Tumours of Uterus and

adnexa complicating p
regnancy and labour
•FIBROID IN PREGNANCY
Fibroids are smooth muscle tumours of the uterus ot
herwise termed myomas or leiomyomas.
The incidence of clinically detectable fibroids in preg
nancy varies from 1 in 500 to 1 in 1000.
Effect of Fibroids on Pregnancy

• The position, size and type of fibroids determine th

eireffect on pregnancy.
• The majority of complications occur when the fibroi
d is submucous and close to the placental implanta
tion site.
• Subserous fibroids are a problem only if they are lo
w lying and become impacted in the pouch of Doug
las causing obstruction to labour
Effect of fibroid on pregna
ncy
• Antepartum
• Miscarriage
• Malpresentation
• Unengaged head at term
• Pressure symptoms

• Submucous fibroids can lead to miscarriage both due to defe

ctive implantation and as there is less space for the fetus to
grow.
• Both first and second trimester miscarriage can occur.
• Intrapartum
• Abruption
• Preterm labour
• Uterine inertia
• Obstructed labour if the fibroids are in the lower
• segment or cervix
• Postpartum haemorrhage and retained placenta
• Difficulties at caesarean section
• Peurperium
• Infection
• Subinvolution
• Inversion
• Secondary PPH
In pregnancies following uterine artery embolistion f
or fibroids are complicated by
miscarriage, preterm labour, intrauterine growth rest
riction and postpartum haemorrhage.
Hence this procedure is not ideal for women contem
plating pregnancy.
• Increase in Size
• Usually fibroids grow in size in pregnancy due to oe
strogen and progesterone.
• In addition, growth factors like insulin growth facto
r and epidermal growth factor are also implicated
Treatment of CIN
Treatment of Invasi
ve cancer
• Functional Cysts
• Corpus luteum cysts comprise 90% of cysts seen
• Theca lutein cysts in ovarian hyperstimulation syndrom
e in pregnancy
• Luteomas of pregnancy
• Pathological Benign Cysts
• Dermoid cyst is the most common
• Serous and mucinous cystadenomas
• Endometriomas
• Malignant ovarian tumour
• Most common Germ cell tumour
• 51-70% resolve during pregnancy
• Acute complication less than 2%
• Effect of the Tumour on Pregnancy
• Malpresentations
• Unengaged head at term
• Obstructed labour
• Effect of Pregnancy on the Tumour
• Torsion (especially in the puerperium)
• Haemorrhage
• Rupture of the cyst in labour
• Infection in the puerperium
DIAGNOSIS
• CA125
• Peak in the first trimester (7-251 U/ml) and decrea
se consistently thereafter
• Low level elevations are not associated with malign
ancy
MANAGEMENT
• Indication of Surgical Intervention
• A strong suspicion of malignancy and/or large size
(>8-10 cm)
• Symptomatic patients
• An increased risk of torsion/rupture/obstruction of l
abour
MANAGEMENT

• All solid tumours and suspicious cysts are best removed.

• It would be reasonable to remove all cyst larger then 10 c
m due to the risk of malignancy and torsion.
• Tumours betweeen 6 and 10 cm are to be carefully evalua
ted by ultrasound with colour Doppler and MRI if needed.
• If a neoplasm is suggestive it would be better to wait unti
l 14-20 weeks and then do a laparotomy. Surgery in the fir
st trimester is best avoided, as removing a corpus luteum
cyst can end up in a miscarriage.
• If surgery is performed in the first trimester. progeste
rone supplementation is advisable.
• At laparotomy, ovarian cystectomy is done as far as
• possible. If cystectomy is not feasible, an ovariotomy
• may have to be done.
• The uterus should be handled as little as possible.
• If the cyst is endometriotic it is best left alone.
• If the appearance is that of a simple cyst, close monit
oring is reasonable
• Cysts which are detected in the late second and thir
d trimesters can also be left alone and closely monit
ored, provided there are no signs of malignancy.
Torsion or Rupture of cyst
• If there is torsion or rupture of the cyst, the woman
will present with an acute abdomen
• Irrespective of the period of pregnancy, immediate l
aparotomy has to be performed.
• If done in the first trimester, progesterone supplem
entation is mandatory as the corpus luteum may be
removed.
 Delivery
• If the tumour is well above the presenting part, vagi
nal delivery can be allowed.
 Delivery

• Caesarean Section
• In cases where the cyst is likely to cause obstruction
to labour, it is preferable to do a caesarean section
and remove the cyst at the same time. This will pre
vent the potential complication of rupture of the cy
st in labour.
• Puerperium
• lf the delivery is vaginal, a laparotomy can be donea
fter 24 hours, as this is the period at which there is
ahigh risk of torsion.