Ep 103: Uterine Fibroids in Pregnancy

Ep 103: Uterine Fibroids in Pregnancy

Nicole: This is a topic that I've gotten a lot of questions about, and that is fibroids in pregnancy. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Well, hello! Welcome to another episode of the podcast. This is episode number 103. Thank you. Thank you for being here and spending some of your time with me today. So you're going to learn today about uterine fibroids in pregnancy, and I've actually gotten quite a few questions about this more honestly than I think I would have expected. And the questions indicate that there's just a lot of unknown, uncertainty, maybe a bit of misunderstanding about fibroids in pregnancy. So in this episode, you're going to learn first a bit about fibroids outside of pregnancy, because it's important to understand that in order to understand how they impact pregnancy. So we'll just talk about what fibroids are, how common they are, some risk factors for fibroids, and then go into what happens with uterine fibroids in pregnancy. Some of the symptoms that you may experience, complications that can arise, how fibroids can change the way that we manage pregnancy, and then what happens if you've had fibroids removed before your pregnancy. Now, before we get into the episode, let me do a listener shout out. This is to the colors of the harder style and the title of the podcast is, I'm sorry, the title of the review is my favorite podcast. And the review says I am currently 30 weeks pregnant and found this podcast when I was about nine weeks along. I have made my way through almost every episode now. And I just love Dr. Rankins. She has a very unique and unbiased way of delivering information and her voice is so soothing. My husband and I just started her online birth course as well. And it is just as amazing as the podcast. I am so grateful I found this pod. It has truly been a highlight in this journey. Well, thank you. Thank you for that really, really lovely review.

Nicole: I so appreciate you inviting me to be along on your pregnancy journey. And I'm glad that you found the podcast helpful. I'm also thrilled that you're in the Birth Preparation Course and that you and your husband are going through the course together. It's so important that your partner participates in childbirth education as well. It will help them be ready to advocate for you if need be. And this is especially important during COVID times where hospitals are necessarily limiting who can be in the delivery room. Now the updated version of the Birth Preparation Course is dropping next week. Yay. And I am super excited about that. And as you heard from the colors of the harder style in her review, she said the course is already great, and now it's going to be even better. So don't wait, just come on in now. When you enroll, you get access to the updated versions for free.

Nicole: You also get lifetime access to the course. And the course also has this fantastic bonus where you get access to a private Facebook group. I'm in the group, weekly doing Q and A sessions. We have a wonderful community manager, Keisha, who is an amazing doula, but the best part of the group is the members and how they support one another throughout the pregnancy, birth and postpartum journey as well. So come on, join us, check out the details of the course at drnicolerankins.com/enroll. The course is currently 40% off, COVID discount. So it is super affordable for all the value. I would love to see you there again. That's drnicole rankins.com/enroll. All right, so let's get into the episode and talk about uterine fibroids.

Nicole: So fibroids are non-cancerous tumors that come from the smooth muscle cells. The muscle cell layer of the uterus. The uterus has three layers. The inner most layer is the endometrium. That is the layer that sheds during a menstrual period. Then the thick or middle layer, the muscle layer, is the myometrium. That is where fibroids develop from smooth muscle cells in the myometrium. And then the outermost layer of the uterus is the serosa layer. And that's kind of a thin filmy layer that overlays the uterus. Now fibroids are often or sometimes referred to as myomas and the medical term is leiomyoma, but I'm just going to say fibroids during the episode, fibroids happen almost exclusively in reproductive aged women, like you're not going to see them in children. You also don't see new fibroids develop after menopause. You may see them in younger women, very, very rarely, very rarely in adolescents, but mostly it's reproductive age women and outside of pregnancy.

Nicole: If they cause symptoms and keep in mind that not all fibroids cause symptoms, there are plenty of people who have uterine fibroids and they don't bother the person at all. They don't cause any symptoms, but if you do have symptoms, so symptoms will typically be abnormal uterine bleeding, and that's typically going to be heavy menstrual periods. Sometimes the periods are also irregular, but heavy bleeding, and then also symptoms just from the size of the fibroids being there. And typically that can manifest as pelvic pain or pelvic pressure. Now, the way that we describe fibroids is by their location within the uterus. So submucosal fibroids, those are fibroids that are in the muscle layer, but they're closest to the endometrium, to the lining of the uterine cavity. And we classify these roughly as protruding into the uterine cavity, less than 50%, greater than 50%. So these again are ones that are closest to the endometrium or the uterine cavity.

Nicole: Then intramural fibroids are just mostly in the wall, in that muscle layer of the uterus. And then subserosal fibroids are fibroids that are closer to the serosal side of the uterus. So more on the outside of the uterus, they can sometimes be what's called pedunculated meaning that they are hanging off of a stalk. Okay. So again, the fibroids are either closer to the endometrium. So protruding into the endometrial layer that submucosal, then intramural in the wall, and then subserosal on the outer most part and they can be pedunculated. Oh, there's also rarely cervical fibroids, where you have fibroids in the cervix, the uterine cervix, that's really rare, but that is a possibility as well. I will have a couple of images in the show notes page of the website. If you want to go take a peak and get a better idea of exactly what I'm talking about, it can be easier to see visually.

Nicole: And the show notes page is going to be drnicolerankins.com/episode103. An episode is all spelled out. So drnicolerankings.com/episode103. All right, how common are fibroids? Well, fibroids are actually the most common pelvic tumors in women. It's a little bit hard to know exactly how common they are because studies are always done in people who have symptoms or they're done when we look at the uterus after hysterectomy, hysterectomy is a surgery to remove the uterus. And that's how we look at how often fibroids occur sometimes. So we don't necessarily capture people who are walking around and have fibroids, but don't have any symptoms because in that case, we wouldn't be looking for fibroids. Now, with that being said, we do have some data about fibroids and it varies, but on the end, they occur as low as 7% in white women, around in 25% of black women.

Nicole: And I'll talk about those racial and ethnic, ethnic differences more in just a minute. And then on the high end, studies have shown that fibroids occur as high as 43% in white women and 59% of black women. Okay. So in general, they are pretty common and the prevalence of fibroids increases as women get older. So you're going to find that they're more frequent in women who've, um, who are older. So in their thirties or forties, the good news is they do actually shrink after menopause, or they don't grow after menopause. They're responsive to hormones too. Again, they're only happening at reproductive age women, but they increase as we get older. And then after menopause, they're not a problem anymore. So what are some risk factors for fibroids? One of the biggest factors that risk factors that we know of is race. Black women have a two to three fold, greater risk of fibroids than white women.

Nicole: We do not exactly know why this is the case. It's been hypothesized, that there are differences in genetic factors or diet or lifestyle, uh, stress, um, also environmental exposures between black and white women that contribute to this disparity. But again, we don't know a hundred percent why. There is a study underway called the study of environment, lifestyle and fibroids. It's in the Detroit area. I believe it's enrolled about 1500, 1600 black women in order to understand risk factors for fibroids within black women. So hopefully we'll have more data as studies come out, but there is definitely a big disparity and difference there.

Nicole: They're also different in the natural history of fibroids by race. Most white women with symptomatic fibroids are in their thirties or forties. However, black women typically develop symptoms on average four to six years younger, and they may even have significant issues with fibroids in their twenties. It also appears that fibroids grow at a slower rate after age 45 years in white women, but not in black women. And again, we don't necessarily understand those differences, but we are working to try to understand those differences. So let's talk about some things that influence fibroids developing, and I'm just going to kind of go through a laundry list of things. So one thing that influences fibroids is if you have one or more pregnancy. Pregnancies, rather that goes beyond 20 weeks, that will actually decrease the chance of having fibroids. Again, we don't know why that happens, but having a pregnancy that goes beyond 20 weeks will decrease the chances of fibroids happening. On the flip side, early periods, so you're starting your period early at less than 10 years old in particular. That sounds crazy, crazy young, but starting your period early is associated with an increased risk of developing fibroids. And that may be because you have a longer reproductive lifespan because your periods are the start of technically, you know, when you can get pregnant. So that may be part of it. And it's also thought that this may be part of the reason why fibroids are more common in black patients because black women typically have their periods earlier than white women. Hormones actually don't seem to make fibroids worse. You would think that maybe it would because, you know, they're more active in the reproductive age years when hormones are active, but it doesn't appear that using particularly standard or lower dose oral contraceptive pills, birth control pills, they don't tend to cause fibroids to grow.

Nicole: Therefore birth control pills may be useful, or they may, at least you don't have to stop them. If you do note that you have fibroids. There is one study that showed that this is the nurses' health study that showed that using birth control pills, um, did increase the risk of fibroids if you started using birth control pills as a teenager, but really that's just one study. Overall birth control pills don't seem to make fibroids get worse. Also long acting what's called progestin only contraception. So like Depo Provera may actually protect against the development of fibroids. Also progestin only birth control pills like the progestin intrauterine device, the Mirena, or, uh, Kylena have shown that they can actually decrease fibroids in size by just a little bit, not a lot, but, uh, contraception with only just progestin. And I should back up and say birth control pills typically have both estrogen and progestin.

Nicole: So two hormones in them, whereas progestin only methods like Depo Provera or the Mirena IUD only have progestin in them. Those progestin ones may decrease the size of fibroids. Okay. Some other things that may influence fibroids, there is a relationship shown between fibroids and increasing weight. However, it's varies by study. So that is not a very, very strong association, but that association is there. There are also some differences in fibroid development related to diet. It has been shown that significant consumption of red meat or also ham is associated with an increased risk of fibroids anywhere from a 1.3 to 1.7 increased risk of fibroids, whereas consumption of green vegetables and fruit, especially citrus fruit, like oranges can, uh, decrease the risk of fibroids. And I will say that I have seen a couple of cases where people have, um, had a dramatic difference or decrease in their sizes and the size of their fibroids based on changing their diet, particularly going vegetarian or even vegan.

Nicole: Um, that ha that has made a difference. Again, that's just my anecdotal experience. Not proven by studies that changing your diet will make the fibroids go away. But studies do show that if you consume more vegetables and fruit, you decrease the risk of fibroids. Also consuming vitamin A will decrease the risk of fibroids. You can find items and it has to be vitamin A particularly from animal sources. So like salmon, tuna, or cheeses can decrease the risk of fibroids. And there's also increasing, um, evidence that vitamin D deficiency can increase the risk of fibroids. That's also another reason why it's thought that black people have an increased risk because we have a higher risk of having low vitamin D. Caffeine is not a real strong risk factor for fibroids. Alcohol, however, is a risk factor for fibroids, especially beer. That does appear to increase the risk of developing fibroids.

Nicole: And then oddly enough, smoking decreases the risk of having fibroids. Obviously that is not a reason to smoke, but smoking does decrease the risk of fibroids. There's also a genetic component where you may often see the fibroids run in families, whether it's between mothers and daughters or sisters, there's definitely some genetic predisposition as well. And then finally having trouble with blood pressure, hypertension will also increase the risk of fibroid development. Okay, so let's talk about fibroids in pregnancy. So again, it's a little bit difficult to tell exactly how common they are in pregnancy. Although we do ultrasounds typically in pregnancy, especially if they're small fibroids, we may not see them, but roughly fibroids affect anywhere from two to 10% of pregnancies, the prevalence of fibroids is going to increase as mom's age increase and just like outside of pregnancy, it's higher in black women than in white women or Hispanic women.

Nicole: So what happens with the course of fibroids during pregnancy? We know that there are a lot of hormones in pregnancy. We know that fibroids are influenced by hormones because they happen in reproductive age women. Also, we know that the uterus is growing. So how does that impact fibroids? And then there's also a tremendous amount of increased blood flow to the uterus during pregnancy. So how does that impact fibroids as well? Well, the body of evidence suggests that fibroids actually will remain stable for most folks across pregnancy. So roughly half of cases, fibroids will stay the same. They won't get any bigger, they won't get any smaller, they will stay the same during pregnancy. And then in the other 40% or so, about half of those will increase in size and the rest will decrease in size. There's not a good, hard and fast way to predict which ones will do which, but we do have some factors that may give us some clues, for example, larger fibroids and those that are greater than five centimeters, five centimeters is roughly about a two inches. An inch is two and a half centimeters. So five centimeters is roughly about two inches. So fibroids that are larger than that are more likely to grow. Whereas smaller fibroids are more likely to remain stable in size. And even with fibroids that do increase, they don't increase by a ton, very few increase by more than 25%. So they're not like growing tremendously during pregnancy. Also, they don't grow in a linear fashion, so it's not like they grow a little bit each week, a little bit each week. What we see is that they typically increase in size, the most growth occurs in the first trimester with little growth occurring during the second and third trimester. So that can be reassuring that if you have fibroids that most likely they're going to, or you have a 50 50 shot that they're going to, or more that they're going to stay stable or get smaller.

Nicole: And even if they do increase, they don't increase by a ton. And all of that growth is typically going to happen in the first trimester. And then in the postpartum period, actually almost 90% of women with fibroids, if they were detected in the first trimester, most women postpartum will have regression. They'll get smaller when you look at them three to six months postpartum. So that's also reassuring news. And that kind of goes along with what I said earlier, that if you have children, then it can decrease your risk of fibroids. About 10% though, those other 10% will have a decrease, but again, 90% postpartum they will get smaller. All right, what are the symptoms of fibroids as they relate to pregnancy? Well, the good news is that usually they are completely asymptomatic and most people do not have issues with their fibroids during pregnancy. Now, if you do have symptoms, the symptoms are typically going to be pain, pelvic pressure, and that's very similar to outside of pregnancy.

Nicole: And then rarely vaginal bleeding. The most common symptom by far is pain. And the frequency of pain is going to increase with the increasing size of the fibroids. And again, that makes sense when you have this bigger thing, that's, there is going to cause some discomfort, particularly if it's really big, say seven to 10 centimeters, then it's going to potentially cause some discomfort. And most patients only have a localized pain like where the fibroid is. Sometimes you may have fever with it. Sometimes you may have nausea or vomiting. That's not very common, but most of the time, the most common symptom is pain and it's going to be pain right where the fibroid is. Now that pain typically presents it's going to happen in the first trimester or in the early second trimester, which corresponds to that period of most rapid growth. It can however happen at any point in pregnancy.

Nicole: I know I had a friend who had issues with fibroids in the third trimester of her pregnancy. I've seen it a couple times where folks have issues later on. It's not something that happens very commonly, but it can happen at any point in pregnancy, its more likely to happen in the first trimester or early second trimester. But again, sometimes that pain can happen at any point in the pregnancy. And that pain typically comes from something called degeneration of the fibroid. So what happens is that if the fibroid grows in size, particularly if it grows faster than the blood supply to the fibroid, that leads to a circumstance where the fibroid is actually not getting enough blood to keep up with the growth. And that causes the fibroid to die. Something called necrosis, and that can be painful. So that is the most often reason why a pain happens.

Nicole: It's related to this degeneration. Now rarely there can be issues with something called torsion where fibroids twist on themselves. That's only for pedunculated fibroids. Those ones that can be hanging off of a stalk. And that's much less common in pregnancy. Most often it's going to be pain from the fibroid degenerating. Now let's go through some of those other complications and things that can potentially happen during pregnancy related to fibroids. And I'm going to go through the things that are most strongly associated. And then to the end of the list, things that are least associated with fibroids. I just talked about degeneration. That's the most common thing that we know. Miscarriage can also happen in patients with fibroids for those submucosal fibroids. And submucosal fibroids again are the ones that are closest to the endometrium, the inner layer of the uterus. And if that fibroid is there, particularly if it's a bigger fibroid and the placenta implants near that, or around that it can affect implantation, they can affect the ability of the placenta to establish a normal blood flow so that can potentially increase risk for miscarriage.

Nicole: Um, with those submucosal fibroids, we definitely don't see that same sort of effect with intramural fibroids. Those fibroids that are in the wall of the uterus and the pedunculated fibroids are the one that ones that are furthest away from the endometrium, the subserosal fibroids, they don't particularly cause any issues with miscarriage. The risk is with those submucosal fibroids and the more submucosal fibroids you have, the higher the risk. And that makes sense, because again, there's going to be areas where it may be difficult for the placenta to implant properly because the fibroids are distorting the normal anatomy. There's also a little bit, bit of an increased risk of preterm labor and preterm birth in pregnancies where uterine fibroids are an issue. That's going to be more, the risk is going to increase, I should say, rather with having multiple fibroids or if the placenta is near the fibroid.

Nicole: Also, if the fibroid is larger, okay. And again, all of these things make sense. If you have this fibroid, this thing, that's there, this tumor and it's interfering with the placenta and the bigger it is, the more likely it is to take up space. Then that's going to increase the risk of things happening. It can similarly increase the risk of bleeding during pregnancy, as well as something called placenta abruption. Placenta abruption is when the placenta separates away from the wall of the uterus prematurely. So the placenta is not supposed to separate away from the wall of the uterus until the baby is delivered because being connected to the uterine wall is how it connects to mom's blood flow and does the oxygen exchange and exchanges nutrients and all of those things like that. So the placenta has to stay firmly attached to the uterus until after the baby is born.

Nicole: Placenta abruption is when that process happens before the baby is born, it can be quite dangerous in certain circumstances. And there is a slightly increased risk of placenta abruption with fibroids. Again, it's going to be related to the location of the fibroid and where that is in relation to the placenta in order to determine whether or not that is a big risk, if the fibroid is near where the placenta is, then that's going to increase the chances of placenta abruption. And I'm feeling like I'm sounding like a broken record at this point, but also if the fibroid is bigger than that is going to increase the risk of abruption as well. So another thing that may happen with fibroids, and I should say, let me back up. Most women with fibroids. I don't think I said this. Most women with fibroids actually have no complications during pregnancy related to the fibroids.

Nicole: I should have led with that. That should have started with that first, most women do not have any complications during their pregnancy or birth related to fibroids. Okay. So let, let me say that for sure, but I do want to make you aware of the possible things that can happen. So let's continue to go through that list. The next one is mal presentation, meaning that the baby presents in a, uh, uh, presentation other than the head down, and that is going to happen if a large fibroid distorts the shape of the uterine cavity and makes it so that the baby settles in a position and can't get in a position that's head down that is going to be related to larger fibroids and particularly over 10 centimeters. So those really big fibroids will make it hard for the baby to turn inside the uterus. So mal presentation is a possibility as well.

Nicole: Dysfunctional labor is also a possibility. Fibroids are in that muscle layer of the uterus. And if those muscles have to work around this fibroid, this tumor that's there, particularly if it's large, then it may decrease the force of contractions. Contractions happen in that muscle layer of the uterus. So it may make it difficult for the uterus to kind of have that nice coordinated contraction or spread that contraction all through that muscle layer. And if so, then that potentially may lead to a dysfunctional labor pattern where the contractions aren't as strong as we'd like, or they're not as regular as we like because the uterus can't quite get the contractions coordinated around the fibroids. And then finally, fibroids are associated with a slightly increased risk of Cesarean birth, especially if the fibroids are located in the lower part of the uterus. And part of it is related to mal presentation, meaning the baby can't get in the right position.

Nicole: And part of it may be related to dysfunctional labor. Some of it may be related to literal obstruction of the baby coming out if the fibroid is in the way of the baby coming through the vagina. Then that is going to increase the risk of the Cesarean as well. Part of it may be related to the increased risk of placenta abruption. And it's hard to determine like which one of those factors is the most, um, or strongly, most strongly associated I should say. But all of those things together can increase the risk of Cesarean birth. Fibroids can also increase the risk of postpartum hemorrhage, a slightly increased risk of postpartum hemorrhage with fibroids, especially if fibroids are larger, especially if fibroids are near the placenta. Uh, and also if the delivery is by Cesarean birth. Now I know I just laid out a lot of like potential difficult things, but again, let me reiterate that most women with fibroids do not have any significant problems or issues or complications during pregnancy or birth.

Nicole: The most common thing that I see for sure is pain. If something is going to happen, it's going to be pain for my degenerating fibroid. And I'll talk a minute about how we manage that. But most people do not have any issues related to fibroids. Now I do want to take a moment and mention some things that are not associated with fibroids. So some things that you don't have to worry about an increased risk of, and that's preterm, pre-labor rupture of membranes. So, uh, peop prom preterm, um, pre-labor rupture of membranes. It doesn't increase your risk of your water breaking early. It doesn't increase your risk of placenta previa, which is where the placenta is overlying the opening to the cervix. So fibroids do not increase the risk of placenta previa. Fibroids do not increase the risk of growth restriction or they don't interfere with the baby growing well.

Nicole: So that is good to know. Also do not increase the risk of stillbirth. Also another good thing to know, to know and don't increase the risk of preeclampsia. So although fibroids do have some things that they're associated with, there are some things that are definitely not increased with fibroids. So that's good news too. So let's end with how we manage fibroids during pregnancy. All right. So one thing to talk about is, is it possible, or is it appropriate rather, should I say to have fibroids removed before pregnancy? All right. In order to reduce the risk of any complications or issues happening and that decision is really made on an individual basis. It depends on a lot of factors. It depends on your age. It depends on your past pregnancy history. It depends on the severity of your symptoms. It depends on the size, the location of the fibroids.

Nicole: So I cannot give a, uh, cut and dried response about you should have it removed, or you shouldn't have a re have it removed. It's really an individual approach, but that is something to consider. If you know you have fibroids, then you may want to talk about whether it's worthwhile or appropriate or beneficial to have them removed prior to pregnancy. Now, as far as how we manage things that may pop up related to fibroids, as I said, multiple times, the most common thing is going to be pain. Very rarely, uh, pregnant people may require a hospitalization for pain management related to fibroids when that degeneration happens and that necrosis is tissue dying, and that is perceived as a painful process. So typically we start with Tylenol. We don't have a whole lot of pain management options available other than Tylenol. And then, um, we can use NSAIDs nonsteroidal anti-inflammatory drugs.

Nicole: So that's Motrin. The generic is ibuprofen. Um, also Aleve is in the NSAID family, but we can only use those for a short course, less than 48 hours or around 48 hours or ideally 48 hours, I should say, because they have some effects on pregnancy. They can, um, cause oligohydramnios, where the fluid is low. They can cause some issues in the baby's heart if used for a long period of time. So we really want to avoid NSAIDs for longer than 48 hours. If we have to, if for some reason we had to do it longer than that, then typically we do weekly ultrasounds to check on the baby, but we use Tylenol and combination with NSAIDs for a short period of time can, because usually that degeneration is not like, um, it's not going to happen like over like weeks and weeks and weeks, it's typically a short term thing that happens over a few days.

Nicole: And once we get you over that hump, then things are typically, okay. So it's a short-term thing that happens in that short course of NSAIDs works really well. And then if the Tylenol and the NSAIDs aren't working, then we can certainly add opioid medications if need be for, um, managing pain. We do have to be careful about using opioids because longer opioid use increases the risk of opioid dependence, but we can certainly use opioids if need be. And that may be Percocet or Oxford park has said is a combination of oxycodone, which is the opioid and Tylenol, but that's the most common one that we use. We can use those opioid medications if needed. And we can also repeat the core, the medicines if needed. So for example, if it, you know, 18 weeks you have a bout of pain because of the fibroid. And then for some reason it pops back up again at 25 weeks, then we can repeat a course of the NSAID medications, again, a short course of the opioids again, if need be.

Nicole: Um, so it can be repeated if, if, if that's necessary. Now, the other option for treatment of fibroids is procedures or surgeries. And actually let me back up for a second and say that in general, fibroids are treated either by hormones or medications that indirectly affect hormones. So either we try birth control pills, progestins or something called, is it like big classes of medicines that can affect your brain, sends you in the menopause, so to speak that affect hormones, but none of these can be used in pregnancy. So we can't use those hormones. We can't use medicines that throw you into menopause in pregnancy. Um, so our only option really are those pain management medications. And then the other option for treatment of fibroids, um, outside of pregnancy is procedures or surgeries where we block blood flow to just the fibroid itself, as best we can.

Nicole: We use something called high-frequency ultrasound to basically make the fibroid die, essentially removing the fibroid itself and then hysterectomy. And as you can imagine, all of those things are going to impact a developing pregnancy if you're blocking the blood flow, trying to, to the fibroid, but in the blocking the blood flow to the uterus that's to cut off the blood supply to the baby, you can't use like high-frequency ultrasound in order to cause a fiber to die without that ultrasound, high-frequency different than regular ultrasound, how that ultrasound is going to affect a baby. If you're removing the fibroid, you're cutting the uterus open, then that's going to potentially disrupt the pregnancy. And obviously you can't do a hysterectomy. So I say all that to say is that there aren't a lot of options available for treatment of fibroids in pregnancy. I had someone message me and she sounded so desperate.

Nicole: I felt really bad. My heart went out to her because she was just perplexed that there wasn't a lot that could be done in order to manage the discomfort that she was having from this large fibroid. And, um, you know, she had like I've searched and I've had my doula search. And, um, it was hard to say, you know, you don't see anything because there's nothing there. Unfortunately, really the biggest thing that we have is pain control with medication and then, uh, addressing the fibroid with surgery afterwards. Now there are some rare circumstances where a myomectomy and myomectomy is just removing just the fibroid where that may happen during the pregnancy. I have never, in my 15 years of practicing seen this happen, because there is a big potential for bleeding. There's a big potential for miscarriage, for preterm delivery, for uterine rupture, where the uterus opens up.

Nicole: So I have never seen a myomectomy done during pregnancy because it is definitely, definitely very risky. Uh, but if there is a circumstance where there's no other way to, to fix the problem or the pain, then that may be an option as, as well. I think one place where it may be an option for sure is if you have a pedunculated one that's hanging off of a stalk and that is causing a lot of pain or discomfort or, um, from necrosis or is causing some sort of obstruction or in the way with things. And that may be something to consider during pregnancy. But again, in general, doing a myomectomy during pregnancy is very risky. And there's also a lot of, uh, bleeding during a myomectomy outside of pregnancy. And certainly during pregnancy where the blood flow to the uterus is increased by a tremendous amount.

Nicole: So hysterectomy is an assess is possible as well. So again, we avoid myomectomy unless we absolutely have to. Now just to wrap up as far as the route of delivery, um, most women with fibroids will have a successful vaginal birth. Okay. So let me say that again, most women with fibroids will have a successful vaginal birth. So you should definitely be offered the opportunity to have a fibroid. Indeed, ie actually prefer to avoid a Cesarean birth if we can with fibroids, because depending on the location, bleeding can be quite significant. And if you have to go through a fibroid to get through the baby, like cut through a fibroid to get through the baby, um, that can definitely increase the risk of hemorrhage. So we would prefer a vaginal birth for sure, in someone who has fibroids. We occasionally may plan a Cesarean birth if the fibroid is in a place where we know it's going to obstruct labor, and then we're going to plan it as best we can to have blood products available, have support staff available, all of those things available.

Nicole: But in general, we definitely want to try for a vaginal birth and most women will have a vaginal birth. And if you do end up needing a Cesarean, please know that most of the time things go just fine. And it's not an issue and not any problems. Sometimes if fibroids are right in the way of where we're cutting, then we have to be creative about where we cut on the uterus in order to get the baby out. But even this, the Cesarean birth, uh, tends to go fine without any issues. We just have to be prepared, have blood products available just in case, have help available just in case. A really common question is why not just remove the fibroid at the time of the Cesarean since you're already in there. But again, removing fibroids even outside of pregnancy can cause a lot of bleeding definitely in pregnancy can cause even more bleeding because of the increased uterine blood flow to the uterus.

Nicole: So we do not remove fibroids at the time of Cesarean unless we absolutely absolutely have to. And remember that most often they're going to decrease in size after pregnancy anyway. And I said, that was the final thing, but actually there's one more thing. What about if you've had a fibroid removed prior to pregnancy, how does that affect your route of delivery? Well, it really is individualized debate based on what type of surgery you had in order to remove the fibroid. The issue is that essentially if we have to cut through a lot of the uterus and remove several fibroids and then put all of that back together, that the uterus is not going to be as strong as it was before all of that happened. And when the uterus is weaker, similar to, uh, in the situation of having had this multiple Cesarean births before, for instance, or a classical Cesarean, um, incision before then.

Nicole: And that's when the uterine incision is up and down on the uterus, whereas a low transverse incision, the incision is crosswise on the uterus. So if you had like a lot of surgery on your uterus before to, to remove fibroids, and it's not as strong, that increases the risk of uterine rupture, which can be catastrophic. It can be dangerous for baby, including up to brain problems or death. It can also increase bleeding and risk for mom. So we very often, if you've had extensive fibroid removal, for sure we'll recommend a Cesarean birth before you go into labor, definitely before 39 weeks, sometimes as early as between 36 and 37 weeks, depending on the extent of the surgery, because ideally we want to do it in a very planned and control circumstance and avoid that risk of uterine rupture. So it's really going to depend on your individual circumstance and what type of procedure you had in order to know whether or not you, um, need a Cesarean birth, whether that's the safest thing for you, if you've had fibroids removed. Its typically going to be the case if you had multiple fibroids removed or, or if you've had a really large fibroids removed that were in the wall of the uterus. But again, it's going to be individualized. And I honestly think we tend to err on the side of caution, um, and more frequently suggest a Cesarean birth that there are a lot of fibroids removed. Now, if you had just a one removed, um, hysteroscopically meaning like through your uterus, it was smaller. It was just on the inside of the cavity, then that may not not happen. But for those bigger fibroids, more extensive surgery, then yes, most likely the safest thing is a Cesarean birth. Ooh. Okay. That was a lot. So just to recap, fibroids are common, especially in black women. Most often fibroids do not cause problems in pregnancy, but if they do the most likely thing is going to be pain and that can be effectively treated.

Nicole: We don't have a lot of options though, to treat fibroids in pregnancy. So if you know that you have fibroids before you get pregnant, it's worthwhile to talk to your doctor about how your fibroids may affect your pregnancy. It really is individualized, and it may be recommended that you have them removed prior to pregnancy. So do have that chat if you know that you have fibroids, but again, most women with fibroids do not have any problems with pregnancy. Um, also most women with fibroids have a vaginal birth and know that those fibroids are typically going to get smaller postpartum. So there you have it. Be sure to subscribe to the podcast in Apple Podcasts or wherever you're listening to me right now, Spotify, Google Play, Amazon even has podcasts these days. And I would really love it. If you left that honest review in Apple Podcasts in particular, it helps the show to grow.

Nicole: It helps other women to find the show. And I do shout outs from those reviews as well. Also be sure to check out the Birth Preparation Course, I would be so thrilled to have you there and in our lovely online private community, all the support with the other pregnant mamas with Keisha, the community manager, who's a doula with me. You can check out all the details of the course at drnicolerankins.com/enroll and then new, um, version of the course completely updated with new images with me, with more content, is coming out next week. So that is it for this episode, do come on back next week. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast, head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class, on How To Make A Birth Plan That Works, as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.