Department Of Obstetric & Gynecology PELVIC MASS

1. JORDAN UNIVERSITY OF SCIENCE AND TECHNOLOGY Department Of Obstetric & GynecologyPELVIC MASS Supervised by Dr Isam Lataifeh Esra Sami Mohamed Fayez

2. Introduction

3. Differential Diagnosis • Gynecological causes: 1) uterine masses • pregnancy • fibroids • endometrial carcinoma • adenomyosis

4. Differential Diagnosis 2) Tubal masses • inflammatory origin • ectopic pregnancy • carcinoma 3) Ovarian masses • functional cysts • endometriomas • Ovarian neoplasms

5. Differential Diagnosis Non - gynecological causes bowel • gas or faeces in sigmoid or caecum • appendicitis • diverticular diseases miscellaneous • distended bladder, pelvic kidney • abdominal wall hematoma • retroperitoneal neoplasm

6. History • age • pain (onset and type,site ), menstrual status, menstrual disturbances, interference with sexual activity , look for GIT symp (abd.bloating or fullness ,constipation or change in stool caliber) • parity, gravidity (obs hx), • previous personal (past surgical & medical) and family history • family history breast( BRCA family Risk ), ovarian , GI tumors + ( Fibroids have a familial pr) • weight loss

7. Physical Exams • General exam (VS ,weight, hydration, anemia) • Lymphadenopathy (supraclavicular) • chest + breast exam • abdominal exam : masses and tenderness etc • bimanual exam (size,shape,irregularity ,mobility , consistency) ( sensitivity and specificity of pelvic exam R both only 50 %) • rectovaginal exam (post.uterine surface, uterosacral ligament , POD, rectum )

8. FIBROIDS • tumors or lumps made of muscle cells and other tissue that grow within the wall of the uterus. • may grow as a single tumor or in clusters

9. Where do uterine fibroids grow?

10. Where do uterine fibroids grow? • Submucosal fibroids grow just underneath the uterine lining. • Intramural fibroids grow in between the muscles of the uterus. • Subserosal fibroids grow on the outside of the uterus. • Pedunculated fibroids grow out from the surface of the uterus, or into the cavity of the uterus

11. Symptoms (patient’s history) GYNECOLOGICAL PROBLEMS 1) Abnormal vaginal bleeding - intermenstrual - menorrhagia - irregular bleeding 2) Pain -acute (degeneration & torsion) -chronic pelvic pain -deep dysparunia pain -throughout menstruation

12. Symptoms cont’ 3) Pressure symptoms - bladder pressure - bowel compression - nerve compression 4) Infertility -tube obstruction -interfere with implantation

13. Associative Risk Factors • Hereditary? • Null parity • Black women, low in asian • Age : 35-50 (reproductive age) – estrogen & progesterone’s role - Fibroids grow rapidly during pregnancy when hormone levels are elevated. - Fibroids shrink after menopause when hormone levels are decreased. • Obesity is associated with the presence of uterine fibroids. *genetic, hormonal, environmental

14. Investigation & Diagnosis • complete blood count (CBC) - anaemia • blood tests (bleeding disorder & hormonal level) • Most often confirmed by transabdominal ultrasound • Transvaginal ultrasound • endometrial biopsy – rule out carcinoma

15. Investigation & Diagnosis • Pelvic exams

16. Hysterosalpingography - uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images.

17. Hysteroscopy - small, lighted telescope

18. MRI, CT Scan

19. Management and Treatment • Treated only if : -symptomatic regardless of the size -if the size > 12 W fetal gestational age even if it’s asymptomatic • Medical Rx - Uterine Artery Embolization - GRHA & Androgens Analogues • Surgical Rx -myomectomy -hysterectomy

20. Surgical Rx • Myomectomy (laparoscopy, hysteroscopy, open laparatomy) -removes only the fibroids and leaves the healthy areas of the uterus in place -preserving ability to have children

21. Surgical Rx • Hysterectomy -removal of the whole uterus -done if fibroids are large + abnormal bleeding + nearly menopause + not wanting children

22. Types of hysterectomy • Abdominal hysterectomy is a procedure that involves a cut into the abdomen to remove the uterus. • Vaginal hysterectomy is less invasive because the doctor reaches the uterus through the vagina, instead of making a cut into the abdomen

23. Medical Rx • Uterine Artery Embolization (radiology intervention) - cuts off the blood supply to the fibroids, making them shrink -access to femoral artery -tiny tube into the vessel -guided to the uterus (fluoroscopy) -inject tiny plastic particles into artery supplying the fibroid -fibroid shrinks

24. Uterine Artery Embolization

25. Uterine Artery Embolization • Advantages - Relief of symptoms in 85 % - non-surgical, safe - no significant blood loss - one-night stay - resume daily activities in short time • Disadvantages -moderate to severe cramps -injury to uterus -infection

26. Focused ultrasound surgery • inside of a specially crafted MRI scanner • visualize fibroid’s anatomical location, and then locate and destroy (ablate) them • focused high-frequency, high-energy sound waves are used to target and destroy the fibroids • single treatment session is done in an on- and off-again fashion, sometimes spanning several hours

27. Focused ultrasound surgery

28. Medical Rx • Gonadotropin Releasing Hormone Agonists -Estrogen and progesterone levels fall, menstruation stops, fibroids shrink and anemia often improves • Androgens -Danazol, a synthetic drug similar to testosterone, has been shown to shrink fibroid tumors, reduce uterine size, stop menstruation

29. Obstetric Complications • Abortions (submucous) • Abnormal fundal height, lie and presentation • Failure of implantations • Abnormal labor • Preterm labour and prematurity • Atonic postpartum haemorrage ~ sarcomatous change?