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Myoma Uteri OB-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 Illness. 2yrs PTA

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myoma uteri ob gyn rotation quirino memorial medical center

Myoma UteriOB-GYN Rotation Quirino Memorial Medical Center

Lazaro, Tonyrose C.

San Beda College of Medicine

general data
General Data
  • A.E.
  • 44 y/o female
  • G3P3
  • Admitted for the second time at QMMC - June 13,2011
chief complaint
Chief Complaint
  • Vaginal Bleeding
history of present illness
History of Present Illness

2yrs 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
slide5

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
slide6

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
slide7

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
slide8

Transvaginal ultrasound

Myoma Uteri (intramural with submucosal component)

  • Endometrial biopsy

Proliferative Endometrium with necrosis and chronic inflammation

slide9

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

slide10

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.

slide11

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
slide12

On the day of admission

  • Hgb stable
  • Glucose controlled
  • Claimed ready for surgery
  • Scheduled for OR
  • admitted
ob gyn history
OB-GYN History
  • LMP: April 25, 2011
  • G3P3 (3003)
menstrual history
Menstrual History
  • Menarche- 13 y/o
  • interval 25-28 days
  • Lasting 3-4days
  • Using 3-4 soaked pads/day
  • With occasional dysmenorrhea
sexual history
Sexual History
  • First intercourse- 29y/o
  • Only 1 partner (husband)
  • No contraceptive used
  • No STD
  • No recent sexual activity
past medical history
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
Family Medical History
  • No history of Diabetes Mellitus, Lung diseases, kidney diseases, cardiac diseases, and psychiatric disorders.
personal social history
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
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
slide20

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
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
slide22

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

slide23

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
ADMITTING DIAGNOSIS
  • G3P3 (3003) Abnormal Uterine Bleeding, Myoma Uteri, Proliferative Endometrium, s/p LTCS 3x malpresentation and repeat
slide25
Plan
  • Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAHBSO)
course in the wards pre operative work ups
Course in the Wards/Pre-operative Work ups

COMPLETE BLOOD COUNT (6/13/2011)

slide29

CHEST X-RAY (6/15/2011)

  • Clear lungs. No other significant findings.
medications
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
PRE-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

intraoperative findings
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
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
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
uterine leiomyoma
Uterine Leiomyoma
  • “fibroids”
  • “uterine myomas”
  • benign proliferations of smooth muscle cells of the myometrium.
pathogenesis
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
slide39

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
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
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
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 manifestations
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 examination1
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
Diagnostic Evaluation
  • Pregnancy test- all women
  • History and PE
  • Ultrasound (pelvic/transvaginal) – MC means of diagnostics
treatment
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
slide48

Treatment depends on the patient’s

    • Age
    • Pregnancy status
    • Desire for future pregnancies
    • Size and location of the fibroids
medical therapies
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
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
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.
slide52

Indications for Surgical Intervention for Uterine Leiomyomas

  • Abnormal uterine bleeding, causing anemia
  • Severe pelvic pain or secondary amenorrhea
  • Uterine size (>12 weeks) obscuring evaluation of adnexae
  • Urinary frequency, retention, or hydronephrosis
  • Growth after menopause
  • Recurrent miscarriage or infertility
  • Rapid increase in size
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