Myoma uteri ob gyn rotation quirino memorial medical center
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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


Myoma uteri ob gyn rotation quirino memorial medical center

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


Myoma uteri ob gyn rotation quirino memorial medical center

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


Myoma uteri ob gyn rotation quirino memorial medical center

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


Myoma uteri ob gyn rotation quirino memorial medical center

  • Transvaginal ultrasound

    Myoma Uteri (intramural with submucosal component)

  • Endometrial biopsy

    Proliferative Endometrium with necrosis and chronic inflammation


Myoma uteri ob gyn rotation quirino memorial medical center

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


Myoma uteri ob gyn rotation quirino memorial medical center

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.


Myoma uteri ob gyn rotation quirino memorial medical center

  • 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


Myoma uteri ob gyn rotation quirino memorial medical center

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


Myoma uteri ob gyn rotation quirino memorial medical center

  • 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


Myoma uteri ob gyn rotation quirino memorial medical center

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


Myoma uteri ob gyn rotation quirino memorial medical center

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


Myoma uteri ob gyn rotation quirino memorial medical center

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)


Myoma uteri ob gyn rotation quirino memorial medical center

BLOOD CHEMISTRY (6/15/2011)


Myoma uteri ob gyn rotation quirino memorial medical center

COAGULATION PANEL (6/15/2011)


Myoma uteri ob gyn rotation quirino memorial medical center

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


Operation procedure performed 6 17 2011 at 7 00am

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

TAHBSO + ADHESIOLYSIS/GEA


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


Discussion

Discussion


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


Myoma uteri ob gyn rotation quirino memorial medical center

  • 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


Myoma uteri ob gyn rotation quirino memorial medical center

  • 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.


Myoma uteri ob gyn rotation quirino memorial medical center

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


Myoma uteri ob gyn rotation quirino memorial medical center

Thank You..


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