Uterine fibroid - Case scenarios and Discussion

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This presentation is prepared to meet out the undergraduate medical student needs especially to understand the practical aspects of uterine fibroid and to rapidly revise some important viva questions.

Dedicated to my Great Teachers in the Dept. of Obstetrics & Gynaecology Dr. Lavanya Kumari and Dr. Sangeereni, Inspiring Friends Dr. Paulin Benedict, Dr. Jeyakumar Meyyappan and Dr. Hannah Jane and our REVELLIONZ 08’ batch.

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Uterine fibroid - Case scenarios and Discussion

  1. 1. UTERINE FIBROID CASE SCENARIOS & DISCUSSION By Dr. K. Haynes Raja, Junior Resident, Rajah Muthiah Medical College & Hospital, Annamalai University.
  2. 2. PREFACE This presentation is prepared to meet out the undergraduate medical student needs especially to understand the practical aspects of uterine fibroid and to rapidly revise some important viva questions. DEDICATION Dedicated to my Great Teachers in the Dept. of Obstetrics & Gynaecology Dr. Lavanya Kumari and Dr. Sangeereni, Inspiring Friends Dr. Paulin Benedict, Dr. Jeyakumar Meyyappan and Dr. Hannah Jane and our REVELLIONZ 08’ batch.
  3. 3. CASE SCENARIO - 1 A 36 Year old woman has noticed abdominal swelling for 10 months. She has to wear large clothes and people asked her if she is pregnant, which she finds distressing having been trying to conceive.
  4. 4. She has no abdominal pain and her bowel habit nauseated is normal. when she She eats feels large amounts. She has urinary frequency but no dysuria or haematuria.
  5. 5. Her periods are regular, every 27 days and have always been heavy, with clots and flooding on the second and third days. She has never received any treatment for her heavy periods.
  6. 6. She has been with her partner for 7 years and despite not using contraception she has never been pregnant.
  7. 7. Examination The woman has a very distended abdomen. A smooth firm mass is palpable extending from symphysis pubis to midway between the umbilicus and the xiphisternum (equivalent to a 32 week pregnancy). It is non-tender and mobile. It is not fluctuant and it is not possible to palpate beneath the mass.
  8. 8. On speculum examination it is not possible Bimanual to visualise examination the cervix. reveals a non-tender firm mass occupying the pelvis.
  9. 9. Investigations Haemoglobin 6.3 g/dL Mean cell volume 68fl White cell count 4.9 * 109/L Platelets 267 * 109/L
  10. 10. Magnetic resonance imaging
  11. 11. Diagnosis The woman has a large uterine fibroid. This is causing menorrhagia and hence the microcytic anaemia from iron deficiency. It is also likely that fibroid is infertility history. accounting for her
  12. 12. DISCUSSION
  13. 13. What is the differential diagnosis? Uterine fibroids Pregnancy Full bladder Haematometra/pyometra Adenomyosis Bicornuate uterus Bilateral tubo-ovarian masses Ectopic pregnancy Pelvic Endometriosis Endometrial carcinoma Uterine sarcoma Ovarian neoplasms
  14. 14. What is fibroid?  Fibroid is the commonest benign tumour of uterus  Arises from smooth muscle cells and hence called as Leiomyoma
  15. 15. What is the incidence? At least 20% of women in the reproductive age group
  16. 16. Whether fibroid is hormone dependant?  Fibroid is hormone dependant. Predominantly oestrogen dependant.  Other hormones implicated are growth hormone, human placental lactogen
  17. 17. What are the hyperoestrogenic states?  Nulliparity  Obesity  Polycystic Ovarian syndrome  Endometrial hyperplasia
  18. 18. Explain the Anatomy & pathology of fibroid?  Derived from smooth muscle cell rests, either from vessel walls or uterine musculature  Well circumcised, firm, round tumours with a pseudocapsule  They become soft and cystic when degenerative changes occur  They may be single or multiple
  19. 19. Explain the Anatomy & pathology of fibroid?  Usually arises from body of uterus and less commonly from cervix  The vessels which supply lie in capsule and send radial branches, so innermost part receives least blood supply  The innermost part is the first to undergo degeneration whereas the outermost part is the first to calcify  Cut surface shows whorled appearance
  20. 20. What are the synonyms of fibroid? Fibromyoma Leiomyoma myoma
  21. 21. What are the types of fibroid?
  22. 22. What are the types of fibroid? Uterine Body of uterus Extrauterine Cervix Ovary Subserous (10%) Broad ligament fibroid Intramural(75%) 1. True (originates in broad Submucous (15%) ligament) 2. False (arises in uterus & grows into broad ligament)
  23. 23. What is parasitic fibroid? Rarely, a extruded fibroid gets detached from uterus and attaches to a vascular organ (omentum or bowel). This fibroid is called parasitic fibroid or wandering fibroid.
  24. 24. CASE SCENARIO - 2 A 32 year old woman complains of increasingly long and heavy periods over the past 5 years. Previously she bled for 4 days but now bleeding lasts up to 10 days. The periods still occur every 28 days. She experiences intermenstrual bleeding between most periods but no postcoital bleeding.
  25. 25. The periods were never painful previously but in recent months have become extremely painful with intermittent cramps. She has had four normal deliveries and had a laparoscopic sterilization after her last child.
  26. 26. Her smear tests have always been normal, the most recent being 4 months ago. She has never had any previous irregular bleeding or other gynaecological problems.
  27. 27. Examination: The abdomen is soft and nontender with Speculum no palpable examination mass. shows a normal cervix. On bimanual palpation, the uterus is bulky (approximately 8 week size), mobile and anteverted. There are no adnexal masses.
  28. 28. Investigations Haemoglobin 9.2 g/dL Mean cell volume 75 fl White cell count 4.5 * 109/L Platelets 198 * 109/L
  29. 29. Hysteroscopy
  30. 30. Diagnosis This woman has a Submucosal fibroid. Submucosal fibroids are a common cause of menorrhagia and can cause, as in this case, intermenstrual bleeding. “Fibroids usually don’t cause intermenstrual bleeds other than when there is ulceration or it is submucous or cervical fibroid”
  31. 31. DISCUSSION
  32. 32. What are the clinical manifestations? Menorrhagia, polymenorrhoea, metrorrhagia Infertility, recurrent abortions Pain – spasmodic dysmenorrhoea, backache, due to pyelitis Pressure symptoms – bladder, ureter, rectum Abdominal lump or mass protruding at introitus Vaginal discharge As many as 50% women are asymptomatic
  33. 33. How do they cause menorrhagia?  Increased surface area of endometrium  Hyperoestrogenism  Intramural fibroid prevents adequate contraction and retraction of uterus  Associated pelvic inflammatory disease
  34. 34. Can fibroids cause polycythaemia? Yes. Huge fibroid compresses renal artery  Reduced renal perfusion  Hypoxia  activation of Renin- angiotensin aldosterone  Renal erythropoietin secretion increases  polycythaemia
  35. 35. How do they cause infertility?  Cervical fibroid does not allow nidation of sperms  Fibroid in Cornual end does not allow fertilised ovum to enter uterine cavity  Increased chances of abortion is seen with submucous fibroid due to improper implantation  Associated infertility Hyperoestrogenic state can cause
  36. 36. When do fibroids present as emergency? When do they cause pain?  Acute torsion of a pedunculated fibroid or degeneration are the main causes of pain  Intracapsular haemorrhage  Rarely, a submucous fibroid trying to get expelled from the cervix will produce pain
  37. 37. CLINICAL SCENARIO - 3 A 33 Year old women complains of worsening abdominal pain for 4 days. She is 16 week pregnant in her third pregnancy. She has a 10 year old son, by normal delivery and a miscarriage 8 years ago. Her pregnancy has been uneventful until now with unremarkable first trimester scan. an
  38. 38. The pain is in the left lower abdomen and is constant and sharp. She has taken paracetamol with little effect and she is unable to sleep due to pain.
  39. 39. She has had no vaginal bleeding and reports urinary frequency since the beginning of the pregnancy. She is mildly constipated and has no nausea and vomiting. There is no history of trauma. She has not felt the baby moving yet.
  40. 40. EXAMINATION The woman is apyrexial and pulse rate is 125/min, with blood pressure 110/68 mm Hg. The uterus is palpable just above the umbilicus. There is significant tenderness over the left uterine fundal region, where it also feels firm. The abdomen is otherwise soft and non-tender.
  41. 41. There is voluntary guarding but no rebound tenderness. Bowel sounds are normal. Speculum examination shows a normal, closed cervix and no blood. The fetal heart beat is heard with hand-held Doppler.
  42. 42. Investigations Haemoglobin 10.6 g/dL Mean cell volume 79 fl White cell count 7.2 * 109/L Platelets 378 * 109/L C-reactive protein <5 mg/L
  43. 43. Diagnosis The patient has fibroid undergoing Red degeneration. The uterine size is larger than dates and the localised uterine tenderness are the important features in making this diagnosis. “Red degeneration happens exclusively in pregnancy” almost
  44. 44. DISCUSSION
  45. 45. What are the obstetric complications of fibroid? a) Increased risk of Abortions b) Threatened preterm labour c) Premature delivery d) Abruptio placenta. e) IUGR f) Intrapartum problems if fibroid large & located in the lower uterine segment. Cervical fibroid  caesarean delivery. g) Interference with propagation of myometrial contractility uncoordinated uterine contraction or PPH. 
  46. 46. What are the general complications of fibroid?  Degeneration  Torsion  Inversion of uterus  Capsular haemorrhage  Infection  Associated endometrial carcinoma
  47. 47. What are the secondary changes in fibroid?  Atrophy  Hyaline/cystic/fatty degeneration  Calcareous degeneration  Red degeneration  Sarcomatous degeneration
  48. 48. What is red degeneration?  Occurs most frequently during pregnancy  Becomes tense and tender and causes severe abdominal pain with constitutional upset and fever.  Fibroid becomes reddish with a particular fishy smell.  Leucocytosis and raised ESR may be present but this is an aseptic condition  Examination of fibroid shows thrombosed vessels
  49. 49. Differential diagnosis and management for red degeneration  Differential Diagnosis:  Acute appendicitis  Torsion of ovarian cyst  Acute pyelonephritis  Accidental haemorrhage  Treatment: Self limiting and resolves by itself
  50. 50. When do fibroids grow rapidly? In sarcomatous degeneration (not more than 0.5%)
  51. 51. What are the investigations to do? General Investigations:  Blood investigations:  Haemoglobin & Haematocrit to rule out anaemia  Random Blood sugar to know the diabetic status  Blood grouping and Rh typing for transfusion if necessary  Serum urea and Creatinine for assessing the renal function  Urine Examination:  albumin, sugar and deposit
  52. 52. What are the investigations to do? Special investigations:  Intravenous pyelogram:  To trace the course of ureter to avoid injury during surgery  To rule out renal abnormalities (Eg. pelvic kidney)  Ultrasound abdomen:  To know the site and number of fibroid
  53. 53. Other investigations  Hysterosalpingography and sonosalpingography  Hysteroscopy  Dilatation and curettage to rule out endometrial cancer  Magnetic resonance imaging
  54. 54. When do you treat a fibroid?  Indications for treating an asymptomatic fibroid are  Infertility caused by cornual blocking or abortion caused by submucous fibroid  Fibroid more than 12 weeks size or a pedunculated fibroid which can undergo torsion  Fibroid causing pressure on ureter  Rapidly growing fibroid  If the nature of tumour cant be assessed clinically
  55. 55. When do you treat a fibroid? All symptomatic fibroid needs treatment which can be Medical or surgical
  56. 56. How will you manage Medically?  Iron therapy for anaemia  Surgery is the definitive treatment modality but the use of medical management is to control menorrhagia and to improve haemoglobin before surgery  Drugs can also be used in women nearing menopause or who are not fit for surgery  Drugs used are low dose OCPs(have minimal oestrogen), mifepristone(RU analogues like leuprolide 486), GnRH
  57. 57. What are the indications for use of GnRH agonists in women with leiomyomas?  Preservation of fertility before attempting conception or preoperative treatment before myomectomy  Treatment of anaemia to allow recovery of normal haemoglobin levels before surgical management or allowing autologous blood donation  Treatment of women approaching menopause in an effort to avoid surgery  Preoperative treatment of large leiomyomas to make vaginal hysterectomy, hysteroscopic resection or ablation, or laparoscopic destruction more feasible  Treatment of women with Medical contraindications to surgery
  58. 58. What are the advantages and disadvantages of GnRH analogues?  GnRH analogues causes rapid shrinkage of tumour and reduces vascularity  Hence it decreases the need of surgery in young women with infertility for cornual blockade  It also facilitates vaginal hysterectomy or surgery with minimal blood loss  The main disadvantage is cant be extended beyond 6 months (causes osteoporosis), fibroid capsule becomes thin and enucleation is difficult, recurrence of fibroid is high.
  59. 59. What are the potential indications of surgery?  Abnormal uterine bleeding with resultant anemia, unresponsive to hormonal or other conservative management  Chronic pain with severe dysmenorrhea, dyspareunia, or lower abdominal pressure or pain  Acute pain, as in torsion of a pedunculated leiomyoma or prolapsing submucosal fibroid
  60. 60. What are the potential indications of surgery?  Urinary symptoms or signs such as hydronephrosis after complete evaluation  Infertility with leiomyomas as the only abnormal finding  Recurrent pregnancy loss with distortion of endometrial cavity  Markedly enlarged uterine size with compression symptoms or discomfort
  61. 61. What are the surgical management options?  Myomectomy – Laparotomy / Laparoscopy / Hysteroscopy  Hysterectomy – Abdominal / vaginal / laparoscopic  Uterine artery embolization
  62. 62. What is myomectomy?  Removal of fibroids leaving behind the uterus  Indicated in infertile women or a women desirous of childbearing and wishing to retain uterus
  63. 63. What are the preoperative requisites of myomectomy?  Haemoglobin should be restored  In infertility cases, other causes should have been excluded  SIGNATURE FOR HYSTERECTOMY IS REQUIRED IN DIFFICULT CIRCUMSTANCES  Should be performed in preovulatory period  Endometrial cancer to be ruled out by D&C
  64. 64. Explain the steps of myomectomy  Patient in supine position  The abdomen is draped and opened by pfannenstiel incision  Confirm the feasibility of myomectomy  Anterior uterine wall is incised and as many fibroids are removed by tunneling incisions  Haemorrhage is controlled by myomectomy clamp  The capsule should be incised and fibroid enucleated with the help of myoma screw  Following enucleation, cavity is obliterated with catgut  Release the clamp and secure haemostasis
  65. 65. What are the complications of myomectomy?  Haemorrhage – primary, secondary and reactionary  Trauma to adjacent structures – ureter, bladder, bowel  Infections  Adhesions and intestinal obstruction  Recurrence of fibroids and persistent menorrhagia
  66. 66. When do you employ laparoscopic myomectomy?  Pedunculated fibroid  Subserous fibroid not exceeding 10 cm in size and not more than 4 in number
  67. 67. What are the advantages of subtotal hysterectomy over total hysterectomy?  Cervix is retained for sexual function  Vault prolapse is less  Less surgical morbidity
  68. 68. Will you remove ovaries during hysterectomy for fibroid? Ovaries should be retained to avoid menopausal symptoms in a premenopausal woman provided they look normal.
  69. 69. What is panhysterectomy? Removal of uterus, cervix and ovaries
  70. 70. What is LAVH? Contraindications for this procedure?  LAVH stands for Laparoscope assisted vaginal hysterectomy.  Contraindications are  Uterus more than 14 – 16 weeks size  Fibroid located in broad ligament, cervical fibroid and extensive pelvic adhesions, endometriosis
  71. 71. What are the complications of hysterectomy?  Haemorrhage – Primary, secondary and reactionary haemorrhage  Trauma to adjacent organs – bladder, ureter, bowel and ureter  Postoperative infection and Sepsis  Anaesthetic complications  Paralytic ileus, intestinal obstruction or chronic abdominal pain due to postop adhesions  Thrombosis, pulmonary embolism, chest infection  Burst abdomen, scar, hernia  Residual ovarian syndrome  Dyspareunia
  72. 72. Explain about uterine artery embolization?  Through percutaneous femoral catheterisation, Polyvinyl alcohol (PVA), gel foam particles or metal coils are injected.  This reduces vascularity and size(40% at 6 weeks and 75% at 1 year)  Contraindications:  Subserous, submucous and pedunculated fibroids  Infertility and desire of pregnancy
  73. 73. Explain about uterine artery embolization?
  74. 74. Explain about uterine artery embolization?  Advantages:  No major surgery, intraoperative bleeding, adhesions  Short hospital stay  75 – 80% women are satisfied
  75. 75. Can fibroids grow beyond Menopause? Yes. If the woman is on hormone replacement therapy.
  76. 76. Polypectomy

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