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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

 

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January 2006

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