A 49 yrs female from Nayapati , presented in Gynaecological OPD
with C/O:
Abdominal Pain on/off since 2 yrs
Lumpiness in the lower abdomen
since 1 yr
HISTORY OF PRESENT ILLNESS
Mild grade dull intermittent lower abdominal pain for 2
yrs with no radiation and no aggravating and relieving
factors.
Lumpiness in lower abdomen for 1 yr, gradually
increasing in size.
History of intermittent burning epigastric pain associated with
waterbrash since 1 yr.
Burning micturition and increased frequency of
micturition since 15 days
Bowel habit normal
No history of Per-Vaginal bleeding/discharge/fever
Sleep/Appetite: Normal
PAST HISTORY
No history of similar illness in the past.
No history of still birth,twins,blood transfusion,diabetes mellitus,hypertension,epilepsy.
No history of surgical intervention.
MENSTRUAL HISTORY
Menarche(K) = 13 yr .
Last Menstural Period(L.M.P) = 5th shrawan 2072 .
Flow/Cycle = (34)/(28+/4) days .
Average flow, no clots.
Intermenstural Bleeding =Absent.
Post-coital bleeding = Absent.
OBSTETRICAL HISTORY
Married for 35 yrs
PARITY = 3 , LIVE BIRTHS = 3
Each child was delivered at home, on achieving full term.
Last conception , curettage was done 22 yrs back at
8weeks Period Of Gestation (POG), on patients wish.
CONTRACEPTIVE HISTORY
Minilap was done 22 years back.
PERSONAL HISTORY
Consumes mixed diet.
Non-alcoholic and Non-smoker.
ALLERGIC AND DRUG HISTORY
No history of allergen known till date.
No significant history of drug.
EXAMINATION
ON EXAMINATION
General Condition : Well oriented to time, place and person, average build, supine
decubitus.
Bilateral pitting pedal oedema (mild) .
Other Cardinals (Pallor/Icterus/Lymph/Cyanosis/Clubbing/Dehydration) : Absent .
Vitals :
• Pulse : 78 beats per minute
• Blood Pressure : 120/80 mm of hg(mercury)
• Respiration Rate : 24 breaths per minute
• Temperature : 97 degrees Farhenheit (F)
Chest:
• Bilateral Normal Vesicular Breath sounds heard.
• Absence of Added sounds.
Cardiovascular System(CVS) :
•1st and 2nd heart sounds were heard with an absence of murmurs.
•No deformity detected.
Abdominal Examination :
•Absence of scar marks/bruits/excoriations.
•All quadrants moving equally with each inspiration.
•No local rise of temperature/ Non-tender.
Per-Abdominal Examination:
• Uterus at 16 weeks size.
• Firm smooth mass, more often felt towards the right side.
• Upper edge and two lateral boarders smooth, lower
boarders couldn’t be palpated.
• Nontender.
Per-Vaginal Examination :
• Vulva/Vagina: Normal
• Solid firm mass of 16 wks size felt through right Fornix,
mass mobile and non tender
• Left Fornix free.
Investigations
INVESTIGATIONS
Cervical cytology:
• Normal Smear
Ultrasonography:
• Normal Upper abdominal scan.
• Bulky uterus with large uterine fibroid.
• Rounded heterogenously hypoechoic solid
lesion of size 12*11.6*10.5 cm occupying whole of the uterus.
PRE-OPERATIVE Investigations
Total Leucocyte Count:4,600/cu mm
Differential Count: Neutrophils 63, Lymphocytes 33, Eosinophils 00, Basophils 00
Blood group: A+ve
Hb: 12.8 gm%
RBS: 116mg/dl
Platelets: 205000 /cu mm
Urine Routine Examination: Normal.
Na: 136 Meq/L, K: 3.9 Meq/L
Urea: 20mg/dl mCreatinine: 1mg/dl
Chest Xray: There were no abnormality detected.
ECG: Normal Sinus rhythm, nonspecific Twave changes in lead L3 and
AVF
Medical Consultation: Patient was Advised for ECHO
ECHO:
• Mild TR.
•Tivial PR and MR.
• Left Ventricular contraction and
ejection within normal limit
Anaesthesia consultation:
• Patient was fit for surgery.
•Arrange for 2 Pint of
blood for Operation.
OPERATION
Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (done on 2072/04/23)
Operative finding:
• Fibroid of 20wks size
• B/L tubes normal
• Left ovary adherent to intestine
• Rt Ovary Normal
• Specimen sent for HPE(Histopathological Examination)
• Blood loss 500ml.
• 1 Pint of whole blood transfused intraoperatively.
PostOperative Notes:
2nd pint of blood was transfused in Post-Operative
ward on operative day.
Post Operative Period was uneventful and
patient was discharged on 30th after a week (7th postoperative day).
TEXT REVIEW ON UTERINE FIBROID
DEFINATION:
Benign tumours which arise from the uterine
myometrium or less commonly from the cervix.
COMPOSITION:
Smooth muscle with variable amount of connective tissue, but of smooth muscle origin. Also called as leiomyomata or myomas.
Aetiology:
Unclear, each fibroid is derived from smooth muscle cell rest, either from vessel wall or uterine musculature. Fibroid
growth is dependent on ovarian hormones, oestrogen, GH,
HPL.
But points in favour of oestrogen are more suggestive:
• Rarely found before puberty, ceases to grow after
menopause.
• New myomas rarely appear after menopause.
• Association of fibroids in women with
hyperoestrogenism is evidenced by endometrial
hyperplasia, DUB, endometrial Carcinoma.
• Fibroids increase during pregnancy and with OCP.
• Progesterone inhibits the growth of myomas.
EPIDEMIOLOGY:
It is estimated that around 20% of women of reproductive age have ut. Fibroid.
Presentation occurs most commonly towards the end
of reproductive life.
3 fold greater incidence among black where they also
present at younger age.
May be present in as many as 1 in 5 women above
35yrs.
Often enlarge during pregnancy or during oral
contraceptive use, and regress after menopause
Obesity increases the risk of developing fibroids,
cigarette smoking is associated with a reduced risk.
( Ross et al 1986).
ANATOMY:
Typical fibroid is a well
circumscribed tumour with a
pseudo capsule, firm in
consistency.
Cut surface is pinkish white
with whorled appearance.
Capsule consists of
connective tissue which fixes
the tumour to the myometrium.
Microscopic Appearance
Tumour consists of bundles of plain muscle cells, separated by varying
amount of fibrous strands.
Varieties of leiomyoma:
1.Uterine:
•cervical.
•Corporeal
2.Extrauterine:
•Round lig
•broad lig
•Recto-vag.
•utero - sacral
3.Leiomyomatosis
•tunica Myoma
•extension from Myoma
DISTRIBUTION OF UTERINE FIBROIDS
Uterine leiomyoma:
1.Cervical
•1-2%
•solitary
2.Corporeal
•98%
•multiple
Corporeal leiomyoma:
1.Submucous
•15%
•not capsulated
2.Subserous
•10%
3.Interstitial
•75%
VARIETIES OF UTERINE FIBROIDS
INTRAMURAL (interstitial):
•Symetrically growing tumour remaining within the myometrial wall
SUBSEROUS:
•Grows outside towards the peritoneal surface, shows bossy
growth.
•Further extrusion outside with development of pedicel makes it a
PEDUNCULATED FIBROID.
•If such tumour gets attached to a vascular organ and is cut of
from its uterine origin it is called as PARASITIC FIBROID.
SUBMUCOUS:
•Uterine contractions may force fibroids toward the cavity, when it
is Covered by thin endometrium.
•It may force itself down towards the vagina by a pedicle and
become SUBMUCOS FIBROID POLYP.
DEGENERATIVE CHANGES IN THE FIBROID
ATROPHY:
Due to less blood supply after menopause there is shrinkage of tumor which becomes firmer and fibrotic. similar changes after
delivery.
CALCEROUS DEGENERATION:
Phosphates and carbonates of lime are deposited in the periphery along the course of blood vessels. occurs in old patients with long
standing fibroids. “womb stones in graveyard” pattern.
RED DEGENERATION:
Occurs mostly during pregnancy, fibroid becomes tense, tender
and causes severe abdominal pain and constitutional upset and
fever.
TORSION:
Subserous pedunculated fibroid may undergo rotation at its site of attachment. This may result into PARASITIC FIBROID.
INVERSION:
An inversion of uterus is caused by a submucous fundal myoma.
CAPSULAR HEMORRHAGE:
If one of large veins in surface of Subserous myoma ruptures, profuse
intraperitoneal haemorrhage can cause acute hemorrhagic shock.
INFECTION:
Is common in Submucous and myomatous polyp if it projects
into cervical canal or into the vagina.
OTHER COMPLICATIONS
SARCOMATOUS CHANGES:
Sarcomatous change
Extremely rare, no more than 0.5%, intramural and Submucous
tumours have more potential than Subserous.
PREGNANCY COMPLICATION:
While many pregnancy associated with fibroids proceed uneventfully,
there is increased risk of spontaneous abortion and preterm labour.
ASSOCIATED ENDOMETRIAL CARCINOMA:
Is associated with fibroid in women over 40 yrs in 3%.
DIAGNOSIS
History
Examination.
Investigation.
Differential Diagnosis.
Patients may have a single symptom or present with several symptoms depending upon no, size and location though 50% are asymptomatic.
SYMPTOMS
MENSTRUAL DISORDERS:
Progressive menorrhagia: Seen in intramural and Submucous.
Polymenorrhoea:Occurs when cystic ovaries and PID coexist
Metrorrhagia:In submucus fibroid.
INFERTILITY:
Due to associated PID , endometriosis . distortion of uterine cavities
causing obstruction to sperm ascent, Poor nidation , corneal tubal
block.
Submucus myoma is responsible for recurrent pregnancy loss.
PAIN:
Most fibroids are painless
Most complain of heaviness in lower abdomen. Congestion and spasmodic
dysmenorrhoea is often due to associated PID.
Acute pain suggests torsion, haemorrhage and red degeneration.
PRESSURE SYMPTOMS:
Anterior and posterior fibroid lodged in pouch of Douglas cause frequency and
retention of urine.
Broad ligament fibroid causes hydroureter and hydronephrosis.Very rarely
intestinal obstruction due to loop of intestine around pedunculated fibroid.
ABDOMINAL LUMP:
large fibroid may be obscured as an abdominal tumor which grows slowly or not
at all over a long period.
OTHER SYMPTOMS:
Anaemia causing DYSPNOEA AND PALPITATION.
Ascitis if pseudomeigs syndrome is associated.
Haemorrhagic shock if intraperitoneal haemorrhage
PHYSICAL SIGNS
ANAEMIA
Of various degrees.
ABDOMINAL LUMP:
Well defined margin
Firm consistency
Smooth and bossy surface
Mobile side to side unless fixed by large size or adhesions
BIMANUAL EXAMINATION:
Enlarged uterus,regular or bossy depending upon no., and size of
tumor.
Cervix moves with swelling .swelling not felt separate from uterus
unless pedunculated.
Cervical fibroid:-Normal uterus perched on top of fibroid.
Myomatous polyp:-Cervical os is open and it’s lower pole is felt.
Differential diagnosis
Pregnancy
Hematometra
Adenomyosis
Bicornuate uterus
Endometriosis
Ectopic pregnancy
Chr. Inversion of uterus
Chronic PID
Malignant ovarian
tumor
Benign ovarian
tumor
Endometrial Ca
Myomatous polyp
Pelvic kidney
INVESTIGATIONS:
Hb%, Blood grouping
USG
Hysterosalpingography
Hysteroscopy
Dilatation and curettage (D/C)
Laparoscopy
Xray
CT Scan
MRI
IVP
ULTRASONOGRAPHY
USG is helpful to assess the adnexa if these cannot be palpated separately with confidence.
Hysterosalphingogram
• Plain xray showing calcified fibroid
Diagonostic hysteroscopy
Number
Size
Site in relation to the tubal
ostia and the uterine walls
Pedicle
Depth of the myoma in
relation to the uterine wall.
MANAGEMENT
Small and asymptomatic fibroids require no removal , can be observed for 6 months.
Treatment of women with uterine leiomyomas must be individualized, based on:
1. Symptoms,
2. Size and
3. Rate of growth of the uterus, and
4. The woman’s desire for fertility.
INDICATIONS OF TREATMENT
Habitual abortion
Infertility
Fibroid causing menorrhagia and pressure symptoms.
Asymptomatic fibroid causing pressure on ureter.
Rapid growth of fibroma in menopausal women
When nature of tumor can’t be ascertained clinically.
MODE OF TREATMENT :
•MEDICAL
•MINIMAL INVASIVE SURGERY
•SURGERY
MEDICAL TREATMENT:
1.Gonadotropin-releasing hormone (GnRH) agonists.
•Fibroids may be expected to shrink by up to 50% of their initial
volume within 3 months of therapy.
• GnRH agonist treatment should be restricted to a 3- to 6-month
interval, following which regrowth of fibroids usually occurs within
12 weeks.
• GnRH agonists are indicated preoperatively to shrink fibroids and
to reduce menstrual related anemia
2.Tranexamic acid
May reduce menorrhagia associated with fibroids.
3.Danazol
Has been associated with a reduction in volume of the fibroid in the
order of 20% to 25%.
Although the long-term response to danazol is poor, it may offer an
advantage in reducing menorrhagia.
4.Iron therapy
Blood transfusion may be required preoperatively.
5.Mifepristone
50mg daily for 3 months.
SURGERY:
Myomectomy
•Vaginal Myomectomy
•Abdominal Myomectomy
•Hysteroscopic Myomectomy
•Laparoscopic myomectomy
Hysterectomy
•Total Abdominal Hysterectomy
•Subtotal Hysterectomy
•Vaginal hysterectomy
•Laparoscopic Hysterectomy
HYSTERECTOMY
The only indications for hysterectomy in a woman
with completely asymptomatic fibroids are:
1. Rapidly enlarging fibroids or,
2. When enlarging fibroids raise concerns of leiomyosarcoma
(after menopause).
Hysterectomy need not be recommended as a
prophylaxis against increased operative morbidity
associated with future growth.
In women who have completed childbearing,
hysterectomy is indicated as a permanent solution
for leiomyomas causing substantial bleeding,
When considering pelvic pressure, or anemia
hysterectomy for menorrhagia attributed to fibroids,
other causes should be ruled out.
Endometrial biopsy should be considered, to exclude
endometrial lesions.
Myomectomy
MYOMECTOMY THROUGH A LAPAROTOMY INCISION
1. Higher risk of blood loss and
2. Greater operative time with myomectomy than with
hysterectomy
The risk of ureteric injury may be decreased with
myomectomy.
There is a 15% recurrence rate for fibroids and
10% of women undergoing a myomectomy will eventually
require hysterectomy within 5 to 10 years.
Laparotomy is mostly indicated for:
1. Fibroids exceeding 5 cm to 8 cm,
2. Multiple myomas, or
3. When deep intramural leiomyomas are present.
LAPAROSCOPIC MYOMECTOMY
For several pelvic disorders, gynaecologists have resorted to
minimal access surgery in an effort to:
1. Reduce hospital stay and
2. Improve recovery time.
• Myomas may be removed by a laparoscopic approach.
The challenges of this surgery rest with the surgeon’s ability to
1. Remove the mass through a small abdominal incision and
2. Reconstruct the uterus.
Uterine rupture during a subsequent pregnancy has been
reported.
The risk of recurrent myomas may be higher after a laparoscopic
approach, with a 33% recurrence risk at 27 months.
HYSTEROSCOPIC MYOMECTOMY
Is feasible and very effective, and it should be considered in women with
Symptomatic intracavitary or Submucous narrow-based
intrauterine myomas.
Indications include :
• Infertility,
• Repeated pregnancy losses, and
• Abnormal uterine bleeding.
If fertility is not desired and abnormal uterine bleeding is the main
symptom, concomitant endometrial ablation or resection may provide
better resolution of abnormal bleeding than myomectomy alone.
Recently, Electrosurgical loop electrodes using bipolar technology,
as well as Vaporizing electrodes using both monopolar and bipolar
technology, have been described as new technologies to facilitate
hysteroscopic myomectomy.
HYSTEROSCOPIC MYOMECTOMY
HYSTEROSCOPIC MYOMECTOMY
UTERINE FIBFOID EMBOLISATION
Uterine fibroid embolisation (UFE) is a treatment that cuts off the blood supply to the uterus and the fibroids so they shrink. UFE is proving to be an alternative to hysterectomy and myomectomy. The recovery time is also shorter, and there is a much lower risk of needing a blood transfusion than for these surgeries. Many women can have UFE and go home the same day.
THE LATEST IN UTERINE FIBROIDS TREATMENT
MR-Guided Focused Ultrasound Ablation Using ExAblate:
Is noninvasive;
Is an outpatient procedure;
Requires little recovery time;
Does not require constant medication;
Has none of the side effects involved in hormone therapy; and
Does not expose the patient to radiation.
Uterine fibroid tumors are destroyed through the power of ultrasound energy.
MR-guided focused ultrasound ablation (MRgFUS) using ExAblate technology
Family planning:
For young women with fibroids seeking contraceptive
advice , do not give :
a) Oestrogen containing hormonal contraceptives.
b) IUCD
barrier method is suitable for such patients.
THANK YOU!.
