History

Fact Explanation
A female in the reproductive age Fibroids are benign neoplasms of the uterus which is common in the reproductive age of females. [1,2,3,4]
A family history of fibroids in first degree relative females There is a familial predisposition to have leiomyomas. [5,6,7]
A history of subfertility/ assisted fertility Pre-existing uterine leiomyomas may interfere with fertility. [8]
Abdominal pain Rapid onset/ sudden onset moderate-severe abdominal pain can indicate acute torsion of subserosal pedunculated leiomyomata or red degeneration of fibroid. [9,10]
Probable red degeneration Patients with red degeneration presents with acute abdominal pain that could be severe and requiring sedation. [10] The pathophysiology behind red degeneration is rapidly growing tumors outgrowing its blood flow and developing anoxia, necrosis, and infarction. The other theories that have been proposed are the growing uterus results in a change in the architecture (kinking) of the blood supply to the fibroid leading to ischemia and necrosis even in the absence of fibroid growth, and that the pain results from the release of prostaglandins from cellular damage within the fibroid [10, 15, 16, 17, 18, 19] It's more common in larger fibroids. i.e. >5cm in diameter, and during the first 10 weeks of pregnancy as the maximum growth happens during that time. [15]
Fever Infection of a fibroid, the commoner causative organisms are Staphylococci or Streptococci. [11]
Acute urine retention Due to compression of a bulky uterus against the bladder and resultant outflow obstruction. [9,12,13]
Vaginal bleeding Could be due to spontaneous miscarriage, placental abruption or placenta previa. [9,14]
Uterus small for gestational age Due to the restriction of uterine space that is available for fetal growth. [8, 14, 15]
Malpositions or malpresentations i.e. breech presentation, transverse lie. Due to restricted uterine space. [8, 14, 15]
Preterm labour It's a common complication of fibroids in pregnancy. [14,15,20]
References
  1. EZZATI MOHAMMAD, NORIAN JOHN M, SEGARS JAMES H. Management of uterine fibroids in the patient pursuing assisted reproductive technologies. Women's Health [online] 2009 July, 5(4):413-421 [viewed 24 August 2014] Available from: doi:10.2217/whe.09.29
  2. STEWART ELIZABETH A. Uterine fibroids. The Lancet [online] 2001 January, 357(9252):293-298 [viewed 24 August 2014] Available from: doi:10.1016/S0140-6736(00)03622-9
  3. WALKER C. L.. Uterine Fibroids: The Elephant in the Room. Science [online] 2005 June, 308(5728):1589-1592 [viewed 24 August 2014] Available from: doi:10.1126/science.1112063
  4. FLAKE GP, ANDERSEN J, DIXON D. Etiology and pathogenesis of uterine leiomyomas: a review. Environ Health Perspect [online] 2003 Jun, 111(8):1037-54 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12826476
  5. CHAN I., WONG T., MARTINEZ-MIR A., CHRISTIANO A. M., MCGRATH J. A.. Familial multiple cutaneous and uterine leiomyomas associated with papillary renal cell cancer. Clin Exp Dermatol [online] 2005 January, 30(1):75-78 [viewed 24 August 2014] Available from: doi:10.1111/j.1365-2230.2004.01675.x
  6. VIKHLYAEVA E.M., KHODZHAEVA Z.S., FANTSCHENKO N.D.. Familial predisposition to uterine leiomyomas. International Journal of Gynecology & Obstetrics [online] 1995 November, 51(2):127-131 [viewed 24 August 2014] Available from: doi:10.1016/0020-7292(95)02533-I
  7. SATO FUMIO, MORI MITSURU, NISHI MOTOL, KUDO RYUICHI, MIYAKE HIROTSUGU. Familial Aggregation of Uterine Myomas in Japanese Women.. Journal of Epidemiology [online] 2002 December, 12(3):249-253 [viewed 24 August 2014] Available from: doi:10.2188/jea.12.249
  8. KLATSKY PETER C., TRAN NAM D., CAUGHEY AARON B., FUJIMOTO VICTOR Y.. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. American Journal of Obstetrics and Gynecology [online] 2008 April, 198(4):357-366 [viewed 24 August 2014] Available from: doi:10.1016/j.ajog.2007.12.039
  9. GUPTA SAHANA, MANYONDA ISAAC T.. Acute complications of fibroids. Best Practice & Research Clinical Obstetrics & Gynaecology [online] 2009 October, 23(5):609-617 [viewed 24 August 2014] Available from: doi:10.1016/j.bpobgyn.2009.01.012
  10. BLAND-SUTTON J. A Lecture ON THE RED DEGENERATION OF UTERINE FIBROIDS COMPLICATING PREGNANCY: Delivered at the Medical Graduates' College and Polyclinic, May 5th, 1909 Br Med J [online] 1909 Jun 19, 1(2529):1471-1474 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2319456
  11. BLAND-SUTTON J. On a Uterine Fibroid in the state of Red Degeneration containing Staphylococcus pyogenes aureus Proc R Soc Med [online] 1909, 2(Obstet Gynaecol Sect):300-302 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2046640
  12. SUZUKI S, ONO S, SATOMI M. Recurrence of urinary retention secondary to retroverted gravid uterus N Am J Med Sci [online] 2009 Jul, 1(2):54-57 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364650
  13. YOHANNES PAULOS, SCHAEFER JOANN. Urinary retention during the second trimester of pregnancy: a rare cause. Urology [online] 2002 June [viewed 24 August 2014] Available from: doi:10.1016/S0090-4295(02)01551-0
  14. OUYANG DAVID W., ECONOMY KATHERINE E., NORWITZ ERROL R.. Obstetric Complications of Fibroids. Obstetrics and Gynecology Clinics of North America [online] 2006 March, 33(1):153-169 [viewed 24 August 2014] Available from: doi:10.1016/j.ogc.2005.12.010
  15. LEE HJ, NORWITZ ER, SHAW J. Contemporary Management of Fibroids in Pregnancy Rev Obstet Gynecol [online] 2010, 3(1):20-27 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876319
  16. AHARONI ARIEL, REITER ALEXANDER, GOLAN DAVID, PALTIELY YOAV, SHARF MORDECHAI. Patterns of growth of uterine leiomyomas during pregnancy. A prospective longitudinal study. BJOG:An international journal of O&G [online] 1988 May, 95(5):510-513 [viewed 25 August 2014] Available from: doi:10.1111/j.1471-0528.1988.tb12807.x
  17. LEV-TOAFF A S, COLEMAN B G, ARGER P H, MINTZ M C, ARENSON R L, TOAFF M E. Leiomyomas in pregnancy: sonographic study.. Radiology [online] 1987 August, 164(2):375-380 [viewed 25 August 2014] Available from: doi:10.1148/radiology.164.2.3299488
  18. DE CAROLIS SARA, FATIGANTE GABRIELLA, FERRAZZANI SERGIO, TRIVELLINI CARMEN, DE SANTIS LIDIA, MANCUSO SALVATORE, CARUSO ALESSANDRO. Uterine Myomectomy in Pregnant Women. [online] 2001 December, 16(2):116-119 [viewed 25 August 2014] Available from: doi:10.1159/000053893
  19. PARKER WILLIAM H.. Etiology, symptomatology, and diagnosis of uterine myomas. Fertility and Sterility [online] 2007 April, 87(4):725-736 [viewed 25 August 2014] Available from: doi:10.1016/j.fertnstert.2007.01.093
  20. THORPE-BEESTON J.G., SEBIRE N.J.. Spontaneous expulsion of submucous fibroid after preterm labour. BJOG: An Internal Journal of Obs Gyn [online] 2002 June, 109(6):726-727 [viewed 24 August 2014] Available from: doi:10.1111/j.1471-0528.2002.01084.x

Examination

Fact Explanation
A palpable pelvic mass Sometimes the fibroid is palpable as a pelvic mass. In some instances, the uterine size will be more than expected according to the dates. [1]
Signs of labor Look for signs of labor. i.e. cervical dilation, vaginal watery discharge, vaginal bleeding, evident contractions. [2,3,4,5,6]
Obstetric examination For fundus, fetal lie and presentation.
References
  1. EVANS P, BRUNSELL S. Uterine Fibroid Tumors: Diagnosis and Treatment. Am Fam Physician. [online] 2007 May 15;75(10):1503-1508. [viewed Aug 24th 2014] Available at : http://www.aafp.org/afp/2007/0515/p1503.html
  2. National Collaborating Centre for Women’s and Children’s Health. Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth; Chapter 7: Normal labour: first stage. [web] [viewed Aug 24th 2014] Available at : http://www.ncbi.nlm.nih.gov/books/NBK49392/
  3. DOWNE S, GYTE GM, DAHLEN HG, SINGATA M. Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term. Cochrane Database Syst Rev [online] 2013 Jul 15:CD010088 [viewed 24 August 2014] Available from: doi:10.1002/14651858.CD010088.pub2
  4. ZHANG J, TROENDLE J, MIKOLAJCZYK R, SUNDARAM R, BEAVER J, FRASER W. The natural history of the normal first stage of labor. Obstet Gynecol [online] 2010 Apr, 115(4):705-10 [viewed 24 August 2014] Available from: doi:10.1097/AOG.0b013e3181d55925
  5. KATZ MICHAEL, GOODYEAR KAREN, CREASY ROBERT K.. Early signs and symptoms of preterm labor. American Journal of Obstetrics and Gynecology [online] 1990 May, 162(5):1150-1153 [viewed 24 August 2014] Available from: doi:10.1016/0002-9378(90)90004-Q
  6. KENT A. Monitoring During Labor Rev Obstet Gynecol [online] 2008, 1(3):144-146 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582638

Differential Diagnoses

Fact Explanation
Pre-term labour Fibroids can cause pre-term labor. But it should be addressed as another different entity because the maternal and fetal outcomes can be different. [1, 2, 3, 4, 5]
Multiple pregnancy The fundus can be enlarged than what's expected for gestational age in both conditions. Obstetric ultrasound scan should be enough to differentiate the two entities. [6, 7, 8, 9]
Other malignant tumor Fibroids are estrogen dependent tumors, it can enlarge with the progress of the pregnancy. The suspicion should be aroused appropriately where a malignant tumor could be a differential. i.e. a patient who had previous gestational trophoblastic disease. A degenerated fibroid can mimic an ovarian cyst. [10, 11, 12, 13, 14]
References
  1. LEE HJ, NORWITZ ER, SHAW J. Contemporary Management of Fibroids in Pregnancy Rev Obstet Gynecol [online] 2010, 3(1):20-27 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876319
  2. VON DER POOL B.A. Preterm Labor: Diagnosis and Treatment. Am Fam Physician. [web] 1998 May 15;57(10):2457-2464. [viewed 24 August 2014] Available from: http://www.aafp.org/afp/1998/0515/p2457.html
  3. THORPE-BEESTON J.G., SEBIRE N.J.. Spontaneous expulsion of submucous fibroid after preterm labour. BJOG: An Internal Journal of Obs Gyn [online] 2002 June, 109(6):726-727 [viewed 24 August 2014] Available from: doi:10.1111/j.1471-0528.2002.01084.x
  4. INSTITUTE OF MEDICINE (US) COMMITTEE ON UNDERSTANDING PREMATURE BIRTH AND ASSURING HEALTHY OUTCOMES, BEHRMAN RE, BUTLER AS. [online] 2007 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20669423
  5. STEER PHILIP. The epidemiology of preterm labour. [online] December, 112:1-3 [viewed 24 August 2014] Available from: doi:10.1111/j.1471-0528.2005.00575.x
  6. GILES WARWICK, BISITS ANDREW, O'CALLAGHAN STEPHEN, GILL ANDREW. The Doppler Assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy. BJOG: An Internal Journal of Obs Gyn [online] 2003 June, 110(6):593-597 [viewed 24 August 2014] Available from: doi:10.1046/j.1471-0528.2003.02066.x
  7. WILSON LM, HOSE PM. Challenges of Twin Pregnancy: Helping parents adjust Can Fam Physician [online] 1991 Sep:1917-1924 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2145925
  8. HACK KARIEN E., DERKS JAN B., SCHAAP ARTY H., LOPRIORE ENRICO, ELIAS SJOERD G., ARABIN BIRGIT, EGGINK ALEX J., SOLLIE KRYSTYNA M., MOL BEN WILLEM J., DUVEKOT HANS J., WILLEKES CHRISTINE, GO ATTIE T., KOOPMAN-ESSEBOOM CORINE, VANDENBUSSCHE FRANK P., VISSER GERARD H.. Perinatal Outcome of Monoamniotic Twin Pregnancies. Obstetrics & Gynecology [online] 2009 February, 113(2, Part 1):353-360 [viewed 24 August 2014] Available from: doi:10.1097/AOG.0b013e318195bd57
  9. TCHIRIKOV MICHAEL. Monochorionic twin pregnancy: screening, pathogenesis of complications and management in the era of microinvasive fetal surgery. [online] 2010 January [viewed 24 August 2014] Available from: doi:10.1515/JPM.2010.069
  10. TCHIRIKOV MICHAEL. Monochorionic twin pregnancy: screening, pathogenesis of complications and management in the era of microinvasive fetal surgery. [online] 2010 January [viewed 24 August 2014] Available from: doi:10.1515/JPM.2010.069
  11. GARNER ELIZABETH I. O., GOLDSTEIN DONALD P., FELTMATE COLLEEN M., BERKOWITZ ROSS S.. Gestational Trophoblastic Disease. Clinical Obstetrics and Gynecology [online] 2007 March, 50(1):112-122 [viewed 24 August 2014] Available from: doi:10.1097/GRF.0b013e31802f17fc
  12. AYDIN C, ERIş S, YALçIN Y, ŞEN SELIM H. A giant cystic leiomyoma mimicking an ovarian malignancy Int J Surg Case Rep [online] , 4(11):1010-1012 [viewed 24 August 2014] Available from: doi:10.1016/j.ijscr.2013.08.018
  13. LYNCH FW. FIBROIDS AND OVARIAN CYSTS COMPLICATING PREGNANCY Cal West Med [online] 1931 Dec, 35(6):415-420 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1658008
  14. KERKMEIJER LINDA G.W., WIELSMA SABIEN, MASSUGER LEON F.A.G., SWEEP FRED C.G.J., THOMAS CHRIS M.G.. Recurrent gestational trophoblastic disease after hCG normalization following hydatidiform mole in The Netherlands. Gynecologic Oncology [online] 2007 July, 106(1):142-146 [viewed 24 August 2014] Available from: doi:10.1016/j.ygyno.2007.03.010

Investigations - for Diagnosis

Fact Explanation
Ultrasonography It is the most frequently employed investigation. Trans-abdominal and trans-vaginal ultrasound scans should be performed, but trans-vaginal route gives the best image. In skilled hands can detect fibroids as small as 5 mm on transvaginal ultrasounds. Calcifications, degenerations and cystic changes also can be viewed. Complications of large fibroids also can be viewed. i.e. ureteric obstruction, hydronephrosis. [1, 2, 3, 4, 5, 6, 7, 8]
Doppler ultrasonography It shows the circumferential vascularity of the fibroid. [9]
References
  1. KHAN AT, SHEHMAR M, GUPTA JK. Uterine fibroids: current perspectives Int J Womens Health [online] :95-114 [viewed 24 August 2014] Available from: doi:10.2147/IJWH.S51083
  2. SUE W, SARAH SB. Radiological appearances of uterine fibroids Indian J Radiol Imaging [online] 2009 Aug, 19(3):222-231 [viewed 24 August 2014] Available from: doi:10.4103/0971-3026.54887
  3. DUEHOLM MARGIT, LUNDORF ERIK, HANSEN ESTRID S., LEDERTOUG SUSANNE, OLESEN FREDE. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. American Journal of Obstetrics and Gynecology [online] 2002 March, 186(3):409-415 [viewed 24 August 2014] Available from: doi:10.1067/mob.2002.121725
  4. DUEHOLM M.. Reproducibility of evaluation of the uterus by transvaginal sonography, hysterosonographic examination, hysteroscopy and magnetic resonance imaging. [online] 2002 January, 17(1):195-200 [viewed 24 August 2014] Available from: doi:10.1093/humrep/17.1.195
  5. DUEHOLM MARGIT, LUNDORF ERIK, HANSEN ESTRID S, LEDERTOUG SUSANNE, OLESEN FREDE. Evaluation of the uterine cavity with magnetic resonance imaging, transvaginal sonography, hysterosonographic examination, and diagnostic hysteroscopy. Fertility and Sterility [online] 2001 August, 76(2):350-357 [viewed 24 August 2014] Available from: doi:10.1016/S0015-0282(01)01900-8
  6. VOLKERS NICOLE A., HEHENKAMP WOUTER J. K., SPIJKERBOER ANJE M., MOOLHUIJZEN ALBERT D., BIRNIE ERWIN, ANKUM WILLEM M., REEKERS JIM A.. MR Reproducibility in the Assessment of Uterine Fibroids for Patients Scheduled for Uterine Artery Embolization. Cardiovasc Intervent Radiol [online] December, 31(2):260-268 [viewed 24 August 2014] Available from: doi:10.1007/s00270-007-9209-0
  7. LEVENS ERIC D., WESLEY ROBERT, PREMKUMAR AHALYA, BLOCKER WENDY, NIEMAN LYNNETTE K.. Magnetic resonance imaging and transvaginal ultrasound for determining fibroid burden: implications for research and clinical care. American Journal of Obstetrics and Gynecology [online] 2009 May, 200(5):537.e1-537.e7 [viewed 24 August 2014] Available from: doi:10.1016/j.ajog.2008.12.037
  8. LEV-TOAFF A S, COLEMAN B G, ARGER P H, MINTZ M C, ARENSON R L, TOAFF M E. Leiomyomas in pregnancy: sonographic study.. Radiology [online] 1987 August, 164(2):375-380 [viewed 24 August 2014] Available from: doi:10.1148/radiology.164.2.3299488
  9. ROY C., BIERRY G., GHALI S. EL, BUY X., ROSSINI A.. Acute torsion of uterine leiomyoma: CT features. Abdom Imaging [online] December, 30(1):120-123 [viewed 24 August 2014] Available from: doi:10.1007/s00261-004-0240-1

Investigations - Fitness for Management

Fact Explanation
Complete blood count To exclude anemia and thrombocytopenia because a surgical management option could be inevitable. [1, 2, 3]
References
  1. SCHOLL TO, REILLY T. Anemia, iron and pregnancy outcome. J Nutr [online] 2000 Feb, 130(2S Suppl):443S-447S [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10721924
  2. LEE AI, OKAM MM. Anemia in pregnancy. Hematol Oncol Clin North Am [online] 2011 Apr, 25(2):241-59, vii [viewed 24 August 2014] Available from: doi:10.1016/j.hoc.2011.02.001
  3. LEVY AMALIA, FRASER DRORA, KATZ MIRIAM, MAZOR MOSHE, SHEINER EYAL. Maternal anemia during pregnancy is an independent risk factor for low birthweight and preterm delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology [online] 2005 October, 122(2):182-186 [viewed 24 August 2014] Available from: doi:10.1016/j.ejogrb.2005.02.015

Management - General Measures

Fact Explanation
Patient education Educating the patient about the pregnancy outcome and management options, as well as counseling to ease her fears about the future. [1]
Pain management Best managed conservatively by bed rest, hydration, and analgesics. Out of analgesics, prostaglandin synthase inhibitors (eg, nonsteroidal anti-inflammatory drugs) should be used with caution, especially prolonged use (> 48 hours) in the third trimester where it has been associated with both fetal and neonatal adverse effects, including premature closure of the fetal ductus arteriosus, pulmonary hypertension, necrotizing enterocolitis, intracranial hemorrhage, or oligohydramnios. Sometimes severe pain may require additional pain medication (narcotic analgesia), epidural analgesia, or surgical removal. [2,3,4,5]
References
  1. SIMMS-STEWART DONNETTE, FLETCHER HORACE. Counselling Patients with Uterine Fibroids: A Review of the Management and Complications. Obstetrics and Gynecology International [online] 2012 December, 2012:1-6 [viewed 24 August 2014] Available from: doi:10.1155/2012/539365
  2. LEE HJ, NORWITZ ER, SHAW J. Contemporary Management of Fibroids in Pregnancy Rev Obstet Gynecol [online] 2010, 3(1):20-27 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876319
  3. NORTON MARY E., MERRILL JEFFREY, COOPER BRUCE, KULLER JEFFREY A., CLYMAN RONALD I.. Neonatal Complications after the Administration of Indomethacin for Preterm Labor. N Engl J Med [online] 1993 November, 329(22):1602-1607 [viewed 24 August 2014] Available from: doi:10.1056/NEJM199311253292202
  4. SEKI H, TAKIZAWA Y, SODEMOTO T. Epidural analgesia for painful myomas refractory to medical therapy during pregnancy. International Journal of Gynecology & Obstetrics [online] 2003 December, 83(3):303-304 [viewed 24 August 2014] Available from: doi:10.1016/S0020-7292(03)00207-8
  5. LEACH KARA, KHATAIN LARISSA, TOCCE KRISTINA. First trimester myomectomy as an alternative to termination of pregnancy in a woman with a symptomatic uterine leiomyoma: a case report. Array [online] 2011 December [viewed 24 August 2014] Available from: doi:10.1186/1752-1947-5-571

Management - Specific Treatments

Fact Explanation
Myomectomy Myomectomy in the first half of the pregnancy is rarely done, though it has been proved to be safe. Laparoscopic techniques can be used to have the best outcome. The acceptable indications are intractable pain from a degenerating fibroid especially if it is subserosal or pedunculated, a large or rapidly growing fibroid, or any large fibroid (> 5 cm) located in the lower uterine segment. The concern is that once surgical removal has been done, the mother might need a cesarean section to deliver because of the risk for uterine rupture. Myomectomy at the time of cesarean delivery should only be performed if unavoidable to facilitate safe delivery of the fetus or closure of the hysterotomy. Pedunculated subserosal fibroids can also be safely removed at the time of cesarean delivery without increasing the risk of hemorrhage. [1, 2, 3, 4, 5, 6]
Uterine artery embolization Bilateral uterine artery embolization is done to stop postpartum hemorrhage following cesarean section. [1, 7, 8, 9, 10]
Managing the delivery Managemnet of the delivery with facilities for emergency c-section or surgical correction of postpartum hemorrhage should be done with utmost care. Good maternal and neonatal outcomes are expected in pregnancies with uterine fibroids. Conservative management options should be applied where there is no immediate threat to the mother or the fetus. [11,12,13,14,15]
References
  1. LEE HJ, NORWITZ ER, SHAW J. Contemporary Management of Fibroids in Pregnancy Rev Obstet Gynecol [online] 2010, 3(1):20-27 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876319
  2. LI TC, MORTIMER R, COOKE ID. Myomectomy: a retrospective study to examine reproductive performance before and after surgery. Hum Reprod [online] 1999 Jul, 14(7):1735-40 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10402378
  3. SURREY E, MINJAREZ D, STEVENS J, SCHOOLCRAFT W. Effect of myomectomy on the outcome of assisted reproductive technologies. Fertility and Sterility [online] 2005 May, 83(5):1473-1479 [viewed 24 August 2014] Available from: doi:10.1016/j.fertnstert.2004.11.045
  4. DE CAROLIS SARA, FATIGANTE GABRIELLA, FERRAZZANI SERGIO, TRIVELLINI CARMEN, DE SANTIS LIDIA, MANCUSO SALVATORE, CARUSO ALESSANDRO. Uterine Myomectomy in Pregnant Women. [online] 2001 December, 16(2):116-119 [viewed 24 August 2014] Available from: doi:10.1159/000053893
  5. CELIK C, ACAR A, CIçEK N, GEZGINC K, AKYüREK C. Can myomectomy be performed during pregnancy? Gynecol Obstet Invest [online] 2002, 53(2):79-83 [viewed 24 August 2014] Available from: doi:52997
  6. BROWN D.. Caesarean myomectomy-a safe procedure. A retrospective case controlled study. J Obstet Gynaecol [online] 1999 January, 19(2):139-141 [viewed 24 August 2014] Available from: doi:10.1080/01443619965435
  7. LIU WEI-MIN, WANG PENG-HUI, TANG WUN-LONG, WANG I.-TE, TZENG CHII-REUY. Uterine artery ligation for treatment of pregnant women with uterine leiomyomas who are undergoing cesarean section. Fertility and Sterility [online] 2006 August, 86(2):423-428 [viewed 24 August 2014] Available from: doi:10.1016/j.fertnstert.2006.01.027
  8. GOLDBERG JAY, PEREIRA LEONARDO, BERGHELLA VINCENZO, DIAMOND JAMES, DARAı̈ EMILE, SEINERA PIERO, SERACCHIOLI RENATO. Pregnancy outcomes after treatment for fibromyomata: uterine artery embolization versus laparoscopic myomectomy. American Journal of Obstetrics and Gynecology [online] 2004 July, 191(1):18-21 [viewed 24 August 2014] Available from: doi:10.1016/j.ajog.2004.01.046
  9. OUYANG DAVID W., ECONOMY KATHERINE E., NORWITZ ERROL R.. Obstetric Complications of Fibroids. Obstetrics and Gynecology Clinics of North America [online] 2006 March, 33(1):153-169 [viewed 24 August 2014] Available from: doi:10.1016/j.ogc.2005.12.010
  10. GOLDBERG JAY, PEREIRA LEONARDO. Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy. Current Opinion in Obstetrics and Gynecology [online] 2006 August, 18(4):402-406 [viewed 24 August 2014] Available from: doi:10.1097/01.gco.0000233934.13684.cb
  11. OLIVE DAVID, PRITTS ELIZABETH. Fibroids and Reproduction. Semin Reprod Med [online] December, 28(03):218-227 [viewed 24 August 2014] Available from: doi:10.1055/s-0030-1251478
  12. BAJEKAL N.. Fibroids, infertility and pregnancy wastage. Human Reproduction Update [online] 2000 November, 6(6):614-620 [viewed 24 August 2014] Available from: doi:10.1093/humupd/6.6.614
  13. ZAIMA A., ASH A.. Fibroid in pregnancy: characteristics, complications, and management. Postgraduate Medical Journal [online] December, 87(1034):819-828 [viewed 24 August 2014] Available from: doi:10.1136/postgradmedj-2011-130319
  14. KLATSKY PETER C., TRAN NAM D., CAUGHEY AARON B., FUJIMOTO VICTOR Y.. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. American Journal of Obstetrics and Gynecology [online] 2008 April, 198(4):357-366 [viewed 24 August 2014] Available from: doi:10.1016/j.ajog.2007.12.039
  15. KHAN AT, SHEHMAR M, GUPTA JK. Uterine fibroids: current perspectives Int J Womens Health [online] :95-114 [viewed 24 August 2014] Available from: doi:10.2147/IJWH.S51083