Fibroid is very common benign tumour of uterus, during pregnancy. These are firm, benign tumours of muscular and fibrous tissue, ranging in size from the very small to very large.

TYPES OF FIBROID

EFFECTS OF FIBROID ON PREGNANCY

• Abortion• Pressure symptoms • Malpresentation.• Retro displacement of uterus.• Non- engagement of the presenting part• Preterm labour and prematurity

Cont..

LABOUR:• Malpresentation • Uterine inertia• Premature labour• Dystocia • Post partum hemorrhage• Manual removal of placenta• Difficult caesarean section.

Cont..

PURPERIUM :• Sub involution.• Secondary PPH.• Puerperal sepsis. • Inversion : fundal submucous

fibroid may cause inversion of uterus

EFFECTS OF PREGNANCY AND LABOUR ON FIBROID:

• Size, shape, consistency• Torsion • Degeneration• Impaction in pelvis.• Infection• Injury• Expulsion.• Rupture of subserous vein

SIGNS AND SYMPTOMS

• Most of the times no symptoms are present.

• Acute onset of pain over the tumour• Malaise or even rise of temperature• Retension of urine• Dry or furred tongue• Rapid pulse• Constipation

Cont..

• Tenderness and rigidity over the tumour• Sometimes foetal parts are not easily

palpated or FHS are not auscultated properly.

• Size of uterus may be more than the weeks of gestation.

• Rarely acute symptoms due to red degeneration or torsion can occur.

Cont..

Naked eye appearance of the tumour shows dark red areas with cut section reveals raw-beef appearance often containing cystic spaces. The odour is often fishy. The colour is due to presence of haemolysed red cells and haemoglobin. Microscopically, evidences of necrosis are present. Vessels are thrombosed but extravasation of blood is unlikely.

DIAGNOSTIC TEST

• History: Patient may be elderly primi or known case of fibroid, there may be history of infertility or bad obstetric history.

• Confirmation is commonly and easily done by ultrasound.

• Blood count shows leucocytosis.• The diagnosis is often made only on

laparotomy.

TREATMENT

• In asymptomatic and uncomplicated patients no treatment is required. Only frequent antenatal visits are mandatory and counseling of patient about complications which may occur.

• Conservative treatment should be followed. Patient is put to bed.

• Ampicillin 500 mg capsule thrice daily for 7 days is given. Analgesic and sedative are frequently needed.

Cont..

• In complicated and symptomatic patient treatment is given according to complication.

• In impaction one should manually remove the impaction.

• In retention of urine self retaining catheterization should be done.

• In red degeneration treatment is always conservative i.e. bed rest, higher antibiotics, analgesics, and sedation.

Cont..

• Torsion of subserous pedunculated fibroid It causes acute abdomen and laparotomy with myomectomy is indicated.

• DURING LABOUR • DURING CS

RISK FACTORS

• Human papillomavirus (HPV) infection• Sexual behaviour• Smoking. • Pregnancy• Social class• Cervical smear tests

TYPES

• Squamous cell carcinoma

• Adenocarcinoma.

EFFECTS OF PREGNANCY ON CANCER CERVIX:

• The malignant process remains unaffected during pregnancy.

• There may be a rapid spread following vaginal delivery and induced abortion.

EFFECTS OF CARCINOMA OF CERVIX ON PREGNANCY:

• As such there is no deleterious effect on fetus.

• However it increases the incidence of abortion and premature labour. IUGR can occur in cachexic patient.

• DURING LABOUR• DURING PUERPERIUM

DIAGNOSIS

Cont..

• Colposcopy allows the cervix to be visualised with a powerful light source and examined microscopically to reveal the extent of the lesion.

• Staging : Same as in non-pregnant patient. But wrong staging is possible due to increased vascularity & softening of pregnant state.

MANAGEMENT

• DURING PREGNANCY• CIN : Only follow up during pregnancy,

definitive treatment 6 weeks after delivery to rule out invasion colposcopy detected biopsy is taken.

• Micro invasive : • Cone biopsy is done to rule out deeply invasive

cancer. If cone biopsy shows micro invasion than definitive treatment 6 week after delivery.

For deeply invasive cancer :

INCIDENCE

• Simple cysts : 1 in 50 to 1 in 80.• Benign ovarian tumours :

1 in 1000 to 1 in 1500• Ovarian carcinoma : 1 in

12000 to 1 in 50000 (rare)

EFFECTS OF PREGNANCY ON OVARIAN TUMOUR

• Torsion of the• Rupture of a cyst due to mechanical

compression.• Intracystic hemorrhage due to increased

vascularity.• Incarceration during labour leading to

obstructed labour• Infection after delivery.

EFFECTS OF OVARIAN TUMOUR ON PREGNANCY:

• Pressure symptoms.• Abortion or premature labour in presence

of complications.• Malpresentation.• Impaction in pelvis.• Virilization in case of luteoma,

hyperthecosis and other tumours.

• LABOUR• Nonengagement of head.• Obstructed labour.

SIGNS AND SYMPTOMS

• Patient may remain asymptomatic or presents with the symptoms of

• Retention of urine due to impaction of the tumour.

• Mechanical distress due to the large cyst.• Acute abdomen due to complications of

the tumour.

DIAGNOSIS

• In early pregnancy on P/V examination palpable mass in adnexal region or pouch of douglas separate from uterus may be felt.

• USG in first trimester (TVS) is very helpful for diagnosis. USG also helps in differentiating benign from malignant tumour by tumour

• MRI if available is very helpful in diagnosis of dermoid.

MANAGEMENT

• Early pregnancy• Late pregnancy• DURING LABOUR

DURING PUERPERIUM

• On occasion, the diagnosis is made following delivery. The tumour should be removed as early in puerperium as possible.

• Following operation the specimen is sent for histological examination.

When the long axis of the uterus is directed

backwards during pregnancy, the uterus is said to be retroverted.

ETIOLOGY

• Presence of factors preventing spontaneous rectification.They are :-–Old adhesions,–pelvic tumours &–projecting sacral promontory with

unusually deep concave sacrum preventing upward displacement of uterus.

• Idiopathic.

MORBID ANATOMIC CHANGES IF LEFT UNCARED FOR

• FAVOURBLE:- – In the majority, spontaneous rectification occurs.

As the uterus grows, the fundus rises spontaneously from the pelvis beyond 12 weeks. Thereafter, the pregnancy continues uneventfully.

• UNFAVOURABLE: – In the minority, spontaneous rectification fails to

occur between 12-16 weeks. The developing uterus gradually fills up the pelvic cavity and becomes incarcerated.

The probable cause of incarceration are: –Projected sacral

promontory.–Uterine adhesions.–Pelvic tumour. – Idiopathic (majority).

CHANGES FOLLOWING

INCARCERATION• Changes in the uterus• Changes in the urethra and bladder• Urethral changes• Bladder changes

EFFECTS ON PREGNANCY

• Consequences of incarcerated gravid uterus• Urethra : Due to upward and forward

displacement of cervix & stretching of anterior vaginal wall, there is elongation & distortion of urethra occurs.

• Bladder : Due to acute retention of urine, bladder becomes markedly distended reaching up to umbilicus. Long standing cases edema of bladder wall and cystitis occur

• Uterus : Sometimes a portion of the uterus remains imprisoned in the pelvis, while remainder part enlarges and extends higher in abdomen called sacculation of uterus.

• With sacculation of uterus following can occur –Abortion–Preterm labour–Malpresentation–Nonengagement of

head &–Rupture of uterus during labour.

SIGNS AND SYMPTOMS

• SYMPTOMS• Patient may be asymptomatic. Symptoms

usually develop after 14 weeks.• After incarceration, dull pelvic pain. backache,

and frequency of urine, acute retention of urine, acute abdomen, and After sacculation of uterus symptoms are usually mild e.g. discomfort in pelvis.

• SIGNS• P/A :- tense tender swelling (distended

bladder) reaching up to umbilicus, which disappears after catheterization.

• Per rectum : Confirms the retroverted position of uterus.

• P/V :- Cervix often difficult to feel or felt higher up due to forward and upward displacement. On bimanual examination soft, pulsatile gravid uterus felt posteriorly in pouch of douglas. As uterus becomes impacted it is often difficult to pass a finger beyond the swelling.

DIAGNOSTIC TEST

• The diagnostic features of retroverted gravid uterus are–History of amenorrhoea–Non accessibility of the

cervix with its upward and forward direction– Swelling is due to full bladder –Ultrasonography

TREATMENT

• Before the symptoms of incarceration: In case of symptoms of threatened incarceration, with retroverted gravid uterus, following measures are undertaken.

• Patient is asked to empty her bladder frequently.

• Patient is asked to lie down in prone or semi prone position.

• After the symptoms of incarceration• If spontaneous correction fails –Manual correction by pushing the uterus

• In obstinate cases, when the above method fails due to adhesions, laparotomy may have to be done. Adhesiolysis is to be attempted failing which termination of pregnancy may be indicated.

• In diagnosed cases of anterior sacculation of the uterus, delivery by Caesarean section is the method of choice.

• Pregnancy with 1st degree uterine prolapse with mild cystorectocele is common. Pregnancy, is, however, unlikely when the cervix remains outside the introitus and continuation of pregnancy in 3rd degree prolapse is an extremely rare event

EFFECTS OF PREGNANCY ON PROLAPSE

• There is aggravation of the morbid anatomical changes in prolapse such as marked hypertrophy and oedema of the cervix; first degree becomes second degree; cystocele and rectocele become pronounced and there is aggravation of stress incontinence. These are marked during early pregnancy and the effects are due to the weight of the uterus and increased vascularity.

• Vaginal discharge may be copious and decubitus ulcer may develop when the cervix remains outside the introitus.

• There is chance of incarceration, if the uterus fails to rise above the pelvis by 16th week of pregnancy.

EFFECTS OF PROLAPSE ON

PREGNANCY• Symptoms like lower abdominal pain and

backache increases• Increased vaginal discharge• Difficulty in micturition and defecation.• Abortion• Premature labour.• Premature rupture of the membranes• Intrauterine infection.

• LABOUR:• Early rupture of membranes.• Prolonged labour due to delayed dilatation of cervix

and due to sagging cystorectocoele.• Cervical dystocia.• • PUERPERIUM :• Puerperal sepsis.• Subinvolution.

TREATMENT

• If the cervix is outside the introitus – The cervix is to be replaced

inside the vagina and is kept in position by a ring pessary

– The patient is to lie in bed with the foot end raised by about 20 cm.

• To relieve oedema and congestion of the prolapsed mass, it should be covered by gauze soaked with glycerine and acriflavine.

• Perineal exercises.• The treatment is continued until 18-20th week

of pregnancy till the prolapsed mass is reduced in size and replaced inside the vagina.

• If reposition is not possible and there is incar ceration, termination of pregnancy may be indicated.

• If the cervix remains outside the introitus even in the later months, it is preferable to admit the patient at 36th week.

DURING LABOUR

• The patient should be in bed, not only to prevent early rupture of the membranes but also to facilitate replacement of the prolapsed cervix inside the vagina.

• Intravaginal plugging soaked with glycerine and acriflavine not only helps in reduction of cervical oedema but also facilitates its dilatation.

• Prophylactic antibiotic, in cases of premature rupture of the membranes or when the cervix remains outside, should be administered.

• Hylase injection in the substance of cervix to soften it can be tried. It helps in dilatation

• Manual stretching of the cervix or pushing up the cystocele or rectocele past the presenting part during uterine contractions facilitates progressive descent of the head

• If the head is deeply engaged with the cervix remaining thin but undilated, delivery maybe facilitated by Duhrssen's incision at 2 and 10 O'clock positions followed by ventouse extraction or forceps application.

• If the head is high up and/or the cervix remains oedematous, thick or undilated — Caesarean section is a safe procedure

DURING POST PARTUM PERIOD

• Best rest.• If 3rd degree prolapse,

glycerine + MgSO 4 pack is applied. Ring pessary may be useful.

• Prophylactic antibiotics.

• Surgery for prolapse is contraindicated in antepartum and post partum period. Definitive surgery is done only after 6 months of delivery and preferably after the patient starts menstruating.

• If there is history of sling surgery, some prefer LSCS to prevent recurrence after delivery but usually vaginal delivery is allowed.