LETTER TO THE EDITOR
Fibroids and pregnancy outcomes
TO THE EDITOR: We read the recent article by Shavell et al.
(1) regarding the effects of fibroids on obstetrical outcomes
and have the following comments.
First, the number of women in each group was very small
(n ¼ 95), and the number of women with fibroids >5 cm was
much smaller (n ¼ 42). Compare this with the study by Stout
et al. (2), where 2,058 women with fibroids were compared
with 61,989 without fibroids, all of whom had routine
second-trimester ultrasounds. Stout et al. reported significant
differences in odds ratios for placenta previa, abruption,
premature rupture of membranes, preterm birth <34 weeks,
and intrauterine fetal death, but the differences were all
<2% (2). For women with fibroids considering pregnancy,
these differences are not clinically significant.
Second, a multivariable regression analysis of risk factors
for poor obstetrical outcomes (maternal age, smoking, alcohol
use, gestational diabetes, hypertension, previous preterm
birth, vaginal bleeding during pregnancy) apparently was
not done by Shavell et al., but was done by Stout et al. In Stout
et al.'s study, women with fibroids were older, had a higher
body mass index, a higher rate of gestational diabetes, and
more chronic hypertension. These important confounders
must be adjusted to produce meaningful data. We suppose
that the groups in the Shavell et al. study could not be strat-
ified owing to small numbers, but this may be a major prob-
lem with the study and, in our minds, undermines most of the
findings.
Third, the risk of having a blood transfusion was clearly
much higher for women with fibroids >5 cm. It would be
helpful for the authors to describe criteria for transfusion.
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Finally, Stout et al. reported outcomes for women with
fibroids >5 cm (n ¼ 593) compared with women with fibroids
<5 cm (n ¼ 1,409): Only intrauterine fetal death had a signif-
icantly greater adjusted odds ratio (2.6), and there were
11 women in the large fibroid group and 11 women in the
small fibroid group with this outcome.
Despite its shortcomings, Shavell et al. does not advise
myomectomy to improve outcomes for women with fibroids
>5 cm. Abdominal or laparoscopic myomectomy can be
associated with significant morbidity, including infection,
injury to internal organs, risk of blood transfusions, adhesion
formation, risk of uterine rupture during pregnancy, and
possible need for cesarean section. We do not think this study
should be used as a justification for surgery.
Thank you for considering these issues.
William H. Parker, M.D.a
David L. Olive, M.D.b
Elizabeth A. Pritts, M.D.b
a
UCLA School of Medicine, Los Angeles, California; and
b
Wisconsin Fertility Institute, Middleton, Wisconsin
April 18, 2012
doi:10.1016/j.fertnstert.2012.05.008
REFERENCES
1. Shavell VI, Thakur M, Sawant A, Kruger ML, Jones TB, Singh M, et al. Adverse
obstetric outcomes associated with sonographically identified large uterine
fibroids. Fertil Steril 2012;97:107–10.
2. Stout MJ, Odibo AO, Graseck AS, Macones GA, Crane JP, Cahill AG. Leiomyo-
mas at routine second-trimester ultrasound examination and adverse obstet-
ric outcomes. Obstet Gynecol 2010;116:1056–63.
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