Gynecologic Tumors with Pregnancy
Prof. Dr. Mohamed Samir Fouad
Professor OBGYN Al-Azhar University
President www.arabicobgyn.net
Leiomyoma
n About 1% in pregnant women
n It is formed of fibers and muscle of uterus and can be submucous, interstitial, or subserous
n Effect on Pregnancy
n * Abortion… increase with submucous
n * Incarceration of RVF gravid uterus (posterior wall)
n * Ectopic pregnancy if pressing on the tube
n * Preterm labor
n * Pressure symptoms …increase size of uterus above expected date
n Large abdominal tumor may cause abdominal discomfort, dyspnea, palpitation
n Pelvic tumor may increase pressure on bladder, rectum and pelvic veins
n *Malpresentation
n * non-engagement of presenting part
n * Placenta Praevia due to interference with implantation of fertilized ovum in the upper segment
n * Acute abdomen ...-Red degeneration
n -torsion of pedunculated subserous fibroid
n -hemorrhage from ruptured surface vein
n Effect on Labor
n Uterine Atony… due to mechanical interference with uterine contractions :
n - Prolonged labor
n - retained placenta
n - Postpartum Hemorrhage
n Submucous fibroid increase incidence of placenta accreta and retained placenta
n Obstructed labor:
n - cervical fibroid
n -subserous fibroid impacted in the pelvis below the presenting part
n Effect on Puerperium
n * Subinvolution
n * Secondary Post partum hemorrhage (submucous or fibroid polyp)
n * Inversion of the uterus may be caused by fundal submucous fibroid
n * Increased incidence of puerperal sepsis due to infection of traumatized tumor and interference with drainage of uterus
Effect of pregnancy on Fibroid
n Increase size of fibroid due to hypertrophy and increased vascularity
n Softness of the tumor due to interstitial edema….flattening of fibroid and may become indistinct
n Subserous tumor may be readily palpated as the uterus enlarges and on occasion may be mistaken for fetal parts
n Submucous and fibroid polyp are more prone to infection specially in puerperium and after abortion
n Red degeneration is common leading to subacute or acute abdomen
n Torsion of pedunculated subserous fibroid is common in puerperium when there is rapid involution of uterus and laxity of abdominal wall leading to increased mobility of intra-abdominal organs
Management
n Follow-up
n Red degeneration with abdominal pain:
n -bed rest
n -reassurance
n -analgesics
n Torsion of subserous fibroid: surgery and removal of the stalk with fibroid …no other interferences
n Caeserean section if fibroid causing obstruction to labor ..no interference with fibroid to avoid excessive bleeding and re-evaluate after 6 weeks
n Caeserean hysterectomy may be indicated wit multiple fibroids in patient competed her family
Cancer cervix and Pregnancy
n
n The incidence of CIN varies but it is generally between 1% to 8% of abnormal cytology.
n Invasive cancer is the most common solid tumor during pregnancy
n Fortunately its incidence is 0.2% to0.9% of all pregnancies..1.4% of all cases of cancer cervix
n Symptoms
n Usually asymptomatic, detected during routine Pap smear
n Vaginal bleeding and discharge may be mistaken for pregnancy .complications
n Pelvic pain.. less frequent
Cervical Screening During Pregnancy
n Cervical cancer peaks between age 30 to 49 years
n The mean age of pregnant women with invasive cervical cancer 31.8y.
n Significant numbers diagnosed in 2nd or 3rd trimester
n Efficacy and safety of screening is well-documented
Diagnosis during pregnancy
n Colposcopy is safe and well tolerated and should be used to evaluate abnormal Pap smear
n Any suspicious lesion should be biopsed
n the overall risk of biopsy-related complications is approximately 0.6% usually mild bleeding
n Cervical conization during pregnancy..crucial in diagnosis and staging of MIC.
n Complications of Conization…
n Hemorrhage 2-13%
n Fetal loss 17%-50%, <10% in 2nd,3rd
n *PMRM *Preterm labor *infection, laceration
and stenosis * Fetal Salvage89-95%
Workup during pregnancy
n Physical examination
n cervical biopsy
n conization
n chest x-ray with abdominal shield
n since about 83% of cases are stage I cystoscopy and proctoscopy are eliminated.also I.V.U and Enema.
Treatment of CIN during pregnancy
n No indications for immediate treatment of cases with CIN during pregnancy
n Pap smear and colposcopy every trimester
n Vaginal Delivery with higher rate of regression at 6-week examination compared to Caesarean delivery
n Definitive treatment…6 weeks postpartum
Treatment of invasive cancer during pregnancy
n Invasive cancer during pregnancy is curable
n Treatment is clear in the 1st and 3rd trimester but less clear in the 2nd trimester
n the two modalities used are surgery or Radiotherapy as in non-pregnant
n First trimester(1-12weeks)
n Fetal salvage is not feasible in women receiving treatment for invasive cancer
n The maternal risk from delaying therapy until fetal maturity is excessive
n Surgery with the fetus in situ
n Second trimester (13-25weeks)
n The period of greater uncertainty
n Fetal salvage is exceedingly rare with high neonatal mortality rate
n Delaying therapy for several weeks may subject the mother to the theoretical risk of disease progression
n If patient elects to interrupt pregnancy.. The same as in 1st trimester
n If not ..define a target gestational age for fetal delivery
n Monitor by U/S..and MRI for tumor extension
n Documented lung maturity
3rd trimester Treatment
n Wait for few weeks till fetal maturity then apply definitive therapy
n Surgery in 89% may be coordinated with fetal delivery and completed as a 1-stage operation.
n If R.T..external beam immediately after delivery followed by intracavitary radiation
Ovarian tumors with pregnancy
n Incidence 1:1000 pregnancy
n Benign tumors are common e.g. luteal cyst and Dermoid cyst
n Malignant tumors 5%
-Ovarian malignancy has no effect on pregnancy and pregnancy has no effect on prognosis of ovarian cancer
-Benign cyst may undergo torsion causing acute abdomen commonly in puerperium
n Management of benign tumor
n First trimester….observe and follow-up with ultrasound till second trimester (to reduce risk of abortion) and then removal through laparotomy
n Second trimester….laparotomy
n Third trimester.. Caesarean section and removal of tumor
n Malignant tumors …treated as non-pregnant i.e. surgical staging and cytoreductive surgery
January 2006