachment of the placenta, hypotonic bleeding, subinvolution of the uterus in the postpartum period, etc.).

The complicated course of pregnancy and childbirth determines the high frequency of surgical interventions and obstetric care in pregnant women with uterine tumors. C-section in the presence of uterine fibroids, as a rule, ends with an expansion of volume surgical intervention(myomectomy, hysterectomy). The complicated course of pregnancy and childbirth requires a strictly differentiated approach to the management of pregnant women with uterine fibroids and determines individual obstetric tactics in each specific case. First of all, this concerns resolving questions about the need, possibility and conditions of myomectomy during gestation. Indications for this operation may arise in situations where prolongation of pregnancy is practically impossible (cervical-isthmus or intraligamentous location of the myomatous node, centripetal growth interstitial fibroids, large size of subserous-interstitial tumor). Pregnancy in these women, as a rule, proceeds with a pronounced threat of miscarriage, but when a miscarriage begins, curettage of the walls of the uterine cavity is sometimes technically impossible (cervical-isthmus location of the node). Gynecologists have to resort to radical operations(removal of the uterus along with the fertilized egg), which is a great tragedy for women who do not have children. At the same time, in many women, with a small tumor size and no signs of malnutrition of the nodes, pregnancy proceeds favorably and, as a rule, ends in spontaneous birth.

We observed 153 pregnant women with uterine fibroids. In 80 women, pregnancy ended with spontaneous birth, 63 had a cesarean section, 10 women continue to be monitored for pregnancy (they underwent myomectomy at 15-18 weeks of pregnancy). Another 15 patients underwent surgical treatment during gestation; their pregnancy had already ended with surgical delivery. Thus, 25 women underwent myomectomy during pregnancy.

All pregnant women at various stages of gestation were observed in the scientific advisory department and the department of pathology of pregnant women of MONIIAG, 143 pregnant women gave birth at the institute. There were 33 (23.1%) women aged from 20 to 29 years, 89 (62.2%) from 30 to 39 years old, and 21 (14.7%) pregnant women were over 40 years old. Thus, the age of 76.9% of women exceeded 30 years, 80 (55.9%) pregnant women were about to give birth for the first time. In 128 patients, uterine fibroids were detected before pregnancy and only in 25 - in early dates gestation. In addition to uterine fibroids, 15 (10.4%) patients suffered from adenomyosis, 23 (16.0%) had infertility, and 19 (13.3%) had ovarian dysfunction. Of the extragenital diseases, 13 (9.1%) pregnant women had myopia, 17 (11.9%) had hypertension, 11 (7.7%) had increased thyroid gland, two had mitral valve prolapse.

When examining pregnant women with uterine fibroids, attention was paid to the following features: localization of myomatous nodes, their structure, location of the placenta, tone and excitability of the myometrium. In 6 pregnant women, at the first examination, isthmus uterine fibroids were discovered, but the size of the tumor was small and did not interfere with the development of pregnancy. In 12 women, the nodes were subserous-interstitial (from 8 to 15 cm in diameter), located in the fundus or in the body of the uterus, nutritional disturbances in the nodes were not noted, and the pregnancy was also prolonged to full term. In 106 patients, uterine fibroids were multiple, myomatous nodes were small in size, predominantly subserous-intrastial. In 4 pregnant women, centripetal growth of fibroids was detected, but ovum was implanted on the opposite wall of the uterus, and the pregnancy was also able to be prolonged until the period at which the fetus became viable.

And finally, in 25 patients at 7-14 weeks of gestation, giant tumors were found, located intraligamentously, preventing the development of pregnancy, with symptoms of compression pelvic organs. These pregnant women underwent conservative myomectomy at 16-18 weeks. 3-5 days before surgery, “conservation therapy” was carried out, including tocolytic drugs, which were prescribed to all pregnant women with symptoms of threatened miscarriage and with preventive purpose. Tocolytics - partusisten, bricanil, ginipral - were used either per os, 1/2 tablet 4-6 times a day together with verapamil, or intravenously at a dose of 0.5 mg of a tocolytic drug with 40 mg of verapamil in 400 ml of isotonic sodium chloride solution. The most favorable results were obtained when alternating intravenous administration partusistene with a solution of magnesium sulfate (30.0 g of magnesium sulfate diluted in 200 ml of isotonic sodium chloride solution). At the end infusion therapy used drugs such as baralgin or spazgan in a dose of 5 ml intravenously. They are anti-prostaglandin agents and normalize the tone of the uterus. In addition, the complex of therapy aimed at prolonging pregnancy included drugs such as Magne-B6; vitamin E, spazgan 1 tablet per day.

Considering the adverse effect of uterine fibroids on the state of fetoplacental blood flow, especially when the placenta is localized in the area of the myomatous node, therapy was carried out aimed at its improvement (chirantil 25 mg or trental 300 mg 3 times a day), as well as the prevention of intrauterine fetal hypoxia (sigetin, cocarboxylase , ascorbic acid).

We considered the optimal time for conservative myomectomy to be 16-19 weeks of pregnancy, when the concentration of progesterone produced by the placenta increases approximately 2 times. The latter is considered a “protector” of pregnancy. Under the influence of progesterone contractile activity the uterus decreases, the tone and excitability of the myometrium decrease, the extensibility of muscle structures increases, and the obturator function increases internal pharynx. Deadline possible holding operations during pregnancy - 22 weeks, since in the event of premature labor a very premature newborn is born.

The surgical tactics of conservative myomectomy during pregnancy differ significantly from those performed outside of pregnancy. This is due to the need to perform an operation in compliance with the following conditions: 1) minimal trauma to the fetus and blood loss; 2) selection of a rational incision on the uterus, taking into account subsequent abdominal delivery: 3) suture material with sufficient strength, minimal allergenicity, and capable of forming a full-fledged scar on the uterus. Features of surgical interventions during pregnancy were as follows.

1. The operation was performed under endotracheal anesthesia or epidural anesthesia. This type of anesthesia, from our point of view, is the most preferable, as it allows for maximum relaxation and minimal impact on the fetus.

2. To create the most gentle conditions for the pregnant uterus and fetus, as well as optimal access to atypically located fibroid nodes, lower median laparotomy was used. In this case, the body of the uterus with the fetus located in it was not fixed, but was freely located in the abdominal cavity. Given the pronounced vascular network with well-developed collaterals, in order to avoid additional blood loss, fibroid nodes were captured with gauze swabs moistened with warm isotonic sodium chloride solution, without the use of clamps such as Museau and “corkscrew”.

3. If the myomatous node is located cervically on the anterior wall of the uterus, the peritoneum was opened in the transverse direction between the round ligaments, and the bladder was bluntly relegated to the womb. Then make a longitudinal cut along midline the capsule of the node was dissected. The myomatous node was isolated by sharp and blunt methods with simultaneous ligation of all vessels located in the myometrium. Careful hemostasis was performed, taking into account the severity of the blood supply to the nodes during pregnancy.

4. If the node is located intraligamentously, the round ligament of the uterus was transected above the node. In a number of cases, with large tumor sizes and its intraligamentary location, it became necessary to intersect the ovarian ligament and the tube, vascular bundle(in those cases when the listed formations are located on top of the node). Partly stupid, partly sharp way the node was peeled out. The bed of the latter was sutured with interrupted vicryl sutures in two rows. Careful hemostasis and peritonization of the parametrium were performed.

5. If the node is located subserosally-interstitially, the incision was made longitudinally, bypassing the vessels dilated during pregnancy, reducing trauma to the uterus.

6. An important point surgical tactics during pregnancy, which we want to address Special attention, it is advisable to remove only large nodes (from 5 cm in diameter or more) that interfere with pregnancy real pregnancy. Removal of all nodes (smaller ones) creates unfavorable conditions for the blood supply to the myometrium, wound healing on the uterus and fetal development.

7. We assigned an important place in the outcome of the operation and pregnancy to the suture material and the technique of suturing the uterus. Main suture material, which was used for surgical interventions during pregnancy, was vicryl N 0 and 1. Sutures were applied to the uterus in one or two rows. Only interrupted sutures were applied, since in this case the closure of the wounds was considered more reliable. The distance between the sutures and each other was 1-1.5 cm. Thus, the tissues were kept in a state of reposition, and ischemia of the sutured and adjacent areas did not occur.

Postoperative management of pregnant women who underwent conservative myomectomy had its own specific features, due to the need to create favorable conditions tissue repair, prevention of purulent-septic complications, adequate intestinal functioning. At the same time, a set of therapeutic measures aimed at developing pregnancy and improving uteroplacental blood flow was continued. After surgical intervention intensive infusion therapy was carried out for 2-3 days, including protein, crystalloid drugs and agents that improve microcirculation and tissue regeneration (reopolyglucin in combination with trental and chimes, native plasma, 5-20% glucose solutions, actovegin or solcoseryl). The question of the duration of infusion therapy was decided individually in each specific case and depended on the volume of surgery and blood loss. In order to prevent purulent-septic complications, a course of antibiotic prophylaxis was prescribed (preferably synthetic penicillins or cephalosporins). Bowel stimulants (cerucal, oral magnesium sulfate) were used with caution.

Depending on the severity clinical signs threats of termination of pregnancy continued from the first hours after surgery therapy aimed at maintaining pregnancy (tocolytics, antispasmodics, magnesium sulfate according to generally accepted regimens). Oral administration drugs were prescribed until 36 weeks of gestation with a gradual dose reduction. Taking into account hyperestrogenism in pregnant women with uterine fibroids, progestin drugs (turinal) were used together with minimal doses of glucocorticoids or duphaston until 24-25 weeks of pregnancy. On days 12-14 after surgery, pregnant women with progressive pregnancy were discharged for outpatient treatment.

At 36-37 weeks of gestation, 15 pregnant women were hospitalized at the institute for delivery. In case of full-term pregnancy, a caesarean section was performed. Newborns with a high score on the Algar scale (8 and 9 points) weighing 2800-3750 g were extracted. The incision of the anterior abdominal wall was inferomedian with excision of the skin scar. When opening the abdominal cavity, only three women had a minor adhesive process in the abdominal cavity. Scars on the uterus after myomectomy were practically not visualized. The duration of cesarean section was 65-90 minutes; blood loss during surgery is 650-900 ml. Pregnancies combined with uterine fibroids in another 48 patients were completed by caesarean section. The localization of the tumor was different: in the body of the uterus or the lower segment there were small subserous-interstitial nodes (less than 10 cm in diameter): large subserous-interstitial nodes were located mainly in the fundus of the uterus, as well as in its body, but at a considerable distance from lower segment. In neither case did the presence of a tumor prevent prolongation of pregnancy and the need for surgical treatment there was no birth before the due date. The gestational age before delivery was 37-39 weeks. In only one case, in an elderly primigravida with a history of long-term infertility, with FPN due to the localization of the placenta in the area of a large interstitial myomatous node (15 cm in diameter), a cesarean section was performed at 34-35 weeks of pregnancy. A newborn weighing 1750 g was extracted with an Algar score of 5 and 7 points at 1 and 5 minutes, respectively.

In 32 (66.7%) pregnant women, cesarean section was planned. Indications for surgery in 6 women were the isthmus location of the myomatous node, which prevented the advancement of the fetal head along the birth canal; in 2 - rapid tumor growth at the end of pregnancy with signs of malnutrition; In 24 pregnant women, indications for cesarean section were combined: breech presentation of the fetus, elderly age primigravida, history of long-term infertility, unpreparedness of the body for childbirth, FPN, myopia high degree etc. In 16 (33.3%) women in labor, a cesarean section was performed during childbirth, mainly due to labor anomalies (13 women) and fetal hypoxia (3 women in labor). In 30 women giving birth, the scope of the operation was expanded: 24 women underwent myomectomy, 5 had supravaginal amputation, and one had hysterectomy. 34 (70.8%) children were extracted in satisfactory condition (state assessment on the Algar scale - 8 and 9 points at the 1st and 5th minutes, respectively), 13 (27.1%) - in a state of hypoxia mild degree and only one child with hypoxia medium degree gravity. The weight of the newborns was 2670-4090 g. Current postoperative period In 45 women it was uncomplicated, in two with myomectomy during cesarean section uterine subinvolution was noted and in one there was a wound infection.

Pregnancy in combination with uterine fibroids in 80 women ended in spontaneous birth. Myomatous nodes, as a rule, were small in size and located in the body of the uterus, without interfering with the spontaneous birth of the fetus. In this group, 28 (35%) pregnant women were elderly primiparas: 13 suffered hypertension, 10 were found to have an enlarged thyroid gland, and 9 had myopia. In all pregnant women, at 37-38 weeks of gestation, preparation for childbirth began with antispasmodic, sedatives; 6 women were prepared for intravenous drip administration enza-simple. Childbirth in 34 (42.5%) women was complicated by premature rupture of water, in 4 (5%) - bleeding in the placenta and early postpartum periods. Average duration labor was 10425 minutes +/- 1 hour 7 minutes, anhydrous interval - 15 hours 12 minutes +/- 1 hour 34 minutes. 56 (70%) children were born in satisfactory condition, 22 (27.5%) in mild condition hypoxia and two newborns with moderate hypoxia. The weight of newborns ranged from 2050 to 4040 g. In four, the weight exceeded 4000 g. In all postpartum women, the course postpartum period was uncomplicated. 78 (97.5%) newborns were discharged home on days 5-7 in satisfactory condition, two children were transferred to staged nursing and then also discharged.

Thus, the increasing incidence of uterine fibroids in women of fertile age increasingly raises the question of obstetricians and gynecologists about the possibility of prolonging pregnancy with this pathology. Conservative myomectomy, especially in women with the last and often only opportunity to have a child, is a method that makes it possible to realize this opportunity.

LITERATURE

1, Ivanova N.V., Bugerenko A.E., Aziev O.V., Shtyrov S.V. // Vestn. Ross. accots, obstetrics-gin. 1996. N 4. P. 58-59.
2. Smitsky GA. // News. Ross. assoc. obstetrics-gin. 1997. N3. pp. 84-86.