Regarding the effects of fibroids on obstetrical outcomes

4 05 2012

To the Editor:

We read the recent article by Shavell et al. (1) regarding the effects of fibroids on obstetrical outcomes and have the following comments:

First, the number of women in each group was very small (n=95) and the number of women with fibroids >5cm was much smaller (n=42). Compare this with the study by Stout et al. (2) where 2,058 women with fibroids were compared with 61,989 without fibroids, all of whom had routine second trimester ultrasounds. Stout reported significant differences in OR for placenta previa, abruption, PROM, preterm birth 5 cm. It would be helpful for the authors to describe criteria for transfusion.

Finally, Stout did report outcomes for women with fibroids > 5 cm (n = 593) compared with fibroids 5cm. Abdominal or laparoscopic myomectomy can be associated with significant morbidity including infection, injury to internal organs, risk of blood transfusions, adhesion formation, risk of uterine rupture during pregnancy, and possible need for cesarean section. We do not believe this study should be used as a justification for surgery.

Thank you for considering these issues.

William H. Parker, M.D.
UCLA School of Medicine, Los Angeles, California

David Olive, M.D.
Elizabeth Pritts, M.D.
Wisconsin Fertility Institute, Middleton, Wisconsin

References

1. Shavell VI, Thakur M, Sawant A, Kruger ML, Jones TB, Singh M, et al. Adverse obstetric outcomes associated with sonographically identified large uterine fibroids. Fertil Steril 2012;97:107-10.

2. Stout MJ, Odibo AO, Graseck AS, Macones GA, Crane JP, Cahill AG. Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstet Gynecol 2010;116:1056-63.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2012.05.008

The authors respond:

We appreciate the interest of Drs. Parker, Olive, and Pritts in the impact of uterine fibroids on pregnancy outcome. As indicated in our manuscript (1), there were 95 women in each group; this number of patients was substantial enough to find significant differences in important obstetric outcomes, including delivery at an earlier gestational age, preterm premature rupture of membranes (PPROM), short cervix, blood loss at delivery, and need for postpartum blood transfusion. Thus we believe that our observations represent a significant contribution to the scientific literature.

In contrast to the study published by Stout and colleagues (2), the women with fibroids identified on routine obstetric ultrasound in our study were age-matched to women not found to have fibroids on ultrasound during the same time period. Furthermore, the two groups were not statistically different with respect to gravidity, parity, BMI, race, absence of past medical problems, substance use, and prior preterm delivery. As the two groups were similar with respect to these characteristics, we did not perform logistic regression to account for their impact on obstetric outcomes. However, controlling for age, BMI, history of diabetes or chronic hypertension, and substance use during pregnancy, women with large fibroids (> 5cm in diameter) were 8.8 times more likely to have PPROM compared to women without fibroids, 5.3 times more likely to be diagnosed with short cervix prior to 32 weeks gestational age, and 14.2 times more likely to receive a blood transfusion after delivery. The criteria for blood transfusion at our hospital primarily rely on the discretion of the healthcare provider. Generally speaking, however, a patient who is symptomatic with hemoglobin less than 8 g/dL warrants consideration for transfusion.

Although the findings from this study are compelling, our study did not address a major issue commented upon by Drs. Parker, Olive, and Pritts. Despite our observation that the presence of large fibroids had a substantial detrimental effect on pregnancy outcome, we have not examined the important question of whether performance of a myomectomy to remove large fibroids would improve any or all of these clinical outcomes. Thus we agree that the data presented should not be used as justification for routine myomectomy prior to conception. Future randomized controlled trials must be conducted before the benefits and risks of myomectomy prior to pregnancy may be determined for women with large fibroids.

Thank you for the opportunity to respond to these issues.

The authors would like to acknowledge the work of Mili Thakur, M.D.; Anjali Sawant, M.D.; Theodore B. Jones, M.D.; Manvinder Singh, M.D.; and Elizabeth E. Puscheck, M.D.

Respectfully,

Valerie I. Shavell, M.D., Michael L. Kruger, B.S., and Michael P. Diamond, M.D.
Wayne State University and the Detroit Medical Center, Detroit, Michigan

References

1. Shavell VI, Thakur M, Sawant A, Kruger ML, Jones TB, Singh M, et al. Adverse obstetric outcomes associated with sonographically identified large uterine fibroids. Fertil Steril 2012;97:107-10.

2. Stout MJ, Odibo AO, Graseck AS, Macones GA, Crane JP, Cahill AG. Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstet Gynecol 2010;116:1056-63.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2012.05.009

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