EFFECT OF LEIOMYOMATA IN PREGNANCY
Although leiomyomata are equivocally associated with infertility, patients with leiomyoma do become pregnant. Pregnancy withsmall leiomyomata is usually unremarkable, with a normal antepartum course, labor, and delivery. However, women with myomas greater than 3 cm may have significantly increased rates of preterm labor, placental abruption, pelvic pain, and cesarean delivery. Myomas may sometimes cause pain, as they can outgrow their blood supply during preg-nancy, resulting in red or carneous degeneration. Bed rest and strong analgesics are usually sufficient as treatment, although on occasion myomectomy may be needed. The risk of abortion or preterm labor following myomectomy during pregnancy is relatively high, so that prophylactic β-adrenergic tocolytics are frequently used.Myomectomyduring pregnancy should be limited to myomas with a discrete pedicle that can be clamped and easily ligated. Myomas shouldotherwise not be removed during time of delivery, because bleeding may be profuse, resulting in hysterectomy. Vaginal birth after myomectomy is controversial and must be decided on a case-by-case basis. Removal of an intra-mural leiomyoma is especially hazardous for subsequent pregnancy. After myomectomy there is a significant risk of uterine rupture during a subsequent pregnancy, even at times remote from labor. When a myomectomy results in a defect through the myometrium, subsequent pregnancies should be delivered before active labor begins. Rarely, myomas are located below the fetus, in the lower uterine segment or cervix, causing a soft tissue dystocia, leading to a need for cesarean birth.