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Obstetrics Simplified - Diaa M. EI-Mowafi

Gynaecologic Tumours with Pregnancy

Fibroids with pregnancy

Incidence: 1%.

Effect of Fibroid on Pregnancy and Labour

  • Abortion: particularly in submucous myomas due to:
    • distortion of the uterine cavity,
    • affection of the decidual development,
    • affection of the vascular supply to the implanted ovum.
  • Ectopic pregnancy: if it interferes with the passage of the ovum.
  • Incarceration: of retroverted gravid uterus in case of posterior wall fibroid.
  • Placenta praevia: due to interference with implantation of the ovum in the upper uterine segment.
  • Malpresentations.
  • Abdominal discomfort: if the tumour is large.
  • Torsion of the uterus: very rare in subserous fundal myoma.
  • Premature labour.
  • Nonengagement.
  • Prolonged labour: Inertia may be present due to interference with normal uterine contractions.
  • Obstructed labour: in cervical myoma or pedunculated subserous myoma impacted in the pelvis.
  • Postpartum haemorrhage: due to
    • interference with uterine retraction,
    • increased vascularity.
  • Puerperal sepsis.
  • Inversion of the uterus: rare.
  • Subinvolution of the uterus.

Effect of Pregnancy and Labour on Fibroid

  • Increase in size: due to
    • oedema and increased vascularity,
    • hypertrophy of the uterine muscles.
  • Softening: due to oedema and increased vascularity.
  • Red degeneration.
  • Torsion of a pedunculated myoma.
  • Internal haemorrhage: from rupture of a surface vein.
  • Infection: supervenes bruising during labour.
  • Extrusion: of submucous myoma may rarely occur in puerperium.

Management

  • During pregnancy:
    • No treatment is indicated in the majority of cases.
    • Myomectomy carries the risk of abortion and severe haemorrhage so it is indicated in the following conditions only:
      • Red degeneration which is not responding to the conservative treatment in the form of:
        • rest, analgesics, antibiotics to guard against secondary infection.
        • Give progesterone before and after the operation and remove the affected tumour only.
      • Torsion of a pedunculated myoma.
      • Internal haemorrhage from rupture of a surface vein.
  • During labour:
    • If the myoma lies above the pelvic brim not causing obstruction: vaginal delivery is allowed and myomectomy is done after 3-6 months if indicated.
    • If the myoma lies in the pelvis causing obstruction: caesarean section is indicated, but myomectomy is contraindicated.
  • Postpartum:
    • Give prophylactic antibiotic.
    • Observe for postpartum haemorrhage.

Ovarian tumours with pregnancy

Incidence: 1:1500. The commonest is simple serous cyst followed by dermoid cyst.

Effect of Ovarian Tumours on Pregnancy and Labour

  • Abortion and preterm labour in large and complicated tumours.
  • Pressure symptoms.
  • Malpresentations and nonengagement.
  • Obstructed labour: if a pedunculated tumour is impacted in the pelvis.

Effect of Pregnancy and Labour on Ovarian Tumours

  • Torsion: is the commonest complication particularly in pedunculated tumours that lie above the pelvic brim. It is more common during puerperium than pregnancy due to;
    • lax abdominal wall,
    • large intra-abdominal space after birth allows free mobility of the tumour.
  • Haemorrhage.
  • Rupture.
  • Infection.
  • Rapid growth.

Management

  • During pregnancy:
    • Cyst less than 6 cm in diameter: is left and followed up by periodic examination and ultrasound as it is usually a functional corpus luteum cyst.
    • Cyst of 6 cm or more in diameter:
      • Discovered in the first half of pregnancy: is removed after the 12th week when the placenta is formed so there is less liability for abortion.
      • Discovered in the second half of pregnancy: is left to be removed in the first week of puerperium.
    • Complicated or malignant tumours:
      • are removed immediately irrespective of the duration of   pregnancy.
  • During Labour:
    • If the tumour lies above the pelvic brim- causing no obstruction: vaginal delivery is allowed and tumour is removed in the first week in puerperium.
    • If the tumour is impacted in the pelvis - causing obstruction: caesarean section with immediate removal of the tumour is done.
  • During puerperium:
    • Tumours discovered for the first time should be removed immediately for fear of torsion.

Cancer cervix with pregnancy

Pre-invasive Cancer (CIN)

  • Cytological examination: can be done during pregnancy taking in consideration that some features of dysplasia as increased cells showing mitosis are normally present during pregnancy.
  • Colposcopy: is easier to be done during pregnancy due to physiological eversion of the cervix.
  • If CIN I or CIN II is detected: follow up only as many cases will regress.
  • If CIN III is detected: follow up is indicated till one month after delivery where conisation can be done or hysterectomy if the patient had taken the decision that she had completed her family.

Invasive Cancer Cervix

Incidence: very rare 1:10.000 because;

  • The mean age of cancer cervix is 45-50 years.
  • The associated infection prevents conception.

Effect of invasive carcinoma on pregnancy and labour:

  • Abortion and preterm labour: due to haemorrhage, infection and general health affection.
  • Cervical dystocia, obstructed labour, cervical laceration and/or uterine rupture may occur.
  • Puerperal sepsis.

Effect of pregnancy and labour on invasive carcinoma:

  • Rapid growth: as young patients tend to have a rapidly growing tumours.
  • Rapid spread: if vaginal delivery is allowed.

Management:

  • Early pregnancy:
    • Wertheim’s operation or
    • Hysterotomy followed by radiotherapy.
  • Late pregnancy:
    • Upper segment caesarean section followed by either Wertheim’s operation (caesarean hysterectomy) or radiotherapy.