Uterine Fibroid - viva voce

8/11/2019 Uterine Fibroid - viva voce

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UTERINE FIBROIDCASE SCENARIOS

&DISCUSSION

By

Dr. K. Haynes Raja,

Junior Resident,

Rajah Muthiah Medical College & Hospital,

Annamalai University.


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DEDICATIONDedicated to my Great Teachers

in the Dept. of Obstetrics & GynaecologyDr. Lavanya Kumari and Dr. Sangeereni,

Inspiring Friends Dr. Paulin Benedict,

Dr. Jeyakumar Meyyappan and Dr. Hannah Jane

and our REVELLIONZ 08 batch.

PREFACE

This presentation is prepared to meet out theundergraduate medical student needs especially to

understand the practical aspects of uterine fibroid and to

rapidly revise some important viva questions.


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CASE SCENARIO - 1

A 36 Year old woman has noticed

abdominal swelling for 10 months.

She has to wear large clothes and

people asked her if she is pregnant,

which she finds distressing havingbeen trying to conceive.


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She has no abdominal pain and her

bowel habit is normal. She feels

nauseated when she eats large

amounts. She has urinary frequency

but no dysuria or haematuria.


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Her periods are regular, every 27

days and have always been heavy,

with clots and flooding on the secondand third days. She has never

received any treatment for her heavy

periods.


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She has been with her partner for 7

years and despite not using

contraception she has never been

pregnant.


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Examination

The woman has a very distended

abdomen. A smooth firm mass is

palpable extending from symphysis pubis

to midway between the umbilicus and the

xiphisternum (equivalent to a 32 week

pregnancy). It is non-tender and mobile.

It is not fluctuant and it is not possible to

palpate beneath the mass.


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On speculum examination it is not

possible to visualise the cervix.Bimanual examination reveals a

non-tender firm mass occupying the

pelvis.


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Investigations

Haemoglobin 6.3 g/dL

Mean cell volume 68fl

White cell count 4.9 * 10 9 /L

Platelets 267 * 10 9 /L


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Magnetic resonance imaging


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Diagnosis

The woman has a large uterine

fibroid. This is causing menorrhagia

and hence the microcytic anaemia

from iron deficiency. It is also likely

that fibroid is accounting for herinfertility history.


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DISCUSSION


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What is the differential diagnosis?Uterine fibroids

Pregnancy

Full bladder

Haematometra/pyometra

Adenomyosis

Bicornuate uterus

Bilateral tubo-ovarian masses

Ectopic pregnancy

Pelvic Endometriosis

Endometrial carcinoma

Uterine sarcoma

Ovarian neoplasms


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What is fibroid?

Fibroid is the commonest benign tumour of uterusArises from smooth muscle cells and hence called

as Leiomyoma


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What is the incidence?

At least 20% of women in the reproductive age group


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Whether fibroid is hormonedependant?

Fibroid is hormone dependant. Predominantlyoestrogen dependant.

Other hormones implicated are growth hormone,

human placental lactogen


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What are the hyperoestrogenicstates?

Nulliparity

Obesity

Polycystic Ovarian syndrome

Endometrial hyperplasia


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Explain the Anatomy & pathologyof fibroid?

Derived from smooth muscle cell rests, either from

vessel walls or uterine musculature

Well circumcised, firm, round tumours with apseudocapsule

They become soft and cystic when degenerative

changes occur

They may be single or multiple


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Usually arises from body of uterus and less

commonly from cervix

The vessels which supply lie in capsule and send

radial branches, so innermost part receives least

blood supply

The innermost part is the first to undergo

degeneration whereas the outermost part is the

first to calcify

Cut surface shows whorled appearance

Explain the Anatomy & pathologyof fibroid?


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What are the synonyms of fibroid?

Fibromyoma

Leiomyoma

myoma


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What are the types of fibroid?


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Uterine Extrauterine

Body of uterus Cervix Ovary

Subserous (10%) Broad ligament fibroidIntramural(75%) 1. True (originates in broad

Submucous (15%) ligament)

2. False (arises in uterus &

grows into broad ligament)

What are the types of fibroid?


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What is parasitic fibroid?

Rarely, a extruded fibroid gets detached from

uterus and attaches to a vascular organ (omentum orbowel). This fibroid is called parasitic fibroid or

wandering fibroid.


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CASE SCENARIO - 2

A 32 year old woman complains ofincreasingly long and heavy periods

over the past 5 years. Previously she

bled for 4 days but now bleeding lasts

up to 10 days. The periods still occur

every 28 days. She experiencesintermenstrual bleeding between most

periods but no postcoital bleeding.


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The periods were never painfulpreviously but in recent months have

become extremely painful with

intermittent cramps. She has had four

normal deliveries and had a

laparoscopic sterilization after her lastchild.


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Her smear tests have always been

normal, the most recent being 4

months ago. She has never had any

previous irregular bleeding or other

gynaecological problems.


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Examination:

The abdomen is soft and non-

tender with no palpable mass.

Speculum examination shows anormal cervix. On bimanual palpation,

the uterus is bulky (approximately 8

week size), mobile and anteverted.

There are no adnexal masses.


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Investigations


Mean cell volume 75 flWhite cell count 4.5 * 10 9 /L



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Hysteroscopy


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Diagnosis

This woman has a Submucosal fibroid.

Submucosal fibroids are a common cause

of menorrhagia and can cause, as in thiscase, intermenstrual bleeding.

Fibroids usually dont cause

intermenstrual bleeds other than when

there is ulceration or it is submucous or

cervical fibroid


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What are the clinical manifestations?

Menorrhagia, polymenorrhoea, metrorrhagia

Infertility, recurrent abortions

Pain spasmodic dysmenorrhoea, backache, dueto pyelitis

Pressure symptoms bladder, ureter, rectum

Abdominal lump or mass protruding at introitus

Vaginal discharge

As many as 50% women are asymptomatic


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How do they cause menorrhagia?

Increased surface area of endometrium

Hyperoestrogenism

Intramural fibroid prevents adequate contraction

and retraction of uterus

Associated pelvic inflammatory disease


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Can fibroids cause polycythaemia?

Yes. Huge fibroid compresses renal arteryReduced renal perfusion Hypoxia activation of

Renin- angiotensin aldosterone Renal

erythropoietin secretion increases polycythaemia


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How do they cause infertility?

Cervical fibroid does not allow nidation of sperms

Fibroid in Cornual end does not allow fertilised

ovum to enter uterine cavity

Increased chances of abortion is seen with

submucous fibroid due to improper implantation

Associated Hyperoestrogenic state can cause

infertility


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When do they cause pain?

Acute torsion of a pedunculated fibroid ordegeneration are the main causes of pain

Intracapsular haemorrhage

Rarely, a submucous fibroid trying to get expelled

from the cervix will produce pain

When do fibroids present asemergency?


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CLINICAL SCENARIO - 3

A 33 Year old women complains ofworsening abdominal pain for 4 days.

She is 16 week pregnant in her third

pregnancy. She has a 10 year old son,

by normal delivery and a miscarriage

8 years ago. Her pregnancy has beenuneventful until now with an

unremarkable first trimester scan.


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She has had no vaginal bleeding and

reports urinary frequency since the

beginning of the pregnancy. She is mildly

constipated and has no nausea and

vomiting. There is no history of trauma.She has not felt the baby moving yet.


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EXAMINATION

The woman is apyrexial and pulserate is 125/min, with blood pressure

110/68 mm Hg. The uterus is palpable

just above the umbilicus. There is

significant tenderness over the left

uterine fundal region, where it alsofeels firm. The abdomen is otherwise

soft and non-tender.


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There is voluntary guarding but no

rebound tenderness. Bowel sounds

are normal. Speculum examinationshows a normal, closed cervix and no

blood. The fetal heart beat is heard

with hand-held Doppler.


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Investigations


Mean cell volume 79 fl

White cell count 7.2 * 10 9 /L


C-reactive protein


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Diagnosis

The patient has fibroid undergoing Reddegeneration. The uterine size is larger

than dates and the localised uterine

tenderness are the important features in

making this diagnosis.

Red degeneration happens almostexclusively in pregnancy


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DISCUSSION


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What are the obstetric complicationsof fibroid?

a) Increased risk of Abortions

b) Threatened preterm labour

c) Premature delivery

d) Abruptio placenta.

e) IUGR

f) Intrapartum problems if fibroid large & located in the lower

uterine segment. Cervical fibroid caesarean delivery.

g) Interference with propagation of myometrial contractility

uncoordinated uterine contraction or PPH.


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What are the general complicationsof fibroid?

Degeneration

Torsion

Inversion of uterus

Capsular haemorrhage

Infection

Associated endometrial carcinoma


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What are the secondary changesin fibroid?

Atrophy

Hyaline/cystic/fatty degeneration

Calcareous degeneration

Red degeneration

Sarcomatous degeneration


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What is red degeneration?

Occurs most frequently during pregnancy

Becomes tense and tender and causes severe

abdominal pain with constitutional upset and

fever.Fibroid becomes reddish with a particular fishy

smell.

Leucocytosis and raised ESR may be present but

this is an aseptic condition

Examination of fibroid shows thrombosed vessels


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Differential Diagnosis:

Acute appendicitis

Torsion of ovarian cyst

Acute pyelonephritis

Accidental haemorrhage

Treatment: Self limiting and resolves by itself

Differential diagnosis andmanagement for red degeneration


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In sarcomatous degeneration (not more than 0.5%)

When do fibroids grow rapidly?


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What are the investigations to do?

General Investigations:

Blood investigations:

Haemoglobin & Haematocrit to rule out anaemia

Random Blood sugar to know the diabetic status

Blood grouping and Rh typing for transfusion if

necessary

Serum urea and Creatinine for assessing the renalfunction

Urine Examination:

albumin, sugar and deposit


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Special investigations :

Intravenous pyelogram:

To trace the course of ureter to avoid injury during

surgery

To rule out renal abnormalities (Eg. pelvic kidney)

Ultrasound abdomen:

To know the site and number of fibroid

What are the investigations to do?


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Other investigations

Hysterosalpingography and sonosalpingography

Hysteroscopy

Dilatation and curettage to rule out endometrial

cancer

Magnetic resonance imaging


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When do you treat a fibroid?

Indications for treating an asymptomatic fibroid

are

Infertility caused by cornual blocking or abortioncaused by submucous fibroid

Fibroid more than 12 weeks size or a pedunculated

fibroid which can undergo torsion

Fibroid causing pressure on ureter

Rapidly growing fibroid

If the nature of tumour cant be assessed clinically


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All symptomatic fibroid needs treatment which

can be Medical or surgical

When do you treat a fibroid?


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Iron therapy for anaemia

Surgery is the definitive treatment modality but

the use of medical management is to control

menorrhagia and to improve haemoglobin before

surgery

Drugs can also be used in women nearing

menopause or who are not fit for surgery

Drugs used are low dose OCPs(have minimal

oestrogen), mifepristone(RU 486), GnRH

analogues like leuprolide

How will you manage Medically?


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What are the indications for useof GnRH agonists in women with

leiomyomas?Preservation of fertility before attempting conception orpreoperative treatment before myomectomy

Treatment of anaemia to allow recovery of normalhaemoglobin levels before surgical management orallowing autologous blood donation

Treatment of women approaching menopause in an effortto avoid surgery

Preoperative treatment of large leiomyomas to makevaginal hysterectomy, hysteroscopic resection orablation, or laparoscopic destruction more feasible

Treatment of women with Medical contraindications tosurgery


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GnRH analogues causes rapid shrinkage of tumour

and reduces vascularity

Hence it decreases the need of surgery in young

women with infertility for cornual blockade

It also facilitates vaginal hysterectomy or surgery

with minimal blood loss

The main disadvantage is cant be extended beyond 6

months (causes osteoporosis), fibroid capsule

becomes thin and enucleation is difficult, recurrence

of fibroid is high.

What are the advantages anddisadvantages of GnRH analogues?


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Urinary symptoms or signs such as hydronephrosis

after complete evaluation

Infertility with leiomyomas as the only abnormal

finding

Recurrent pregnancy loss with distortion of

endometrial cavity

Markedly enlarged uterine size with compression

symptoms or discomfort

What are the potential indications ofsurgery?


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What are the surgical managementoptions?

Myomectomy Laparotomy / Laparoscopy /

Hysteroscopy

Hysterectomy Abdominal / vaginal /

laparoscopic

Uterine artery embolization


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What is myomectomy?

Removal of fibroids leaving behind the uterus

Indicated in infertile women or a women desirous

of childbearing and wishing to retain uterus


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What are the preoperative requisitesof myomectomy?

Haemoglobin should be restored

In infertility cases, other causes should have been

excluded

SIGNATURE FOR HYSTERECTOMY IS REQUIRED IN

DIFFICULT CIRCUMSTANCES

Should be performed in preovulatory period

Endometrial cancer to be ruled out by D&C


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Explain the steps of myomectomy

Patient in supine position

The abdomen is draped and opened by pfannenstiel

incision

Confirm the feasibility of myomectomy

Anterior uterine wall is incised and as many fibroids are

removed by tunneling incisions

Haemorrhage is controlled by myomectomy clamp

The capsule should be incised and fibroid enucleatedwith the help of myoma screw

Following enucleation, cavity is obliterated with catgut

Release the clamp and secure haemostasis


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What are the complications ofmyomectomy?

Haemorrhage primary, secondary and

reactionary

Trauma to adjacent structures

ureter, bladder,bowel

Infections

Adhesions and intestinal obstruction

Recurrence of fibroids and persistent menorrhagia


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When do you employ laparoscopicmyomectomy?

Pedunculated fibroid

Subserous fibroid not exceeding 10 cm in size and

not more than 4 in number


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What are the advantages of subtotal

hysterectomy over total hysterectomy?

Cervix is retained for sexual function

Vault prolapse is less

Less surgical morbidity


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Will you remove ovaries duringhysterectomy for fibroid?

Ovaries should be retained to avoid menopausal

symptoms in a premenopausal woman provided they

look normal.


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What is panhysterectomy?

Removal of uterus, cervix and ovaries


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What is LAVH? Contraindicationsfor this procedure?

LAVH stands for Laparoscope assisted vaginal

hysterectomy.

Contraindications are

Uterus more than 14 16 weeks size

Fibroid located in broad ligament, cervical fibroid and

extensive pelvic adhesions, endometriosis

What are the complications of


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W physterectomy?

Haemorrhage Primary, secondary and reactionary

haemorrhage

Trauma to adjacent organs bladder, ureter, boweland ureter

Postoperative infection and Sepsis

Anaesthetic complications

Paralytic ileus, intestinal obstruction or chronicabdominal pain due to postop adhesions

Thrombosis, pulmonary embolism, chest infection

Burst abdomen, scar, hernia

Residual ovarian syndrome

Dyspareunia


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Explain about uterine arteryembolization?

Through percutaneous femoral catheterisation,

Polyvinyl alcohol (PVA), gel foam particles or

metal coils are injected.

This reduces vascularity and size(40% at 6 weeks

and 75% at 1 year)

Contraindications:

Subserous, submucous and pedunculated fibroids

Infertility and desire of pregnancy


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Explain about uterine artery

embolization?


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Advantages:

No major surgery, intraoperative bleeding, adhesions

Short hospital stay

75 80% women are satisfied

Explain about uterine artery

embolization?


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Polypectomy


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Uterine Fibroid - viva voce

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