CASE PRESENTATION ON UTERINE FIBROIDS

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!.