Gynaec case - Fibroid uterus

PERSONAL DATA

● Name: Shalini
● Age: 45
● Address: Mala
● Occupation: Housewife
● Socioeconomic status : Middle class

PRESENTING COMPLAINTS

Heavy menstrual bleeding for 5 months

Lower abdominal pain for 5 month

HISTORY OF PRESENT ILLNESS

Patient was apparently normal 5 months back. Then she developed heavy menstrual bleeding 5 months
back with passage of clots. She used 4-5 pads per day.

History of lower abdominal pain starting 5 months back which was dull aching and intermittent in
nature. Pain aggravates on standing for a long time. She also complains of heaviness of abdomen.

No history of vaginal dishcharge, dysuria, constipation, fever, dyspareunia, post coital bleeding, bleeding
disorders, cold or hot intolerance.

No history of intake of any anticoagulant drugs.

MENSTRUAL HISTORY

Menarche at the age of 13 years. Regular 28 day cycle. LMP was in 15-1-2020.

MARITAL HISTORY

Age at marriage 23 yrs, non consanguinous marriage.

No history of dypareunia or post coital bleeding
No history of any contraceptive use.

OBSTETRIC HISTORY
Parous women with 2 livr children. Full term pregnancy and sterilized

First pregnancy at age of 24 yrs.Antenatal period was normal, full term elective cesearian section.
Female baby weight of 2.6 kg. Puerperium normal, breast fed upto 2 yrs. Immunised for age.

2nd pregnancy at age of 27 yrs. Antenatal period was normal, full term Ceasarian section done. Feale
baby of size 3 kg. Puerperium normal. Concurrent sterilization done. Breast fed upto 2 yrs. Immunized
for age.

PAST HISTORY

No History of DM, HTN, TB, jaundice, bronchial asthma,

history of 2 cesarean section done at 19 and 22 yrs back

History of lipoma excision 16 yrs back.

No history of any drug allergy.

PERSONAL HISTORY

Mixed Diet,Normal appetite and sleep, bowel and bladder habits normal. No addictions

FAMILY HISTORY

History of DM in mother, history of oral cancer in father.

No history of HTN, TB, ovarian cancer, bleeding disorders,breast cancer or endometrial cancer.

GENERAL EXAMIMATION

Patient was conscious,coperative and well oriented in time, place and person

Normally built and nourished.

Weight=57kg, height =160cm, BMI = 22.2kg/m^2

No pallor, icteurus, cyanosis, clubbing, lymphadenopathy or edema.

Vitals

● Pulse: 78 beats per minute

● Respiratory rate: 18 /minute
● Blood pressure 120/86
● Temperature : 37.6°c
Breast examination : 3cm long scar present on upper medial quadrant of left breast
Thyroid: normal
Skin, hair, nails: normal
Spine and gait: normal

ABDOMINAL EXAMINATION

Inspection

Shape of abdomen: Obese

Umbilicus is central amd inverted.

Suprapubic transverse scar present above pubic hair line. No visible swelling, pulsations or dilated veins.

Palpation

No local rise of temperature and tenderness.

No guarding or rigidity

Uterus enlarged to 22 weeks of gravid uterus, flanks not full.

It is firm, irregularly enlarged, lower pole not palpable.

Upper edge and lower 2 borders are irregular, lower pole not palpable.

Percussion : Liver dullness at rigjt 5th intercostal space.

Liver span 11 cm

No shifting dullness or fluid thrill

Dull note heard over the mass in hypogastrium and periumbilical region

Auscultation : Normal bowel sounds heard. No bruit. No uterine souffle

LOCAL EXAMINATION

INSPECTION

● Vulva - Normal
● Cervix- Normal

PAP SMEAR
PALPATION(digital examination of vagina and cervix)

● Cervix- displaced
● Presence of myoma

BIMANUAL PELVIC EXAMINATION

● Uterus- irregularly enlarged

● Movement of mass transmitted to thr cervix.
● No tenderness or mass in the pouch of dulglas.

Summary: 45 yr old women G(2)P(2)L(2)A(0) with 2 live children, previous history of ceaserian
section,and sterilised came with complaints of heavy menstrual bleedin since 5 months

On examination, Patient is overweight, uterus enlarged to 22 weeks, firm irregular margin.

Diagnosis: 45 yr old G(2)P(2)L(2)A(0) sterlised women came with heavy menstrual bleeding indicative of
abnormal uterine bleeding probalbly due to leomyoma

CASE DISCUSSION

Presenting complaints : Heavy menstrual bleeding since 5 months and lower abdominal pain which was
dull aching and non radiating in nature.

Causes of bleeding

Polyp, Adenomyosis, leomyoma, coagulopathies like ITP, ovarian dysfunction

Normal menstrual cycle

2-8 days, less than 80 ml blood, clots will not be present

Dysmenorrhea-

Primary Dysmenorrhea- - not a/w pelvic patholigy

Secondary Dysmenorrhea- a/w pelvic pethology

Here it is 2° Dysmenorrhea- due to fibroid.

Negative histories
No intermenstrual bleeding- Rules out endometriosis, pedunculated subserosal /mucosal fibroid

No pain during intercourse-, Rules out endometriosis/ adenomyosis

No discharge p/v- Rules out associated PID, vaginal infections.

Dysepsia maybe seen in large fibroid- d/t pressure effect of fibroid on bowel.

Urinary retention may be seen d/t pressure effect on bladder especially in posterior fibroid pressing on
neck of bladder. Anterior fibroid cause increased frequency of micturition d/t pressure effect on bladder

In type (0,1,2,3) fibroids,heavy beeding is more common, while in type(5,6,7) pressur effects are more
common

PV examination

In fibroid - Irregular enlarged uterus mininum of 22 weeks size.

In adenomyosis- Uniformly enlarged tender uterus, ‹14 weeks size.

Invesitagations in myomas

(1)USG

On usg, fibroid have solid, hypoechoic and whorled appearance, with posterior acoustic shadowing. Size
number, location of the mass is noted, hydroureteronephrosis is ruled out

There is increased vascularity in periphery of fibroid in doppler usg. Central part of fibrosis may be
relatively avascular.

(2)Saline infusion sonography

For detecting submucosal myomas

(3)Hysteroscopy

For submucosal myoma. Type, resectability is assessed endometrial sampling is taken.

Risk factors of Fibroid

Nulliparity, obesity, familial history, exogenous hormones.

Smoking and low parity reduce the risk of fibroid.

Symptoms of Fibroid

Abnormal uterine bleedimg,

Pressure symptoms like pevic discomfort,

urinary symptoms, infertility, recurrent miscarriage(d/t defective implantation )

Mechanism of menorrhagia

Inccrease in endometrial surface area,increase in vascularity, interference with normal uterine

contractility, compression of venous plexus causing venous stasis and production of growth factors.

Causes of pain in fibroid

Red degeneration, hemorrhage into fibroid, expulsion of submucous fibroid, torsion of pedunculated
fibroid

D/d : adenomyosis, pyometra, endometrial carcinoma, pregnancy, fu bladder, solid ovarian tumors.

Management

Asymptomatic myoma

Assess size,no., location by usg

For perimenopausal women, they are cousilled that myoma will not increase in size after menopause

Annual assessment is done to check progression of myoma

Interfere when myoma become symptomatic

Symptomatic myoma

Indications for medical management

Young women attempting conception

Small symptomatic myoma at any age

Control bleeding while waiting surgery.

Control bleeding while anemia us corrected.

Shrink the myoma preoperatively.

Drugs

Mephenemic acid 500mg - (MOA-NSAID-Inhibit prostagladin production )

Cetrorelix- 0.25mg/day (Gnrh agonists)

Ormaloxifene-60mg/ wk. (SERM)

Ullipristal 5-10mg/day for 13 wks ( SPRM)

Anastozole- 1mg/day (Aromatase inhibitor)

Mifepristone 5-10mg/day (Antiprogestin)

Surgical management

Conservative surgery -myomectomy

It is done in younger women with symptomatic myoma, especially if fertility is desired

Complications of myomectomy-

Immediate complications : Hemorrhage, infection, post op-fever,risk of hysterectomy

Long term complications: Adhesion, recurrence, scar rupture in labor

Newer methods :

1)Myolysis Myolysis is the reduction in size of myoma using the:rmal electrode, croprobe, laser or radio
frequency probes

Eg. Thermal myolisis, cro myolysis, laser myolysis, radio frequency myolysis.

2) Laparoscopic uterine artery ligation

3) Uterine artery embolisation

4) Magnetic resonance guided focused ultrasound surgery

Defintive surgery- Hysterectomy

Hysterectomy is the treatment of choice in symptomatic myoma in the perimenopausal age.

If uterus is ‹14 weeks in size, vaginal hysterectomy is performeperformed

If uterus ›14 weeks, abdominal or laparoscopic hysterectomy is done.