07 February 2018 6546 0

Uterine fibroids are a reaction of the female body to damage. Menstruation is such a damaging factor. Myoma rudiments form in the muscular layer of the uterus, from which myomatous nodes subsequently grow. A woman’s first reaction after being diagnosed with uterine fibroids is confusion and fear.

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Currently, the issue of tactics for managing pregnancy and childbirth in patients with uterine fibroids remains relevant. Myoma is diagnosed in 20% of women over 30 years of age. The number of first-time mothers increases after 30 years, fibroids develop at a young age, and the boundaries of childbearing age expand

Most gynecologists perform supravaginal amputation or hysterectomy after cesarean section in women suffering from fibroids. The only exceptions are nodes located on the stalk and small fibroids along the uterine incision line. In these cases, myomectomy is performed. The young age of many women in labor requires a careful approach to this group of patients and the preservation of the uterus. Doctors at the clinics with which we cooperate perform uterine artery embolization at the pregnancy planning stage. After the procedure, the nodes disappear, the structure of the uterus is restored. Patients whose pregnancy occurs after recovery are allowed to give birth naturally.

Preoperative preparation for delivery

Pregnant women with uterine fibroids at 36-37 weeks of gestation are routinely hospitalized for examination, determination of labor management tactics and preparation for cesarean section. Patients undergo an ultrasound examination, during which the size, number, location of myomatous nodes and their relationship to the vascular bundles of the uterus are determined. Doctors determine indications for cesarean section and surgical removal of fibroids.

Myoma nodes that are removed during cesarean section with a size of 10 to 14 cm are considered large, and fibroids with a diameter of 15 cm or more are considered gigantic. In the pregnant uterus during surgery, interstitial, subserous and subserous-interstitial nodes, as well as their localization along the posterior anterior and posterior wall of the uterus, are found with equal frequency. Sometimes myomatous formations are located in the lower segment of the uterus, preventing natural childbirth.

During pregnancy, 47.4% of women do not experience any significant dynamics in the growth of nodes; in 42.1%, there is a moderate increase in fibroid formations. Only in 10.5% of patients with their first pregnancy, fibroids grow rapidly. Necrotic changes are observed in myomatous formations, often accompanied by leukocyte infiltration or hyalinosis and calcification. In other cases, fibroids are combined with hemorrhages, edema and foci of leukocyte infiltration. Necrotic changes are detected in giant nodes.

Functional examinations before surgery include assessment of the intrauterine state of the fetus: cardiotocography, Doppler measurements of the vessels of the uterus, umbilical cord and fetal aorta. A study of the microflora of the vagina and cervical canal is carried out, since when the uterine cavity is opened during a cesarean section, the infection can enter the abdominal cavity, which leads to complications in the postoperative period.

When deciding on the method of delivery for patients with uterine fibroids, doctors take into account:

woman's age;
obstetric history;
the nature and location of the fibroid node;
the course of this pregnancy;
condition of the fetus.

The presence of uterine fibroids in pregnant women is rarely the only indication for cesarean section.

Indications for caesarean section for uterine fibroids

For women who become pregnant due to uterine fibroids, a cesarean section is performed if the following indications exist:

large fibroids, the location of which prevents the passage of the fetus through the birth canal;
the presence of fibroids of large submucosal fibroids;
degeneration of myoma nodes detected before birth;
torsion of the base of a subserous myomatous formation with the development of inflammation of the peritoneum;
uterine fibroids, accompanied by dysfunction of adjacent organs;
The patient's age is more than 35 years.
suspicion of malignant degeneration of the fibroid node;
myomatous formations in women with a scar on the uterus due to a previous cesarean section, uterine perforation, myomectomy;
the presence of additional unfavorable factors: severe somatic diseases, gestosis, partial placenta previa, large fetus.

Relative indications for cesarean section for uterine fibroids are:

multiple fibroids in “elderly” pregnant women;
uterine fibroids and placental insufficiency (fetal hypotrophy and hypoxia);
fibroids and prolonged fertility (induced pregnancy, unfavorable outcomes of previous pregnancies, prolonged infertility);

Caesarean section is performed in the presence of anomalies in the development of the female internal reproductive organs.

Indications and contraindications for myomectomy

Myomectomy during cesarean section is performed in the presence of subserous nodes on a thin base in any accessible place of the uterus, subserous nodes on a broad base (with the exception of formations located on vascular bundles and in the lower segment of the uterus). The operation is performed in the presence of no more than 5 large nodes whose size is more than 10 cm. During a cesarean section, 1 myoma node with a diameter of no more than 10 cm, located intramurally or with centripetal growth, can be removed. Myomatous formations of different localization are subject to surgical removal with good access to them, with the exception of intramural nodes less than 5 cm in size.

Myomectomy during cesarean section is not performed in the presence of one or more nodes up to 2 cm in size, especially in the presence of concomitant extragenital pathology. Myoma formations are not removed in case of premature placental abruption, leading to acute blood loss, acute bleeding during cesarean section, severe anemia of any origin on the eve of surgery.

Removal of fibroids during cesarean section

Myomectomy during cesarean section is performed under general anesthesia or epidural anesthesia. The surgeon cuts the abdominal wall and examines the uterus. If the fibroid node is small, the doctor first removes the fetus and placenta, and then restores the integrity of the uterus. If the operating gynecologist is convinced that the fibroid is large, he first removes the fibroid formation.

During the operation, special attention is paid to ligation of blood vessels. For a speedy recovery, the abdominal cavity is drained. The patient is prescribed antibacterial, painkillers and detoxification drugs. During the first 24 hours, the patient is in the postpartum ward under the supervision of medical personnel.

A sterile bandage is applied to the suture area. Medical personnel keep the wound and the skin around it clean. During dressing, the skin is treated with antiseptic solutions.

Myomectomy during cesarean section lengthens the rehabilitation period. After the operation, the patient needs dietary nutrition. If she has constipation, she is given a cleansing enema. In order for the uterus to quickly restore its tone, the patient is recommended to breastfeed the baby.

Possible complications of childbirth with fibroids

The presence of a fibroid node can complicate the course of labor. Space-occupying formations are located in the myometrium and cause a decrease in uterine contractility during labor. With fibroids, the structure of the uterus is disrupted, which increases the risk of postpartum hemorrhage. If the node is located in the cervix, it prevents the passage of the fetus through the birth canal. If there is a large fetus in the initial stage of labor, premature placental abruption may develop.

In this case, the optimal option for delivery with fibroids is a cesarean section. The combination of two operations increases the risk of complications in the postoperative period. If fibroid nodes do not interfere with labor, gynecologists prefer to treat fibroids after restoring the functions of the mother’s body.

The organ-preserving surgical method for treating fibroids is conservative myomectomy - removal of fibroid nodes. Surgeons prefer to perform surgery at the stage of pregnancy planning. After surgery, scars form on the uterus. They can cause complications during pregnancy and childbirth. In this regard, women after myomectomy are often delivered by cesarean section.

Our experts are of the opinion that treatment of fibroids should be carried out before conception. Endovascular surgeons perform a safe procedure for patients with fibroids - uterine artery embolization. After it, the fibroid is replaced by connective tissue. No scars form on the uterus, pregnancy proceeds without complications. Women after embolization do not need a caesarean section; they can give birth to a child on their own.

Uterine artery embolization

Gynecologists at our clinics use an innovative method of treating fibroids – uterine artery embolization. The procedure has the following advantages:

Performed under local anesthesia;
Does not require long-term rehabilitation;
Minimum amount of blood loss;
No risk of complications.

After embolization, the structure of the uterus is restored. Myoma formations decrease in size and eventually disappear altogether. The uterine cavity takes on a normal shape. Women's reproductive function is restored. Pregnancy proceeds without complications. Due to the fact that there are no obstacles to the passage of the fetus through the birth canal, the risk of complications during childbirth is minimized. Our gynecologists do not perform cesarean sections after uterine artery embolization, since women give birth without complications.

References

Aksenova T. A. Features of the course of pregnancy, childbirth and the postpartum period with uterine fibroids / T. A. Aksenova // Current issues in the pathology of pregnancy. - M., 1978.- S. 96104.
Babunashvili E. L. Reproductive prognosis for uterine fibroids: dis. Ph.D. honey. Sciences / E. L. Babunashvili. - M., 2004. - 131 p.
Bogolyubova I. M. Inflammatory complications of the postpartum period in women with uterine fibroids / I. M. Bogolyubova, T. I. Timofeeva // Scientific. tr. Center. Institute for advanced training of doctors. -1983. -T.260. - pp. 34-38.

Hello girls. I'll tell you about myself. In 2000, uterine fibroids were discovered. Diagnosis: nodular fibroids of the uterus (14-16 weeks). I really wanted a second child. Drug therapy was used (2 injections of differentiallin. If I'm not mistaken, this is a synthetic hormone that reduces estrogen levels. The result is a reduced blood flow to the uterus, and, accordingly, to the fibrous nodes, which reduces the size of both. To put it simply, I was caused artificial menopause. It lasted 5 or 6 months (I don’t remember exactly now). After that, I had a laparoscopic myomectomy for nodular fibroids of the uterus. 2 months after the operation, an ultrasound scan showed fibroids at 5-6 weeks of pregnancy. 8 years. The nodes did not grow. In 2008, I finally became pregnant! I have several nodes, an intramural node on the back wall, as well as subserous nodes. Everyone told me that it was difficult to say how they would turn out. These nodes will most likely behave, since during pregnancy the level of estrogen, which supposedly has an effect on the nodes, also increases. And so it happened. Already at the 5th month of pregnancy, my stomach was like that of women in labor, and at the 9th month in the morning I could not get out of bed on my own. The baby was lying across, as my fibroids were probably in the way. Naturally, they told me to do a caesarean section so that there would be no threat to the baby. Well, they immediately warned me that the uterus must be removed, since I have a very high risk of bleeding. After 8 years of being diagnosed with infertility, it was a shock for me that the uterus would be removed. In general, they decided that if everything was normal, they would only do a cesarean section, and leave my “infection - fibroids”. I went to the hospital in advance, passed all the tests and was scheduled for a cesarean section. The night before surgery I started having natural contractions. The doctor said that it is very good that the uterus is contracting (less risk of bleeding). She gave birth to a heroic son, 3 kg, 930 g. She breastfed for 8 months. The doctor said that when they cut me open, she was simply horrified by the size of the fibroids. He says it was the size of a large grapefruit. An incision was made transversely from the pubis to the umbilical fossa. Here is an ultrasound in front of me 5 days after cesarean: The uterus is enlarged up to 17 weeks of pregnancy, along the posterior wall intramural 60 mm, subserous 33 mm, 25 mm and further small. Exactly 2 years have passed. Of course, my belly is big, and I also have a hernia. The uterus is enlarged by 10 weeks. I have not yet decided on treatment tactics. Maybe repeat the differential and the operation? I'm still thinking. And one more thing. I am 41 years old.

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, the tumor forms due to low levels of progesterone in the body and grows due to an excess balance of estrogen.

But if no hormone 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.

Reasons

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 numbers. 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;
the 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 clarifying all the nuances, the woman is sent for research, which uses various diagnostic methods.

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 a great impact on 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 the individual characteristics and structure of the fibroid. 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, due to this factor, it is necessary to constantly take a blood test during pregnancy.

Prevention

Prevention consists of taking iron, ascorbic acid and various vitamins. Proper nutrition, which includes food with plenty of protein. 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 is no secret that such formation is negative 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 effects may also cause severe 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. The negative impact of fibroids on pregnancy cannot be ruled out at all, even despite many successful cases.

After 40 years, pregnancy is more difficult, because at this age hormonal imbalance is very likely. Also, the rapid growth of 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, increased blood pressure is observed. A benign tumor can be easily recognized using echo signs of an 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 are structural changes in the tumor;
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 to conceive another 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 be no healthy tissue left on the uterus, so planning conception and pregnancy may 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 at a later date. 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:

insufficient power supply to nodes;
neoplasms begin to grow rapidly;
placental insufficiency;
vein thrombosis;
miscarriage;
anemia.

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 medications. Doctors recommend staying in bed and limiting yourself in physical activity to prevent the occurrence of various complications.

Surgery to remove uterine fibroids during pregnancy

The surgical method is used to treat fibroids. Laparoscopy is an operation that is performed with the necessary instruments and a camera to take video of 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 the 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 proceed in the most normal way, without any intervention. But this is provided that the nodes were small. It is also necessary to undergo a gynecological examination before planning conception to ensure that the scar is in good condition. 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.

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 recent years, obstetricians have increasingly had 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 position and presentation of the fetus. 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. Caesarean section in the presence of uterine fibroids, as a rule, ends with an expansion of the scope of surgical intervention (myomectomy, removal of the uterus). 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 intraligamentary location of the myomatous node, centripetal growth of interstitial fibroids, large sizes of subserous-interstitial tumors). 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 pregnancies had already ended with surgical birth. 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 the early stages of 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 an enlarged thyroid gland, and 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 the fertilized egg 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 of the pelvic organs. These pregnant women underwent conservative myomectomy at 16-18 weeks. 3-5 days before the operation, “conservation therapy” was carried out, including tocolytic drugs, which were prescribed to all pregnant women with symptoms of threatened miscarriage and for prophylactic purposes. 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 by alternating intravenous administration of partusisten with a solution of magnesium sulfate (30.0 g of magnesium sulfate diluted in 200 ml of isotonic sodium chloride solution). At the end of infusion therapy, drugs such as baralgin or spazgan were used 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, the contractile activity of the uterus decreases, the tone and excitability of the myometrium decreases, the extensibility of muscle structures increases, and the obturator function of the internal pharynx increases. The last date for possible surgery during pregnancy is 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, the capsule of the node was dissected with a longitudinal incision along the midline. 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 some cases, with large tumor sizes and its intraligamentary location, it became necessary to intersect the ligament of the ovary and the tube, or the vascular bundle (in those cases when the listed formations are located on top of the node). The node was peeled out using a partially blunt and partially sharp method. 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 in surgical tactics during pregnancy, to which we would like to pay special attention, is the advisability of removing only large nodes (from 5 cm in diameter or more) that prevent the bearing of a 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. The main suture material 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 of the sutures from 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 for tissue repair, prevention of purulent-septic complications, and adequate intestinal functioning. At the same time, a complex of therapeutic measures aimed at developing pregnancy and improving uteroplacental blood flow was continued. After surgery, 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 of clinical signs of threatened miscarriage, therapy aimed at preserving pregnancy (tocolytics, antispasmodics, magnesium sulfate according to generally accepted regimens) was continued from the first hours after surgery. Oral medication was 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: small subserous-interstitial nodes (less than 10 cm in diameter) were located in the body of the uterus or the lower segment: 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 the prolongation of pregnancy and there was no need for surgical treatment 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, the indications for cesarean section were combined: breech presentation of the fetus, advanced age of the primipara, a history of long-term infertility, unpreparedness of the body for childbirth, FPN, high myopia, etc. In 16 (33.3%) women in labor, cesarean section was performed during labor, 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 mild hypoxia and only one child with moderate hypoxia. The weight of the newborns was 2670-4090 g. The course of the postoperative period in 45 women was uncomplicated, in two with myomectomy during cesarean section subinvolution of the uterus 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 from hypertension, 10 had an enlarged thyroid gland, and 9 had myopia. In all pregnant women, at 37-38 weeks of gestation, preparation for childbirth began with antispasmodic and sedative drugs; 6 women were prepared with intravenous drip administration of enza-prost. Childbirth in 34 (42.5%) women was complicated by premature rupture of water, in 4 (5%) - bleeding in the placenta and early postpartum periods. The average duration of labor was 10,425 minutes +/- 1 hour 7 minutes, the anhydrous interval was 15 hours 12 minutes +/- 1 hour 34 minutes. 56 (70%) children were born in satisfactory condition, 22 (27.5%) in a state of mild 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 of the 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.