Fibroids in Pregnancy
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I’ve just had a phone call from an antenatal class client who has been told that because she has fibroids she should not have a home birth. As she is now 37 weeks pregnant she would really like some information ASAP so that she can make a decision she is happy with it. The consultant is saying that because she is much more likely to haemorrhage and because there are likely to be problems with the uterus contracting post partum that he would much rather she has her baby in hospital. Your thoughts and any research would be much appreciated.
Statistically women with fibroids are more prone to postpartum haemorrhage (Both primary and secondary PPH). However, the risk of haemorrhage may depend on where the fibroids are situated. There are different types of fibroids:
*Intramural – within the myometrium (muscle layer) All fibroids start as intramural fibroids and this is therefore the most common type. 70% remain intramural. The uterus becomes enlarged and may not cause heavy periods. However, the myometrium may not contract so well during and after the third stage of labour.
* Submucosal – inward growth occurs in 10% and can cause heavy periods/bleeding. These may also become infected and also may become pedunculated.
* Subserosal – outward growth in 20% of cases, lie beneath the peritoneum (outer layer of the uterus), and may be irregular in shape.
There are also
*broad ligament fibroids and
In pregnancy there may be an increase in the size of the fibroids, but not generally a significant increase They may become more vascular, oedematous and softer. Red degeneration of the fibroid may occur, probably due to obstruction of the venous return. The back pressure causes rupture of the capillaies and bleeding occurs through the fibroid. Rather than being white in colour the fibroid is a ‘raw beef’ colour. Sometimes in pregnancy the fibroids out grow their blood supply and become calcified, known as ‘womb stones’.
I cannot give you statistics of the number of people who have a PPH. However, I would think that a woman who has heavy periods due to fibroids is more likely to have a heavy blood loss at delivery. I would imagine that the subserosal fibroids would be least likely to cause problems. I have cared for a few women with fibroids , who have not had a PPH. However, as the fibroid is in the muscle layer any woman with fibroids is potentially at risk of bleeding, as the fibroids may interfere with contraction of the myometrium.
I found this on PubMed, Jenny, along with a series of other studies that found no issue with fibroids (I have had to look this up before for a colleague – there may be other stuff I missed). The consultant may have other more negative references – it could be worthwhile him sharing them with the mother.
Aust N Z J Obstet Gynaecol 1999 Feb;39(1):43-7
The impact of leiomyomas on pregnancy
Roberts WE, Fulp KS, Morrison JC, Martin JN Jr.
(from the abstract) The discovery of uterine leiomyomas by gestational ultrasound does not appear to place the patient at increased risk for preterm labour, early delivery, or other untoward pregnancy outcomes.
I am 18 weeks into my first pregnancy and have just been told that I may not be able to have a home birth because I have a fibroid on the anterior wall (about 2 inches). Obviously much will depend on what happens with the fibroid as the pregnancy progresses, but my midwife also mentioned that the possibility that I might have to have a cesaerian because of the fibroid.
Has any one either experienced or advised similar cases? I am determined to have a home birth if I possibly can, but obviously don’t want to take a ridiculous risk. Any thoughts on just how significant the risks are, and how aggressively I should push for home birth?
Many thanks, Max
On fibroids: I have read that they increase the possibility of PPH, as the uterus cannot clamp down firmly if there is a large fibroid in it. So it would be sensible to monitor its size & be aware of this around the time of birth.
I think you’ve said it yourself, “Much will depend on the fibroid”. Depending on where it is and how it grows during pregnancy, will probably determine whether the baby descends into your pelvis or not. If the baby does not descend, you are quite likely to have a slow labour with little or no progress. You may not get to the pushing stage if this fibroid obstructs your baby’s descent.
Anecdotally, a friend of mine recently had a c. section due to this same thing (a very large fibroid); the baby never descended at all when she went into labour, her cervix didn’t dilate and her contractions were very irregular. However, since she was well informed all the way through her pregnancy, she made her to decision to have a go at her labour and keep her options open. She was glad that she had done so and felt it was the right decision for her. I think your midwife is correct in informing you that you MAY have to have a c. section. If you choose expectant management (wrong word but can’t think of another), you can see if your labour progresses or not.
A fibroid that does not affect the ability of the baby to exit the uterus nor its ability to contract is unlikely to be a problem. Apparently many of us have fibroids but don’t know about them.
I just saw a woman in antenatal clinic yesterday with a fibriod. It was identified when she had an anomaly scan at 20weeks, but it has grown considerably in the last week.It is low lying and there is concern that her cervix will not be able to dilate once she goes into labour. She is coming back to see the consultant today and surgery antenatally is being considered, due to the rapid growth. As you have said it all depends on the fibroid I think, it’s size, site and whether or not it impedes your baby’s movement through your pelvis or affects cervical dilatation. I’m sure others on the list will give you more info on this and the iron levels question. I have heard that low iron levels are sometimes used to ‘persuade’ a woman into hospital when her care givers are not confident in caring for her at home.
Not very cheery anecdote for you: one of my friends had an elective CS for a large fibroid (she said as big as the baby) and breech presentation (quite possibly the fibroid influenced the baby’s position. IIRC a lot of problems with anaemia too and heavy bleeding after the birth, plus lousy breastfeeding support – but both parents were *very* happy with the birth experience. She was only able to express her distress and doubt about the birth over a year afterwards – so I think that shows the importance of women understanding *why*.
After doing some research, between pregnancies she followed some kind of detox type (no red meat, no dairy etc) diet that appeared to shrink the fibroid – I don’t know if this would be of any value in pregnancy or whether the relevant hormones are too strong.
In a second pregnancy, the fibroid didn’t present anything like the same kind of problem, the baby was head down and she planned a VBAC. A repeat CS was booked for term +14 (as no-one wanted to risk induction) – she went into labour that morning but didn’t progress and no-one fancied acceleration so the repeat was done eventually and a 4kg plus baby was born who fed beautifully (Her mother seriously contemplated not having more children because she was so distressed about the possibility of a repeat CS leading to the same problems with feeding). She’s recently had surgery for the fibroid. I’m not sure how interventionist the hospital is – one of those with individual consultant with a good reputation, but I’m not sure if she had the same one.
A cheerier anecdote – another friend deemed somewhat elderly (40!) and with fibroids was similarly warned of the risk of a CS being necessary and during labour it was deemed necessary. However, whilst this was being arranged, she gave birth vaginally.
I can see no reason at all for a Caesaean Section (C/S) unless the fibroid is below the baby’s head, blocking it’s exit from the uterus. Fibroids are really quite common in pregnancy. It is not likely to cause a problem if the fibroid is an intramural fibroid (70%) (within the muscle layer), or if it is if it is a subseral fibroid, that is, growing outwards (20%), other than labour could be delayed, but then that can be dealt with at the time and does not require a C/S.
The fibroids which may cause problems are the submucosal fibroids (10%) as they can either obstruct the passage of the baby or cause bleeding following delivery. In this case active management of third stage of labour would be recommended. I cannot see a good reason for an elective C/S unless the fibroid is very large and causing obstruction.
As fibroids are oestrogen dependent, some women try an oestrogen reduced diet. However, this is unlikely to work in pregnancy as oestrogen levels are very high.
With regard to the fibroid, I suspect it was picked up on a routine scan – right? It really depends on how the fibroids grows (or not) so your’ll just have to wait and see. And what is the worse thing that might happen in trying labour anyway – no progress in labour and baby not coming been born vaginally.
Kay, Independent midwife
Thanks to the many of you who contributed to the discussion about fibroids and home birth. You may be interested to know that I’ve just had my 20 week scan and the guy who did it couldn’t find the fibroid at all. He looked at the site where he thought it should be based on the previous scan picture/notes (behind the placenta, on the anterior wall), but said that he didnt think it was actually a fibroid. Or even if it was, it was tiny.
It does make the fact that I was told I might have to have a c/s because of it seem quite ridiculous now! In any case, I can’t see that this should stop me from having a home birth.
A woman 30/40 in this class has a fibroid (not low lying and placenta is not near the os) and she has been told that she has to have a c/s. I am trying to research why this is so.
I have found that fibroids may increase the potential for pph (ok, lets be prepared, but this could happen with a section too) .
It may lead to a malpresentation, ie the fibroid restricting the baby’s movement, but I would have thought that this would have been a wait-and-see problem, not a reason to book a c/s. Malpresentation may also lead to the potential problem of cord presentation but once again lets see what position the babe gets into…… . Any thoughts so I can balance this lady’s information so that she can have informed choice rather than (I suspect ) a one sided point of view. Unfortuately I have a feeling that she has mentally prepared herself for a section since she has been told that she needs one by her consultant.
We had a woman last year who had extemely large fibroids but who delivered normally – they were palpable! I can’t remember if she had a venflon in incase of a pph, but I think it was ‘usual’ 3rd stage management. I think the issue is the location of the fibroids really, I’ve got a vague feeling that sometimes they can send a woman into early labour due to increasing uterine size, but I might have dreamt that! Certainly a c/sec wasn’t suggested.
I sometimes suggest to women who are having care suggested that they don’t feel comfortable with to try asking ‘Oh, I had a friend with that and her consultant said there would be no problem with going for a normal delivery; is there a particular reason why you feel differently?’. Doesn’t work everytime but it makes the doctors or midwives think!!!!
Re: the fibroid – I would be interested in knowing where exactly in the uterus it is, whether it is extra or intramural, and how big it is. These are all factors. A friend of mine had an 8cm fibroid in her cervix which grew in pregnancy. Gave her lots of TPL (Threatened preterm labour. Sorry, some people refer to it at PTL, preterm threatened labour (I think)) but also stopped her from dilating! Not suprisingly, she had a C/S as the fibroid was obstructing the outlet!
Fibroids seem to be often discovered on scans these days and this leads to a succession of scans and the intervention scenarios.
In the last two years I attended one woman who had two pregnancies in quick succession. Both times a largish fibroid was detected at first scan and disappeared by 34 weeks. She always palpated large for dates. The first baby was born (term) at home – was meant to be a domino but she laboured quickly -All well. The second was supposed to be a planned home birth but born in the local BT phone box with the paramedic service just arriving, and the midwife on the way. The house phone had been broken that very afternoon so hence her walk up the street to call the midwifery answering service. Also all well in the end.
Another woman with a large fibroid in the upper quadrant that I attended gave birth at term in the hospital and was given syntometrine with her consent – again all well. By the way, that woman often had a plus of haematuria (no obvious cause found). However, she was a heavy cigarette smoker and I have found an association with haematuria and smoking before.
Pre-scan days, fibroids would not have been known about very often and so women would have just got on with giving birth without her or the midwife having to worry about them. This appeals to me both as a woman and a midwife!
My friend has just announced she is expecting. She has fibroids and had bleeding around week 6 pregnancy confirmed by scan at that time(now week 12). She is refusing to believe that she will carry to term. The fibroids are around her cervix. She is not getting any support or information and seems to have hardly any ante-natal appts in the next 6 months.
1. Do fibroids affect chance of coming to term?
2. Does she have a chance of vaginal birth with fibroids being where they are?
3. Any chance of vaginal birth with the fibroids?
1. I think that fibriods often affect pregnancy, but to what extent is entirely individual.
2. Again, individual, which could only be assessed at term, not now.
3. Whilst an NHS midwife, I often cared for women with fibroids, and the usual recommendation is hospital birth. I have seen quick, easy, uneventful births, but I recently attended a woman at home with a fibroid, as an independent midwife. Third stage was difficult, and she did have a post-partum haemorrhage. Mother and baby are well, no admission to hospital required, but certainly not straightforward.
However, even though my client was very weak afterwards, for some time, she dosn’t regret her decision to have a homebirth. She knows that her experience would’ve been very different in hospital. My client got very good relief from the pain the fibriod caused in late pregnancy with a TNS, and it continued to be effective for labour.
Personally, as a midwife, it is unnerving attending such women, but I am happy to do so if I am certain that they understand the risks they may be taking.
I know nothing about fibroids from a professional point of view but my ex-boss had one which was the size of a grapefruit by the time she gave birth. It was extrememly painful during her pregnancy but she had an (induced) vaginal birth on the NHS with no problems – this was at St Thomas’s in 1994 – she raved about her consultant.
Uterine Fibroids, from the Women’s Health website – run by UK obstetrician/gynaecologist Danny Tucker
Fibroids and Pregnancy – from the book “Uterine Fibroids: What Every Woman Needs To Know”, by Dr. Nelson Stringer
Obgyn-net – what you need to know about fibroids. General info, not specific to pregnancy.
The Fibroid Embolisation Website – by Dr WJ Walker. Info on uterine artery embolisation – a conservative treatment for fibroids.
Complementary Therapies for Fibroids from healthy.net
AH updated 10 April 2002