Fibroid in pregnancy is common in clinical obstetric practice. The topic is becoming more relevant in contemporary obstetrics due to the demographic shift towards delayed childbearing, the rising rate of obesity, and many pregnancies occurring after the treatment of fibroids. However, there are conflicting reports in the literature on many so-called fibroid complications in pregnancy, and there are inadequate data on the optimum management strategy. An evidence base is lacking on the pregnancy outcome of many conventional and newer treatment modalities of fibroids. This review addresses the characteristics and behaviour of fibroids during pregnancy, their incidence and demography, diagnosis, the complications that can arise during pregnancy and their antenatal management, the labour pattern, mode of delivery and the postpartum course, with critical appraisal of the literature together with certain special situations such as pregnancy after various types of myomectomy and uterine arterial embolisation.
The best way to ensure that preterm infants benefit from relevant neonatal expertise as soon as they are born is to transfer the mother and baby to an appropriately specialised neonatal facility before birth (“in utero”). This review explores the evidence surrounding the importance of being born in the right unit, the advantages of in utero transfers compared to ex utero transfers, and how to accurately assess which women are at most risk of delivering early and the challenges of in utero transfers. Accurate identification of the women most at risk of preterm birth is key to prioritising who to transfer antenatally, but the administrative burden and pathway variation of in utero transfer in the UK are likely to compromise optimal clinical care. Women reported the impact that in utero transfers have on them, including the emotional and financial burdens of being transferred and the anxiety surrounding domestic and logistical concerns related to being away from home. The final section of the review explores new approaches to reforming the in utero transfer process, including learning from outside the UK and changing policy and guidelines. Examples of collaborative regional guidance include the recent Pan-London guidance on in utero transfers. Reforming the transfer process can also be aided through technology, such as utilising the CotFinder app. In utero transfer is an unavoidable aspect of maternity and neonatal care, and the burden will increase if preterm birth rates continue to rise in association with increased rates of multiple pregnancy, advancing maternal age, assisted reproductive technologies, and obstetric interventions. As funding and capacity pressures on health services increase because of the COVID-19 pandemic, better prioritisation and sustained multi-disciplinary commitment are essential to maximise better outcomes for babies born too soon.
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