What treatment options are available to manage pregnancy complications in women with uterine fibroids (leiomyomas)?

Management of Pregnancy Complications in Women with Uterine Fibroids

For women with uterine fibroids who are pregnant or desire pregnancy, laparoscopic or open myomectomy is the most appropriate treatment option to improve pregnancy outcomes and reduce complications. 1

Treatment Options Based on Fertility Preservation

Surgical Approaches

• Myomectomy (Laparoscopic or Open)

  • Most effective option for women desiring fertility preservation
  • Similar pregnancy and live birth rates between laparoscopic and open approaches
  • Combined miscarriage rate comparable to general population at 14% 1
  • Advantages of laparoscopic approach:
    • Decreased postoperative fever
    • Shorter hospital stays
    • Smaller decrease in postoperative hemoglobin 1

• Hysteroscopic Myomectomy

  • Indicated specifically for submucosal fibroids
  • Evidence on fertility improvement is mixed:
    • Retrospective studies show 85% pregnancy rates with 65% live birth rates 1
    • Randomized trials show conflicting results on pregnancy rates 1
    • Miscarriage rates reported between 30-50% in some studies 1

Medical Management

• Ulipristal Acetate (UPA)

  • Selective progesterone receptor modulator (SPRM)
  • One of few medical options compatible with fertility goals
  • Demonstrated 41% reduction in fibroid volume in women with submucosal fibroids undergoing IVF 1
  • Pregnancy rates similar to matched controls without fibroids 1
  • Impact on subsequent pregnancy outcomes requires further research 1

• GnRH Agonists

  • Can be used preoperatively to:
    • Increase hemoglobin levels
    • Reduce fibroid and uterine volume
    • Decrease blood loss during surgery
    • Reduce operation time and complication rates 2
  • Not suitable for long-term use due to bone loss concerns 2

Minimally Invasive Procedures

• MR-Guided Focused Ultrasound (MRgFUS)

  • Evidence limited to case reports for fertility enhancement 1
  • Can reduce fibroid diameter by approximately 18% 2
  • Randomized trial for fertility indication terminated due to lack of enrollment 1

• Uterine Artery Embolization (UAE)

  • Retrospective data shows:
    • 29.5% spontaneous pregnancy rate at 1 year
    • 40.1% spontaneous pregnancy rate at 2 years
    • 81% live birth rate among pregnancies 1
  • May impact fertility and pregnancy - patients should be counseled about this risk 3

Pregnancy Complications Associated with Fibroids

• Painful degeneration (most common complication) 4
• Increased risk of miscarriage
• Preterm labor
• Placental abruption
• Fetal growth restriction
• Fetal malpresentation 4

Treatment Algorithm for Pregnant Women with Fibroids

1. Asymptomatic fibroids

   • Observation with additional maternal and fetal surveillance 3
   • No intervention required unless complications develop

2. Symptomatic fibroids during pregnancy

   • Conservative management of acute symptoms
   • Pain management with approved analgesics
   • Monitoring for signs of preterm labor or placental issues

3. Pre-pregnancy planning for women with fibroids

   • Consider myomectomy before conception if:
     • Previous pregnancy had complications related to fibroids 3
     • Submucosal fibroids are present and affecting fertility
     • Multiple or large fibroids that could significantly impact pregnancy

Important Considerations

• Less than half of patients achieve pregnancy after myomectomy at up to 3 years of follow-up 2
• Of these pregnancies, less than half result in a live birth 2
• Myomectomy carries risk of uterine rupture during subsequent pregnancy 2
• Hysterectomy is not an option for women desiring future fertility 1
• Endometrial ablation is associated with high risk of pregnancy complications and not recommended for women desiring pregnancy 1

Pitfalls to Avoid

• Performing myomectomy during pregnancy carries significant risks and should be avoided unless absolutely necessary
• Assuming all fibroids require treatment - many are asymptomatic and do not impact fertility or pregnancy
• Using medical treatments that suppress fertility (most hormonal options) when pregnancy is desired
• Recommending UAE as first-line treatment for women desiring pregnancy due to potential fertility impacts
• Delaying treatment of submucosal fibroids in women with infertility, as these have the greatest impact on implantation

The American College of Radiology recommends that in most cases, medical management should be trialed prior to pursuing more invasive therapies for women with fibroids desiring pregnancy 1, with ulipristal acetate being the most promising medical option that doesn't suppress fertility.