6Personal/Social/Sexual History no vicescollege undergraduatefirst coitus was at 28 years old with one non promiscuous sexual partnerno history of use of OCPs, IUD, condoms, or any forms of contraception
7Menstrual History Menarche at 15 years old regular intervals, 4-5 days, 3-4 pads per dayno dysmenorrhea nor intermenstrual bleedingLNMP: July 15, 2009PMP: June 2009AOG: 30 1/7 weeks by amenorrhea
9History of Present Illness 6 months PTC:(+) note of missed menses consult with a private physician where a PT was done and was (+)Pt asked to follow-up after 1 month
10History of Present Illness 5 months PTC:sudden onset hypogastric pain, “humihilab”, VAS 5/10, nonradiating.no vaginal bleeding , watery vaginal discharge, fever or dysuria.Consulted a local hopital where an UTZ was done: SLIUP, cephalic with AOG of 15 weeks and 5 days, normohydramnios, large IM and SS myoma in the lower anterior uterine segment more to the left side.
11History of Present Illness Due to unavailability of an obstetrician, pt was referred to a LH in Cavite for further managementPt was admitted for 5 days, given unrecalled antibiotics, and was sent homeTHM: Isoxilan 1 tab q6, Amoxicillin 500 mg/cap 1 cap TID x 5 days, Flagystatin suppository per vagina during bedtime x 4 days.
12History of Present Illness Pt continued to have her prenatal checkups with a private obstetrician.Plan was for CS however, due to financial constraints, pt transferred to our institution for further management.
13Review of Systems(-) weight loss, anorexia, fever, blurring of vision, headache, vomiting, abdominal pain, watery or bloody vaginal discharge, dysuria, edema, decreased fetal movement.
15Physical ExaminationAbdomen: globular, NABS, (+) 10 x 11 cm mass at the left lower quadrant, firm, movable and slightly tenderFH 37 cm, EFW kg, FHT 130s, RLQ, cephalic presentationIE: NEG, smooth nulliparous vagina, cervix was soft, smooth, (-) AMTFEP, PNB, (-) cyanosis, (-) edema.
17PlanPt was sent to OBAS immediately due to preterm labor.
18Ultrasonography TV and AP UTZ (09/20/2010) Transvaginal and abdominopelvic ultrasound were done. Within the gravid uterus is a single live fetus in variable presentation. BPD measures 15 cm compatible with 15 weeks and 5 days. HC measures 11.9 cm compatible with 16 weeks and 0 days. AC measures 9.8 cm compatible with 15 weeks and 6 days. FL measures 1.7 cm compatible with 15 weeks and 2 days. There is good cardiac activity with FHR = 158 bpm. The amount of amniotic fluid appropriate for AOG. The immature placenta is posterior in location. EFBW = 130g. There is a huge well rounded heterogenous solid mass located in the lower anterior uterine segment left side of the uterus measuring 8.9 x 7.6 x 8.4 cm suggestive of myoma.
19Ultrasonography Impression: Single, live intrauterine pregnancy, cephalic with AOG of 15 weeks and 5 days. Normohydramnios. Large intramural and subserous myoma in the lower anterior uterine segment more to the left side.
20Ultrasonography Fetal and Obstetrical Sonography (12/02/2009) Number of fetus: singleLie: Vertical breechSomatic movement: activeAmniotic fluid: Anechoic normohydramniosPlacental location: Posterior grade0Fetal HR: 134 bpmEstimated fetal weight: 1030 gFetal sex: Male
21ULtrasonography Biometry BPD 66 mm 27 weeks FL 49 mm 26 weeks HC 240 mm 26 weeksAC 219 mm 26 weeksEstimated AOG: 26 weeks and 2 daysEDC: March 8, 2010
22Ultrasonography Impression: Within the gravid uterus is a sinle livefetus breech at present with estimated AOG of 26 weeks and 2 days by biometry. The fetus is active with good cardiac pulsation and normal amniotic fluid. Placenta is located posterior, high lying, with grade 0. No gross fetal anomaly. Note of left lateral wall myoma measuring 6.8 x 8 cm.
23Guide Questions What are Uterine Myomas? What are the different types? What is the pathophysiology of the development of myomas?What are the forms of myoma degeneration? Differentiate each.What are the effects of myomas in pregnancy?What are the effects of pregnancy on myomas?
24Guide Questions How should we work-up the patient? How do we manage our patient?What is the ideal management of myomas during pregnancy? Include medical and surgical management.