J Clin Ultrasound 21:241-244, May 1993

0 1993 by John Wiley & Sons, Inc. CCC 0091-27511931040241-04

Myoma vs. Contraction in Pregnancy:

Differentiation with Color Doppler Imaging
Ada Kessler, MD, Donald G. Mitchell, MD, Kathleen Kuhlman, MD,
and Barry B. Goldberg, MD

Abstract: During pregnancy, leiomyomas may cause complications such as sponta-

neous abortion, premature labor, and obstruction of labor. The conventional real-time
ultrasound examination usually detects myomas adequately, but, in some cases, a lo-
cal thickening of the uterine wall persists throughout the examination, interfering
with the differentiation between myoma and contraction. In such cases, repeat scan-
ning approximately 30 minutes later differentiates contractions, which usually re-
solve, from myomas.
We examined 10 patients with B mode and color Doppler ultrasonography. In the 5
patients with myoma, we observed splaying of the vessels around the mass, whereas
in the 5 patients with contraction, there was no vessel displacement in the area of the
local myometrial thickening. The use of color Doppler and observation of these find-
ings may obviate a prolonged ultrasound examination in questionable cases. 0 1993
John Wiley & Sons, Inc. Indexing Words: Uterus * Pregnancy Myoma * Contrac-
-
tion Color Doppler ultrasonography

The incidence of myomas in pregnancy varies
from 0.3% to 2.6%. Complications include in-
creased incidence of spontaneous abortions, pre-
mature labor, and obstruction of 1 a b 0 r . l ~In~
B-mode ultrasound images, myomas are usually
well-circumscribed, solid, hypoechoic masses
that may have calcifications or degenerative
changes. However, this characteristic appear-
ance cannot always be appreciated, and an area
of persistent focal myometrial thickening may be
demonstrated that does not disappear during the
course of the ultrasound e ~ a m i n a t i o n .In
~ , order
~ son 128, Toshiba SSA-270A, or ATL-Ultramark
to differentiate a myoma from a focal contrac-
tion, a delayed scan (in 30 minutes) is often per-
formed that may demonstrate the disappearance
of this thickening in the case of a contraction
while no interval change will be observed in the
case of a myoma.
The purpose of our study was to determine
From the Thomas Jefferson University Hospital and Jeffer-
son Medical College, Department of Radiology, Division of
Diagnostic Ultrasound, Philadelphia, Pennsylvania. For re-
prints contact Donald G. Mitchell, MD, Thomas Jefferson
University Hospital, Department of Radiology, 10th Floor,
1096 Main Building, 132 South 10th Street Philadelphia, PA
19107- 5244.
whether a color Doppler examination might ob-
viate the prolonged ultrasound examination by
improved discrimination of myomas from con-
tractions.
MATERIAL AND METHODS
Color Doppler imaging was performed in 10
pregnant women with myomas or with focal con-
traction.
The examinations were performed with Acu-
9 using sector or curved array 3.5-MHz or
5-MHz transducers, at low power settings.
Doppler spectral analysis was not performed.
Follow-up ultrasonography was obtained in 6 pa-
tients.
RESULTS
Among 10 patients with a persistent focal uter-
ine thickening, 5 patients had uterine contrac-
tions detected by color Doppler imaging (CD) as
crowding of the vessels within the mass (Fig-
ure 1). Five patients had myomas, detected by
distortion and splaying of the blood vessels
around the periphery of the uterine mass (Figure
241
 KESSLER ET AL.

A B
FIGURE 1. Ultrasound images from a woman presenting with vaginal bleeding and suspected placental abruption. (A) Transverse view: hypo-
echoic, solid, retroplacental lesion (arrows). (B) Longitudinal view: notice the inferior edge is well defined (arrow) making it difficult to differen-
tiate between a hematoma, myoma and contraction.

FIGURE 2. (A) Well-defined, hypoechoic. retroplacental lesion, most consistent with fibroid (arrows).

242 JOURNAL OF CLINICAL ULTRASOUND

 MYOMA VS CONTRACTION IN PREGNANCY

2). In 3 of the 5 patients who were diagnosed as

having a contraction on the initial scan, there
was disappearance of this focal thickening dur-
ing the first examination. Follow-up ultrasonog-
raphy was performed in 6 patients: 5 of the 6 pa-
tients were again diagnosed as having a myoma,
and 1 was again diagnosed as having a contrac-
tion. In 4 of the 5 patients with myoma, the
follow-up scan was done for monitoring fetal
growth. In the fifth patient, follow-up was indi-
cated for fetal structural abnormalities. Of the 2
patients thought to have a contraction that did
not disappear during the first examination one
had a subsequent ultrasound examination for fe-
tal growth, and no contraction or myoma was
noted. The other patient did not have a follow-up
scan.

FIGURE 1 (C). Color Doppler imaging: blood vessels are demon-
strated crowding i n this area, consistent with spasm or contraction
rather than myoma. The presence of vessels in this area excludes
hematoma.
DISCUSSION
The presence of myomas in pregnancy increases
the risk of pregnancy loss. In most cases, conven-
tional ultrasound examination permits us to di-
agnose and monitor these patients based on the
following criteria: a more hypoechoic mass than
the adjacent myometrium, attenuation of the
acoustic beam, and mass effect with distortion of

FIGURE 2 (B). Color Doppler imaging: blood vessels are splayed around the lesion, confirming the diagnosis
of fibroid (arrows).

VOL. 21, NO. 4, MAY 1993 243

 KESSLER ET AL.
uterine serosal and endometrial contour. It is
known that pregnancy has been associated with
a rapid increase in size of leiomyomas as well as
hemorrhagic or myxoid degeneration. When this
happens, the ultrasonic appearance of the my-
oma will be heterogeneous with possible cystic
changes representing hemorrhage or necrosis
within the tumor. Microcalcifications may also
be present. This appearance permits a confident
diagnosis of myoma in pregnancy with gray scale
ultrasonography .
A homogeneous mass, isoechoic with the adja-
cent myometrium, without acoustic attenuation
or with distortion of only the endometrial sur-
face, is more consistent with focal
However, variations in appearance of homoge-
neous, nonhemorrhagic, nondegenerating leio-
myoma and contractions result in overlapping
images that make distinguishing between these
two entities difficult.
Myomas consist of bundles of nonstriated
muscle fibers with varying amounts of connec-
tive tissue and diminished vascularity.8 There-
fore, myomas are usually hypovascular. Com-
monly myomas are more cellular than the sur-
rounding m y o m e t r i ~ m . Vascular
~,~ leiomyomas
have also been encountered, though rare. These
contain a proliferation of large-caliber, thick-
walled vessels, usually at the periphery of
the mass.g Contractions that consist of focal
thickening of normal myometrium appear as
focal hypervascular myometrium during preg-
nancy.
Our findings with CDI, of namely splaying of
the blood vessels around the periphery of the
uterine mass, consistent with vessels around a
myoma, correlate with other authors' findings in
magnetic resonance images of a high-signal in-
tensity rim around a myoma." Pathologic corre-
lation demonstrated that these are dilated myo-
metrial veins, lymphatics, and/or edema pro-
duced by local vascular congestion related to the
leiomyoma. We have not encountered a patient
with visible vessels within a myoma in our small
series. Based on the findings, we postulate that
in vascular myomas CDI may demonstrate hy-
pervascularity within the mass itself as well as
splayed vessels around the mass. There should
be no difference in the appearance of the splayed
vessels around a hypovascular myoma versus the
splayed vessels around a vascular myoma, as
these are myometrial vessels. In a pregnant pa-
244
tient with a uterine contraction, CDI should not
demonstrate splayed vessels.
Our preliminary results suggest that the con-
fidence of differentiation between a myoma and
contraction can be increased by CDI, thus obviat-
ing the need for a delayed ultrasound scan.
ACKNOWLEDGMENT
The authors thank Anita Urban for technical as-
sistance.
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JOURNAL OF CLINICAL ULTRASOUND