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
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
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
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
Transvaginal ultrasound Myoma Uteri (intramural with submucosal component) Endometrial biopsy Proliferative Endometrium with necrosis and chronic inflammation
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
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.
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
On the day of admission – Hgb stable – Glucose controlled – Claimed ready for surgery – Scheduled for OR – admitted
OB-GYN History LMP: April 25, 2011 G3P3 (3003) G11995CSPrivate hosp at Montalban Post term/ Breech presentation No fetomaternal complications G21997CSMontalbanTermNo fetomaternal complications G31999CSMontalbanTermNo fetomaternal complications
Menstrual History Menarche- 13 y/o interval 25-28 days Lasting 3-4days Using 3-4 soaked pads/day With occasional dysmenorrhea
Sexual History First intercourse- 29y/o Only 1 partner (husband) No contraceptive used No STD No recent sexual activity
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 No history of Diabetes Mellitus, Lung diseases, kidney diseases, cardiac diseases, and psychiatric disorders.
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 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
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 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
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
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.
COAGULATION PANEL (6/15/2011) ParametersResultsReference range Prothrombin time (PT) 10.610-14 secs APTT40.328-44 secs
CHEST X-RAY (6/15/2011) Clear lungs. No other significant findings.
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: 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): TAHBSO + ADHESIOLYSIS/GEA
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 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: 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 “fibroids” “uterine myomas” benign proliferations of smooth muscle cells of the myometrium.
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
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 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 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 increasing age early menarche low parity tamoxifen use Obesity 2.5x more likely develop fibroids-1 st degree relatives and in some studies a high-fat diet. Smoking has been found to be associated with a decreased incidence of myomata
Clinical Symptoms of Uterine Leiomyomas Bleeding (MC symptom) Longer, heavier periods Endometrial ulceration Pressure Pelvic pressure and bloating Constipation and rectal pressure Urinary frequency or retention Pain Secondary dysmenorrhea Acute infarct (especially in pregnancy) Dyspareunia Reproductive difficulties Infertility (failed implantation/spontaneous abortion) Fetal malpresentation Intrauterine growth restriction (IUGR) Premature labor and delivery
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 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 Pregnancy test- all women History and PE Ultrasound (pelvic/transvaginal) – MC means of diagnostics
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
Treatment depends on the patient’s – Age – Pregnancy status – Desire for future pregnancies – Size and location of the fibroids
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) 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 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.
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