No two uteri are alike: clinical variability and management of uterine fibroids in pregnancy – a case series

Abstract

Uterine fibroids present with unpredictable clinical behavior during pregnancy depending on their size, number, and anatomical location, as gestational hormonal shifts and altered uteroplacental dynamics influence tumor growth, placentation, and labor mechanics. This prospective case series evaluated four singleton pregnancies (mean maternal age: 29.5 years; 3 primigravidae, 1 multigravida) complicated by subserosal and intramural fibroids ranging from 1.9 to 7.0 cm. One patient exhibited transient second-trimester uterine artery Doppler notch resistance without fetal growth restriction. Intrapartum, three patients required emergency caesarean delivery secondary to failed labor induction or labor dystocia, while one underwent elective caesarean section for cephalopelvic disproportion. Selective caesarean myomectomy was successfully performed in two cases (50%) where fibroids directly obstructed the lower uterine segment incision line. Conversely, myomectomy was intentionally deferred in the remaining two cases due to deep intramural placement or transient intraoperative uterine atony. All four neonates were delivered at term with favorable birth weights (mean: 3.03 kg) and robust Apgar scores, requiring no NICU admissions. Uterine fibroids exhibit marked clinical heterogeneity; however, vigilant antenatal surveillance, selective Doppler application, and individualized intrapartum decision-making performing myomectomy specifically when fibroids impede surgical access ensure optimal maternal and neonatal outcomes.