CASE REPORT

Uterine Leiomyoma

Supervised by:

dr. Mutawakkil J.P, Sp.OG

Presented by:

Neng Angie Rivera

2014730073

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

RSUD SYAMSUDIN SH SUKABUMI

UNIVERSITY OF MUHAMMADIYAH JAKARTA

FACULTY OF MEDICINE AND HEALTH SCIENCE
2019
 CHAPTER I
INTRODUCTION

Uterine leiomyoma or myoma or uterine fibroid is a benign smooth muscle

neoplasm that typically originates from the myometrium. Fibroids are the commonest
benign tumor of the uterus and also the commonest benign solid tumor in female. It has
been estimated that 20 percent of women at the age of 30 have got fibroid in their wombs
and more than 70% of women have fibroids by the age of fifty, but most are
asymptomatic. In Indonesia, the prevalence of uterine myoma found in gynecologic
patients is about 2.39% to 11.7%.1-3
The cause of uterine myoma is still not known. Several studies
have identified specific gene mutations associated with myoma. Some mutations have been
linked to defects in cell transformation involving the RNA polymerase II transcriptional
mediator subunit, MED12. Some risk factors associated with myomas include increasing
age during the reproductive years, ethnicity, nulliparity, obesity, and family history.4,5
Uterine myoma is classified based on the location in the uterus and the direction of
growth. The typical classification includes submucosal (beneath the endometrium),
intramural (in the muscular wall of the uterus), and subserosal (beneath the uterine serosa
and their growth is directed outward). When these are attached only by a stalk to their
progenitor myometrium they are called pedunculated submucosal or subserosal uterine
myoma. Intramural uterine myoma are the most common type (75%), and submucosal
fibroids are commonly associated with heavy and prolonged bleeding.1,2
The majority symptoms of uterine myoma is asymptomatic. Occasionally, a
woman may be able to feel a lower abdominal mass when the fibroid
protrudes above the pelvis. However, affected women may complain of heavy
menstrual bleeding, pain, chronic pressure, or infertility. In general, symptom risk
increases with myoma size and number.1
Most cases of asymptomatic uterine myomas do not require treatment, and
expectant management is appropriate. However, when it results in symptoms, treatment
should be considered. The choice of treatment depends on the patient’s age, pregnancy
status, desire for future pregnancies, size, and location of the myoma.3

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 CHAPTER II
CASE REPORT

2.1. Patient’s Identity

Name : Mrs. R
Date of birth/Age : October 10th 1970/ 48 years old
Address : Pabuaran 03/05, dayeuhluhur
Marital Status : Married
Occupation : Housewife
Religion : Moslem
Date of admission : August 03th 2019
Date of examination : August 06th 2019

2.2. History Taking

Chief Complaint
Vaginal bleeding
History of Present Illness
Patient with P4A2 complains a vaginal bleeding since 2 years ago. The
bleeding comes on and off, the total of bleeding is + 6-7 pads. The consistency
sometimes become clot, the grievance accompanied of lower abdominal pain
particularly appears if the bleeding comes out a lot.

A year ago the patient took medical checkup to find out the disease at
public health center (puskesmas) it referenced to syamsudin general hospital with a
note there is a bump on lower abdominal.

2 months ago the patient feel the bleeding and the pain on the lower
abdominal appears so much then she decided to go to al mulk general hospital. The
patient referenced again to syamsudin general hospital to take the surgery. When
the patient checked up at syamsudin general hospital, the patient did the
examination for pre-surgery and the result is patient’s HB 6,5 it requires blood
transfusion before take the surgery. Patient treated approximately 4 days and got 3
flacon of blood, after that, the plan is the surgery and will be taken one month later.

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 After that, the patient come back to the hospital with same grievance and it
is planned to take the surgery. The patient took several pre surgery check up
however the patient HB is still less than it required for surgery so it needed re-blood
transfusion. Patient needs two times blood transfusion to reach the HB surgery
requirements.

The patient also complained of pain when urinating accompanied with the
feeling of voiding or obstructive symptoms like hesitancy.
Patient last sexual intercourse was also ariund 5 monts ago, and she didn’t
experienced post coital bleeding, fever, trauma is denied.
In this case the patient never checked the disease because she thinks it just a
long time menstruation period furthermore the financial problem makes the patient
is not aware enough to her health.

History of Past Illnesses

History of hypertension : Twice
History of hypertension : She don’t know but lately the tension is high +
140-150 in sistole
History of asthma : Denied
History of diabetes mellitus : Denied
History of allergy : Denied
History of trauma : Denied
History of past surgery : Denied
History of tuberculosis : Denied

Familial History
History of hypertension : Denied
History of kidney disease : Denied
History of diabetes mellitus : Denied
History of auto immune disease : Denied
History of cancer : Denied
Menstruation History
Menarche : 12 years old
Menstrual cycle : Iregularly every 22 days, 10 days duration
and with history of pain during menstruation

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 Amount of menstrual blood : 6-8 pads/ day, full
1st day of last menstrual cycle : July 6th 2019
Contraception History
 Denied
Habitual History

 Smoking : denied
 Alcohol : denied
 Drugs and herbs : denied

Marital History
Married twice, she has been married for 26 years.
Obstetric History
Gestational Birth
No Labor History Sex
Age Weight
1. Aterm Spontanous Female 3.5 kg
2. Aterm Spontanous Female 3 kg
3. 6 weeks Abortus
4. Aterm Spontanous Died after 7 days
5. Aterm Spontanous Died after 15 days
6. 8 weeks Abortus

2.3. Physical Examination

General condition : mildly ill
Consciousness : compos mentis
Blood pressure : 120/90 mmHg
Heart rate : 80 bpm
Respiratory rate : 18x/minute
Temperature : 36 0C
Weight : 49,1 kg
Height : 150 cm
BMI : 21,8 kg/m2 (normal)

General Examination

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 Eyes : anemic conjunctiva +/+, icteric sclera -/-
Mouth : wet oral mucosa membrane
Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in breathing
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing -/-
Abdomen
Inspection : rounded shape
Auscultation : bowel sound 6x/minutes
Palpation : palpable mass in the hypogastric area (2 fingers below the
umbilicus), round shape, size of ±10 x 5 cm, consistency solid,
mobile, well-defined margin, smooth surface, tenderness (-)
Percussion : flat in the mass area

Extremities : warm, edema -/-/-/-, CRT < 2 seconds

Gynecologic Examination
Vaginal toucher : v/v in normal limit, corpus uterine 6-16-18 gram, solid
but like jelly, dextra sinistra the parenchim of uterus: hard consistency, no pain in
touch, cavum douglass not bulging
Inspeculo : Flour albus in small amounts and redness in portio
Bimanual examination : Not performed

2.4 Laboratory Results

Types Results Units Normal Value

Hematology (02/08/2019)
Hemoglobin 8.9 g/dL 12 – 14

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Hematocrit 30 % 37-47
Leucocyte 6.400 /uL 4.000 – 10.000
Trombocyte 703.000 /uL 150.000-450.000
Erythrocyte 4.4 Millions/ uL 3.8-5.2
MCV 68 fL 80-100
MCH 20 pg 26-34
MCHC 30 g/dl 32-36
Hematology (04/08/2019)
Hemoglobin 11.2 g/dL 12 – 14
Hematocrit 39 % 37-47
Leucocytes 8.000 /uL 4.000 – 10.000
Trombocyte 634.000 /uL 150.000-450.000
Erythrocyte 5,3 Millions/ uL 3.8-5.2
MCV 74 fL 80-100
MCH 21 pg 26-34
MCHC 29 g/dL 32-36

2.6. PAP smear Result

Non specific chronic cervicitis, cell- cell squamousa atipic was found but cant be
determined (ASCUS).

2.7. Thorax Photo

TBC was not found, Cardiomegali without lung edema, Elongatio aorta.

2.8. BNO IVP

The function of 2 renal are good. There is a shadow opaque on the pelvic cavity
(mass) (myoma) indentation on superior wall of vesica urinaria ec the pressure of
the mass. Kidney with in normal range.

Working Diagnosis
Mrs. R, 48-years-old, P4A2, with uterine leiomyoma and anemia

2.7. Management
 Preparation for total hysterectomy with bilateral salpingo-oophorectomy

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  Fasting 6 hours before the operation
 IVFD Ringer Lactate
 Antibiotic prophylaxis Ceftriaxone 1 x 1 gram 1 hour before operation
 Consult anesthesiologist for operation preparation
 Observation for general condition and vital signs
 Observation for the bleeding

2.8. Operation Report

 Patient in supine position
 Asepsis and antiseptic
 Incision mediana inferior
 After the peritoneum was opened the uterus appears to be suitable for pregnancy 16
to 18 weeks and solid consistency
 Total hysterectomy with bilateral salpingo-oophorectomy
 Continuos suture for vaginal stump
 Control the bleeding, the abdomen washed by physiologic NaCl
 Continuos suture for the fascia
 Subcuticular suture for the cutis
 The bleeding ± 300 cc
 Diuresis 100 cc
2.9. Operation Findings
 The uterus appears to be suitable for pregnancy 16 to 18 weeks and solid and
spongy consistency
 Adnexa in the left and right in normal range and impress uterine myoma

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2.10. Final Diagnosis
Mrs.R, 48-yeasr-old, P4A2, post total hysterectomy with bilateral salphingo-
oophorectomy and anemia
2.11. Post operation Management
 Fasting until bowel sounds present
 Ceftriaxone 2 x 1 gram
 Fetic supp 2x
 Check hemoglobin 6 hours after operation

2.11. Follow Up

Date Subjective Objective Assessment Planning

07/08/2019 Pain on the  General condition : P4A2, 48-year-  Fasting until
operation mildy ill old, post total bowel sound +
site VAS 3-  Level of hysterectomy  Ceftriaxone
4 consciousness: CM with bilateral 2x1g IV
 Vital Sign : salphingo-  Fetic supp 2x1
 Blood Pressure : oophorectomy  Observe
140/90 mmhg and anemia bleeding,
 Heart Rate : general
74x/minute condition and
 Respiratory Rate : vital signs

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 24x/ minute
 Body Temperature :
37,2°C
 Operation site :
The wound is closed
by bandage, no
blood leakage
 Hb post operation: 9,7
g/dL
08/08/2019 Pain on the  General condition: P4A2, 48-yeasr-  Discharged
operation moderate ill old, post total  Take home
site VAS 2-  Level of hysterectomy medicine :
3 consciousness: CM with bilateral  Cefadroxil 2 x
 Vital Sign: salphingo- 500 mg
 Blood Pressure: oophorectomy  Mefenamic acid
130/80 mmHg and anemia 3 x 500 mg
 Heart Rate: 112 POD 2  Channa 1x1
x/minute
 Respiratory Rate :
20 x/ minute
 Body Temperature:
36,5°C
 The wound is closed
by bandage, no
blood leakage

2.7. Prognosis
Quo ad vitam : bonam
Quo ad functionam : malam
Quo ad sanationam : bonam

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 CHAPTER III
CASE ANALYSIS

3.1. Diagnosis
Theory Case
History  75% women with uterine myoma are  Patient complained of
asymptomatic. vaginal bleeding since 2
 The patient may have a sense of years ago with pain on the
heaviness in lower abdomen. She may lower abdomen
feel a lump in the lower abdomen even  Abdominal mass was
without any other symptom. found when she checked
 Menstrual abnormality can occur, such up to public health center.
as menorrhagia and metrorrhagia  Patient had a trouble
(irregular bleeding). Blood loss from urinating like urinary
irregular bleeding can lead to chronic frequency
iron deficiency anemia, dizziness,  Patient’s last sexual
weakness and fatigue. intercourse was also
 Pressure-related symptoms (pelvic around 5 months ago, and
pressure, constipation, hydronephrosis, she didn’t experienced
and venous stasis) vary depending on post coital spotting.
the number, size and location of uterine
myoma. If a fibroid impinges on
nearby structures, patients may
complain of constipation, urinary
frequency, or even urinary retention as
the space within the pelvis becomes
more crowded.
 Fibroids can also cause spotting after
intercourse (postcoital spotting).
Risk factors Uterine myoma risk factors:  Mrs. R is 48-years-old
 Early menarche and might be in
 Nulliparity perimenopausal period,
 Perimenopause have hypertension, and
 Increased alcohol use Age greater than 40-
 Hypertension years- old
 Obesity
 Hyperestrogenic state
 Age greater than 40-years- old
Examination o If the uterus enlarged to 14 weeks or o Abdominal examination :
more, the following features are noted : Inspection : rounded
o Abdominal examination shape
Feel is firm, more toward hard; may be Auscultation : bowel
cystic in cystic degeneration. Margins sound 6x/minutes
are well-defined except the lower pole Palpation:
which cannot be reached suggestive of palpable mass in the
pelvic in origin. Surface is nodular; hypogastric area (2
may be uniformly enlarged in a single fingers below the

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 fibroid. Mobility is restricted from umbilicus), rounded
above downwards but can be moved shape, size of ±10 x 5
from side to side. cm, consistency solid,
o Bimanual examination reveals the mobile, well-defined
uterus irregularly enlarged by the margin , smooth surface,
swelling felt per abdomen. That the tenderness (-)
swelling is uterine is evidenced by: Percussion :
Uterus is not felt separated from the Flat in the mass area
swelling and as such a groove is not o Bimanual examination :
felt between the uterus and the mass. not performed
The cervix moves with the movement
of the tumor felt per abdomen.
Imaging o Ultrasound and Color Doppler (TVS) o No data
findings are: (i) Uterine contour is
enlarged and distorted. (ii) Depending
on the amount of connective tissue or
smooth muscle proliferation, fibroids
are of different echogenecity-
hypoechoic or hyperechoic. (iii)
Vascularization is at the periphery of
the fibroid. (iv) Central vascularization
indicates degenerative changes.
Transvaginal ultrasound can accurately
assess the myoma location, dimensions
volume and also any adnexal
pathology. Three-dimensional
ultrasonography can locate fibroids
accurately. Serial ultrasound
examination is needed during medical
or conservative management

3.2 Treatment

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Theory Case
 In this case,
When asymptomatic fibroids are detected, treatment is not necessary
and watchful waiting may be the best option. Regardless of their size, Mrs. R already
asymptomatic leiomyomas usually can be observed and surveilled have some
with an annual pelvic examination. At times, adnexal assessment may symptoms in
be hindered by large uterine size or irregular contour, and adequate urinating, so she
uterine and adnexal assessment can both be limited by patient obesity. needed
In these cases, some may choose to add annual sonographic treatment. The
surveillance. abdominal mass
 already as big as
If the fibroid uterus is causing bothersome symptoms or is implicated a fist so consider
as a cause of infertility in a woman seeking pregnancy, then some to did surgical
treatment is indicated. The ideal treatment satisfies four goals: relief of excision. In this
signs and symptoms, sustained reduction of the size of fibroids, case total
maintenance of fertility (if desired), and avoidance of harm. hysterectomy
 Progestin-only therapies (oral or injected medroxyprogesterone with bilateral
acetate, progestin-only oral contraceptive pills, or levonorgestrel- salphingo-
releasing intrauterine devices) or combination hormonal contraceptive oophorectomy
methods (oral contraceptive pills, vaginal rings, or patches) are usually was chosen.
the first therapeutic option for reduce monthly menstrual blood loss
and dysmenorrhea. Gonadotropin-releasing hormone (GnRH)
analogues (agonists and antagonists) block ovarian steroidogenesis,
which reduces the volume of the myometrium and fibroids and stops
menstrual bleeding.
 Consider surgical excision of leiomyomas larger than 4 to 5 cm or
multiple smaller tumors in this range regardless of location. The
surgical approach depends on the size, number, and location of the
various fibroids. Submucosal fibroids less than 5 cm may be resected
at the time of hysteroscopy. Pedunculated, subserosal, and many
intramural fibroids may be removed laparoscopically. Laparotomy is
generally reserved for larger or more numerous tumors. For women
desiring uterine preservation but not future fertility, surgical
management of excessive bleeding is possible using procedures that
ablate the endometrium. Another procedure is Uterine Artery
Embolization (UAE) that using microspheres or small coils introduced
into the uterine artery via a transcutaneous femoral approach. These
coils and/or particles occlude the artery feeding the fibroid, leading to
necrosis of the myoma.
 Hysterectomy is the operation of choice in symptomatic fibroid when
there is no valid reason for myomectomy. The patients over the age of
40 years and in those not desirous of further child are the classic
indications.

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3.3 Prognosis
About 3% to 7% of untreated fibroids in premenopausal women regress over six
months to three years, and most decrease in size at menopause. An estimated 15% to 33%
of fibroids recur after myomectomy, and approximately 10% of women who undergo this
procedure will have a hysterectomy within five to 10 years. In uterine artery embolization
symptom recurrence of more than 17 percent at 30 months. Kotani Y et al found that
cumulative recurrence rates between the two groups were 76.2% laparoscopic
myomectomy vs. 63.4% open myomectomy at eight years postoperatively.1,6-7

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 CHAPTER IV
CONCLUSION

Uterine leiomyoma or myoma or uterine fibroid is a benign smooth muscle

neoplasm that typically originates from the myometrium. The cause of uterine myoma is
still not known. The typical classification includes submucosal (beneath the endometrium),
intramural (in the muscular wall of the uterus), and subserosal (beneath the uterine serosa
and their growth is directed outward). The majority symptoms of uterine myoma is
asymptomatic. Occasionally, a woman may be able to feel a lower
abdominal mass when the fibroid protrudes above the pelvis. uterine myoma
can be assessed by performing physical examination and ultrasonography examination.
Management for uterine myoma can divided based on whether asymptomatic or
symptomatic. The definitive treatment for uterine myoma is hysterectomy.

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In: Williams Gynecology. 3rd ed. McGraw Hill Education; 2016. p. 202–12.

2. Hiralal K. Benign Lesions of the Uterus. In: DC Dutta’s Textbook of Gynecology. 6th
ed. Jaypee Brothers Medical Publishers; 2013. p. 272–86.

3. Siregar MFG. Association between menarche age and menstrual disorder with the
incidence of uterine fibroid in medan, Indonesia: based on hospital data. Int J Reprod
Contracept Obstet Gynecol. 2017 Feb 9;4(4):1025–8.

4. Florence AM, Fatehi M. Leiomyoma. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2019 [cited 2019 Jul 23]. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK538273/

5. Hacker NF, Gambone JC, Hobel CJ. In : Hacker and Moore’s Essentials of obstetrics
and gynecology. Philadelphia PA: Saunders. 2010
6. Cruz MSDDL, Buchanan EM. Uterine Fibroids: Diagnosis and Treatment. Am Fam
Physician. 2017 Jan 15;95(2):100–7.

7. Kotani Y, Tobiume T, Fujishima R, Shigeta M, Takaya H, Nakai H, et al. Recurrence

of uterine myoma after myomectomy: Open myomectomy versus laparoscopic
myomectomy. J Obstet Gynaecol Res. 2018 Feb;44(2):298–302.

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