4History of Present Illness 2yrs PTA(+) hypogastric pain, 5/10 , shearing/compressingOcc minimal intermenstrual vaginal bleedingUsed 1-2pads/day(+) palpable mass at hypogastric area – tennis ball sizeNo consult, no meds
56 months PTAIntermenstrual bleeding and occ hypogastric pain persistedProgressive enlargement of the mass approx. double the size of a tennis ballNo consult, no medications
61 ½ month PTA(+) profuse vaginal bleeding with blood clots for 2 weeksUsed 3 fully soaked pedia diaper/dayHypogastric pain became severe, 9/10
71 month PTA Consulted at QMMC OB-GYN OPD CBC- low hemoglobin Elevated blood glucoseAdmitted for correction of anemia, 2 weeksTransfused 5 u PRBC w/c corrected anemia
8Transvaginal ultrasound Myoma Uteri (intramural with submucosal component)Endometrial biopsyProliferative Endometrium with necrosis and chronic inflammation
9TRANSVAGINAL 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
10HISTOPATH 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.
11Discharged improved, advised weekly ff up Prescribed FeSO4 TID, Tranexamic acid OD x7days, Ascorbic acidContinue Metformin 500mg TIDAdvised elective surgery (TAHBSO) after 2 weeks or once hgb and glucose become stable
12On the day of admission Hgb stable Glucose controlled Claimed ready for surgeryScheduled for ORadmitted
13OB-GYN History LMP: April 25, 2011 G3P3 (3003) G1 1995 CS Private hosp at MontalbanPost term/ Breech presentationNo fetomaternal complicationsG21997MontalbanTermG31999
14Menstrual History Menarche- 13 y/o interval 25-28 days Lasting 3-4days Using 3-4 soaked pads/dayWith occasional dysmenorrhea
15Sexual History First intercourse- 29y/o Only 1 partner (husband) No contraceptive usedNo STDNo recent sexual activity
16Past Medical HistoryFeb 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.
17Family Medical History No history of Diabetes Mellitus, Lung diseases, kidney diseases, cardiac diseases, and psychiatric disorders.
18Personal/Social History widowLives in a single abode with her 3 children.non-smokernon-alcoholic beverages drinkerdenied illicit drug used
19Review of Systems General: no weight loss, no easy fatigability, fever CNS: occasional headache, no loss of consciousnessRespiratory: no difficulty of breathing, no colds, no coughCardio: no chest pain, no palpitation, no orthopneaGIT: no constipation, no diarrhea, no vomiting
20GUT: no dysuria, no polyuria, no hematuria, no urinary urgency Extremities: no weakness, no numbnessM/S: no limitation of movement, no joint painPsychiatric: no mood changes, depression or suicidal attempts.
21Physical Examination GENERAL SURVEY Patient is conscious and coherent, alert, ambulant; oriented to time, person, and place; not in cardiorespiratory distress.VITAL SIGNSBlood pressure: 120/80RR: 18/minHR: 85 bpmTemperature: 36.4°C
22SkinPatient’s skin is fair in color, no discolorations, moist and warm to touch, no masses, no lesionsHEENT: anicteric sclera, slightly pale palpebral conjunctivaChest/Lung: symmetrical chest expansion, clear breath sound, no retractionsHeart: adynamic precordium, normal rate and rhythm, no murmurExtremities: full pulses, pink nailbeds
23Abdomen: globular, uterus enlarged to 18x18x10 cm, doughy, slightly movable, non-tender Speculum Exam: pink and smooth cervix, no erosions, no dischargeInternal Exam: cervix short, firm, closed; uterus asymmetrically enlarged, non-tender on deep palpation, doughy, slightly movable.
25PlanTotal Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAHBSO)
26Course in the Wards/ Pre-operative Work ups COMPLETE BLOOD COUNT (6/13/2011)RESULTSREFERENCE RANGERBC4.31x10^12/LHemoglobin113g/dLHematocrit0.38%Platelet335x10^9/LWBC7.85-10x10^9/LNeutrophils0.439Lymphocytes0.197Eosinophils0.312Monocytes0.049
27BLOOD CHEMISTRY (6/15/2011) TEST NAME RESULT REFERENCE RANGE Glucose 5.52Creatinine45.11umol/LSGPT9.37-35 u/LBlood Urea Nitrogen2.53mmol/LUric Acid302.82umol/LCholesterol4.74mmol/LTriglycerides1.34mmol/LHDL Cholesterol0.740-1.5 mmol/LLDL3.4mmol/LVDLD0.61--1.0mmol/LSodium135 lowmmol/LPotassium3.8mmol/LHbA1C5.1%
28COAGULATION PANEL (6/15/2011) ParametersResultsReference rangeProthrombin time (PT)10.610-14 secsAPTT40.328-44 secs
29CHEST X-RAY (6/15/2011)Clear lungs. No other significant findings.
30MEDICATIONS Cefuroxime 1 cap BID x7days Mefenamic acid 500mg/ cap TID FeSO4 1 tab ODAscorbic acid ODBisacodyl 1 tab TIDBisacodyl HSMetronidazole 500mg/tab
31PRE-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
32OPERATION/PROCEDURE PERFORMED (6/17/2011 at 7:00am): TAHBSO + ADHESIOLYSIS/GEA
33INTRAOPERATIVE FINDINGS Uterus enlarged to 20x22x14cm with submucous myoma on cut section measuring 18x15x6cm.Cervix 3x3x3cmNormal- both ovariesNormal- both FTsLiver edge smoothOmentum not matted
34POST 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.
35POST-OPERATIVE MEDICATIONS: Nalbuphine 10mg IV q4 x 6dosesKetorolac 30mg IV loading then 15mg q6 x 4dosesOmeprazole 40mg IV ODCefoxitin 1gm IV q8
37Uterine Leiomyoma “fibroids” “uterine myomas” benign proliferations of smooth muscle cells of the myometrium.
38Pathogenesis Cause of uterine leiomyomas is unclear Fibroids are monoclonalEach tumor resulting from propagation of a single muscle cellProposed 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
39Hormonally responsive to estrogen and progesterone Pregnancy- grow quickly and to huge proportionsMenopause- stop growing and atrophy in response to naturally ↓ endogenous estrogen levels.Progesterone- Increases the mitotic activity of fibroids in women
40Classification by locations Submucosal- beneath the endometrium, commonly assoc w/ heavy of prolonged bleedingintramural- in the muscular wall of the uterus, MCsubserosal -beneath the uterine serosa
41Epidemiology30% of all American women and 50% of African American women will develop leiomyoma by age 40highest prevalence occurring during the fifth decadeRare before puberty
42Risk Factors increasing age early menarche low parity tamoxifen use Obesity2.5x more likely develop fibroids-1st degree relativesand in some studies a high-fat diet.Smoking has been found to be associated with a decreased incidence of myomataWomen who smoke cigarettes and are thus relatively estrogen-deficient have a lower incidence of myomas.
43Clinical Symptoms of Uterine Leiomyomas Bleeding (MC symptom)Longer, heavier periodsEndometrial ulcerationPressurePelvic pressure and bloatingConstipation and rectal pressureUrinary frequency or retentionPainSecondary dysmenorrheaAcute infarct (especially in pregnancy)DyspareuniaReproductive difficultiesInfertility (failed implantation/spontaneous abortion)Fetal malpresentationIntrauterine growth restriction (IUGR)Premature labor and delivery
44Clinical manifestations 50-65% have no clinical symptomsAbnormal uterine bleeding- MC symptomMenorrhagia- presents as increasingly heavy periods of longer durationMetrorrhagia- bleeding between periodsMenometrorrhagia- heavy irregular bleedingChronic IDA, dizziness, fatigue
45Physical Examination Depending on their location and size uterine leiomyomas can sometimes be palpated on bimanual pelvic examination or on abdominal examinationnontender irregularly enlarged uterus with “lumpy-bumpy” or cobblestone protrusions that feel firm or solid on palpation.
46Diagnostic Evaluation Pregnancy test- all womenHistory and PEUltrasound (pelvic/transvaginal) – MC means of diagnostics
47Treatment Most cases of uterine fibroids do not require treatment Px with actively growing fibroids- ff up every 6months to monitor size and growthTreatment- severe pain, heavy or irregular bleeding, infertility, or pressure symptoms; extremely rapid growth
48Treatment depends on the patient’s AgePregnancy statusDesire for future pregnanciesSize and location of the fibroids
49Medical TherapiesMedroxyprogesterone- shrink fibroids by decreasing circulating estrogen levelsGnRH agonists- shrink fibroids by decreasing circulating estrogen levels; stop bleeding, and increase the hematocrit prior to surgical treatment of uterine fibroids.
50Uterine artery embolization (UAE) decrease the blood supply to the fibroid, thereby causing ischemic necrosis, degeneration, and reduction in fibroid sizeNo to women planning to become pregnant after the procedure
51Surgical 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.
52Indications for Surgical Intervention for Uterine Leiomyomas Abnormal uterine bleeding, causing anemiaSevere pelvic pain or secondary amenorrheaUterine size (>12 weeks) obscuring evaluation of adnexaeUrinary frequency, retention, or hydronephrosisGrowth after menopauseRecurrent miscarriage or infertilityRapid increase in size