Myoma UteriOB-GYN Rotation

Quirino Memorial Medical Center

Lazaro, Tonyrose C.San Beda College of Medicine

General Data

• A.E.• 44 y/o female• G3P3• Admitted for the second time at QMMC - June

13,2011

Chief Complaint

• Vaginal Bleeding

History of Present Illness2yrs PTA– (+) hypogastric pain, 5/10 , shearing/compressing– Occ minimal intermenstrual vaginal bleeding– Used 1-2pads/day– (+) palpable mass at hypogastric area – tennis ball

size– No consult, no meds

6 months PTA– Intermenstrual bleeding and occ hypogastric pain

persisted– Progressive enlargement of the mass approx.

double the size of a tennis ball– No consult, no medications

1 ½ month PTA– (+) profuse vaginal bleeding with blood clots for 2

weeks– Used 3 fully soaked pedia diaper/day– Hypogastric pain became severe, 9/10

1 month PTA– Consulted at QMMC OB-GYN OPD– CBC- low hemoglobin– Elevated blood glucose– Admitted for correction of anemia, 2 weeks– Transfused 5 u PRBC w/c corrected anemia

• Transvaginal ultrasoundMyoma Uteri (intramural with

submucosal component)

• Endometrial biopsyProliferative Endometrium with necrosis

and chronic inflammation

TRANSVAGINAL ULTRASOUND (5/16/2011)

The uterus is anteverted with smoothe contour and heterogenous echopattern measuring 14.8x12.8x13.1cm. There is a well-circumscribed heterogenous mass seen at posterior wall measuring 12.3x12.9x10.4cm (intramural with submucosal.) Cervix measures 3.40x2.12x2.35cm. Endometrium is hyperechoic measuring 0.4cm.

The left ovary measures 3.11x2.63x2.72cm. the right ovary not seen.

Impression: Myoma Uteri (intramural with submucous

component); Normal Left Ovary

HISTOPATH RESULT: ENDOMETRIAL BIOPSY (5/26/2011)Gross and Microscopic Description:

Specimen consists of several tan brown soft irregular tissue fragments aggregately measuring 3.0x2.5x0.5cm. All tissues processed.

Section discloses irregularly shaped endometrial

glands lined by tall columnar cells having aligned cigar shaped nuclei surrounded by a fibrous stroma infiltrated by lymphocytes and plasma cells and focal areas of necrosis.

Diagnosis: Proliferative Endometrium with necrosis and Chronic Inflammation.

• Discharged improved, advised weekly ff up• Prescribed FeSO4 TID, Tranexamic acid OD

x7days, Ascorbic acid• Continue Metformin 500mg TID• Advised elective surgery (TAHBSO) after 2

weeks or once hgb and glucose become stable

On the day of admission– Hgb stable – Glucose controlled– Claimed ready for surgery– Scheduled for OR– admitted

OB-GYN History

• LMP: April 25, 2011• G3P3 (3003)

G1 1995 CS Private hosp at Montalban

Post term/ Breech presentation

No fetomaternal complications

G2 1997 CS Montalban Term No fetomaternal complications

G3 1999 CS Montalban Term No fetomaternal complications

Menstrual History

• Menarche- 13 y/o• interval 25-28 days• Lasting 3-4days• Using 3-4 soaked pads/day• With occasional dysmenorrhea

Sexual History

• First intercourse- 29y/o• Only 1 partner (husband)• No contraceptive used• No STD• No recent sexual activity

Past Medical History

• Feb 2009- DM, hospitalized and diagnosed at Montalban, Metformin 500mg TID.

• No history of HPN, lung diseases, kidney diseases, cardiac diseases, psychiatric disorders.

• No allergies to foods and medications.

Family Medical History

• No history of Diabetes Mellitus, Lung diseases, kidney diseases, cardiac diseases, and psychiatric disorders.

Personal/Social History

• widow • Lives in a single abode with her 3 children.• non-smoker• non-alcoholic beverages drinker• denied illicit drug used

Review of Systems

• General: no weight loss, no easy fatigability, fever• CNS: occasional headache, no loss of consciousness• Respiratory: no difficulty of breathing, no colds, no

cough• Cardio: no chest pain, no palpitation, no orthopnea• GIT: no constipation, no diarrhea, no vomiting

• GUT: no dysuria, no polyuria, no hematuria, no urinary urgency

• Extremities: no weakness, no numbness

• M/S: no limitation of movement, no joint pain

• Psychiatric: no mood changes, depression or suicidal attempts.

Physical Examination

GENERAL SURVEY• Patient is conscious and coherent, alert, ambulant;

oriented to time, person, and place; not in cardiorespiratory distress.

VITAL SIGNS• Blood pressure: 120/80• RR: 18/min• HR: 85 bpm• Temperature: 36.4°C

Skin• Patient’s skin is fair in color, no discolorations, moist and

warm to touch, no masses, no lesions HEENT: anicteric sclera, slightly pale palpebral conjunctiva

Chest/Lung: symmetrical chest expansion, clear breath sound, no retractions

Heart: adynamic precordium, normal rate and rhythm, no murmur

Extremities: full pulses, pink nailbeds

Abdomen: globular, uterus enlarged to 18x18x10 cm, doughy, slightly movable, non-tender

Speculum Exam: pink and smooth cervix, no

erosions, no discharge

Internal Exam: cervix short, firm, closed; uterus asymmetrically enlarged, non-tender on deep palpation, doughy, slightly movable.

ADMITTING DIAGNOSIS

• G3P3 (3003) Abnormal Uterine Bleeding, Myoma Uteri, Proliferative Endometrium, s/p LTCS 3x malpresentation and repeat

Plan

• Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAHBSO)

Course in the Wards/Pre-operative Work ups

RESULTS REFERENCE RANGERBC 4.31 4.20-5.40 x10^12/LHemoglobin 113 120-160 g/dLHematocrit 0.38 0.36-0.47 %Platelet 335 150-450 x10^9/LWBC 7.8 5-10x10^9/LNeutrophils 0.439 0.500-0.700Lymphocytes 0.197 0.200-0.700Eosinophils 0.312 0.000-0.060Monocytes 0.049 0.000-0.020

COMPLETE BLOOD COUNT (6/13/2011)

BLOOD CHEMISTRY (6/15/2011)TEST NAME RESULT REFERENCE RANGE

Glucose 5.52 4.1- 5.9

Creatinine 45.11 53-115 umol/L

SGPT 9.3 7-35 u/L

Blood Urea Nitrogen 2.53 2.50-6.40 mmol/L

Uric Acid 302.82 155-428 umol/L

Cholesterol 4.74 0-5.20 mmol/L

Triglycerides 1.34 0-2.26 mmol/L

HDL Cholesterol 0.74 0-1.5 mmol/L

LDL 3.4 26-4.1 mmol/L

VDLD 0.61 --1.0mmol/L

Sodium 135 low 136-145 mmol/L

Potassium 3.8 3.5-5.1 mmol/L

HbA1C 5.1 4.8-6.0%

COAGULATION PANEL (6/15/2011)

Parameters Results Reference range

Prothrombin time (PT)

10.6 10-14 secs

APTT 40.3 28-44 secs

CHEST X-RAY (6/15/2011)

• Clear lungs. No other significant findings.

MEDICATIONS

• Cefuroxime 1 cap BID x7days• Mefenamic acid 500mg/ cap TID• FeSO4 1 tab OD • Ascorbic acid OD• Bisacodyl 1 tab TID• Bisacodyl 2supp/rectum @ HS• Metronidazole 500mg/tab

PRE-OPERATIVE DIAGNOSIS:

Abnormal Uterine Bleeding Secondary to Myoma Uteri,Proliferative Endometrium, S/P CS 3x Malpresentationand Repeat, Bilateral Tubal Ligation, DM Type II

Controlled

OPERATION/PROCEDURE PERFORMED (6/17/2011 at 7:00am):

TAHBSO + ADHESIOLYSIS/GEA

INTRAOPERATIVE FINDINGS

• Uterus enlarged to 20x22x14cm with submucous myoma on cut section measuring 18x15x6cm.

• Cervix 3x3x3cm• Normal- both ovaries• Normal- both FTs• Liver edge smooth• Omentum not matted

POST OPERATIVE DIAGNOSIS

Abnormal Uterine Bleeding Secondary to Myoma Uteri, Proliferative Endometrium, S/P CS 3x Malpresentation and Repeat, Bilateral Tubal Ligation, DM Type II Controlled.

POST-OPERATIVE MEDICATIONS:

• Nalbuphine 10mg IV q4 x 6doses• Ketorolac 30mg IV loading then 15mg q6 x

4doses• Omeprazole 40mg IV OD• Cefoxitin 1gm IV q8

Discussion

Uterine Leiomyoma

• “fibroids”• “uterine myomas”

• benign proliferations of smooth muscle cells of the myometrium.

Pathogenesis

• Cause of uterine leiomyomas is unclear• Fibroids are monoclonal• Each tumor resulting from propagation of a single

muscle cell

• Proposed etiologies include development from --smooth muscle cells of the uterus or the uterine arteries ,from metaplastic transformation of connective tissue cells, and from persistent embryonic rest cells

• Hormonally responsive to estrogen and progesterone

• Pregnancy- grow quickly and to huge proportions

• Menopause- stop growing and atrophy in response to naturally ↓ endogenous estrogen levels.

Classification by locations Submucosal- beneath the endometrium, commonly assoc w/

heavy of prolonged bleeding• intramural- in the muscular wall of the uterus, MC• subserosal -beneath the uterine serosa

Epidemiology

• 30% of all American women and 50% of African American women will develop leiomyoma by age 40

• highest prevalence occurring during the fifth decade

• Rare before puberty

Risk Factors

• increasing age• early menarche• low parity• tamoxifen use• Obesity• 2.5x more likely develop fibroids-1st degree relatives• and in some studies a high-fat diet.

• Smoking has been found to be associated with a decreased incidence of myomata

Clinical Symptoms of Uterine LeiomyomasBleeding (MC symptom)Longer, heavier periodsEndometrial ulceration

PressurePelvic pressure and bloatingConstipation and rectal pressureUrinary frequency or retention

PainSecondary dysmenorrheaAcute infarct (especially in pregnancy)Dyspareunia

Reproductive difficultiesInfertility (failed implantation/spontaneous abortion)Fetal malpresentationIntrauterine growth restriction (IUGR)Premature labor and delivery

Clinical manifestations

• 50-65% have no clinical symptoms• Abnormal uterine bleeding- MC symptom• Menorrhagia- presents as increasingly heavy

periods of longer duration• Metrorrhagia- bleeding between periods• Menometrorrhagia- heavy irregular bleeding• Chronic IDA, dizziness, fatigue

Physical Examination

• Depending on their location and size

• uterine leiomyomas can sometimes be palpated on bimanual pelvic examination or on abdominal examination

• nontender irregularly enlarged uterus with “lumpy-bumpy” or cobblestone protrusions that feel firm or solid on palpation.

Diagnostic Evaluation

• Pregnancy test- all women• History and PE• Ultrasound (pelvic/transvaginal) – MC means

of diagnostics

Treatment

• Most cases of uterine fibroids do not require treatment

• Px with actively growing fibroids- ff up every 6months to monitor size and growth

• Treatment- severe pain, heavy or irregular bleeding, infertility, or pressure symptoms; extremely rapid growth

• Treatment depends on the patient’s– Age– Pregnancy status– Desire for future pregnancies– Size and location of the fibroids

Medical Therapies

• Medroxyprogesterone- shrink fibroids by decreasing circulating estrogen levels

• GnRH agonists- shrink fibroids by decreasing circulating estrogen levels; stop bleeding, and increase the hematocrit prior to surgical treatment of uterine fibroids.

Uterine artery embolization (UAE)

decrease the blood supply to the fibroid, thereby causing ischemic necrosis, degeneration, and reduction in fibroid size

• No to women planning to become pregnant after the procedure

Surgical Intervention

• Myomectomy- surgical resection of one or more fibroids from the uterine wall; preserve fertility; increase risk of recurrence- 50%

• Hysterectomy- DEFINITIVE TREATMENT.

• Because of the potential for hemorrhage, surgical intervention should be avoided during pregnancy, although myomectomy or hysterectomy may be necessary at some point after delivery.

Indications for Surgical Intervention for Uterine Leiomyomas

Abnormal uterine bleeding, causing anemiaSevere pelvic pain or secondary amenorrheaUterine size (>12 weeks) obscuring evaluation of

adnexae• Urinary frequency, retention, or hydronephrosis• Growth after menopause• Recurrent miscarriage or infertilityRapid increase in size

Thank You..