Fibroid for undergraduate

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Undergraduate course lectures in Obstetrics&Gynecology prepared by DR Manal Behery .Professor of OB&Gyne .Faculty of medicine ,Zagazig University

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Fibroid for undergraduate

  1. 1. Bengin tumors arising from the smooth muscle cells of the myometrium They are the most common pelvic tumor in women. 20% of women >of 35 years .
  2. 2. PathologyPathology Well circumscribed white firm mass with a whorled appearance - surrounded by false capsul formed by compressed by uterine muscle
  3. 3. PathologyPathology MicroscopicallyMicroscopically Smooth muscle & Connective tissues .
  4. 4. Pathology Of FibroidPathology Of Fibroid SizeSize Varies from very small fibroidsVaries from very small fibroids (seedlings) to huge tumours(seedlings) to huge tumours ShapeShape Starts as a small spherical tumourStarts as a small spherical tumour but as it enlarges its shape may bebut as it enlarges its shape may be changed by compression.changed by compression. ConsistencyConsistency Firm unless affected by degenerationFirm unless affected by degeneration
  5. 5. Secondary pathological degenerative changes and complications of fibroids
  6. 6. 1)1) Atrophy.Atrophy. 2)2) Necrosis.Necrosis. 3)3) Degeneration.Degeneration. 4)4) Malignancy.Malignancy. 5)5) Infection.Infection. 6)6) Torsion.Torsion. 7)7) Incarceration.Incarceration. 8)8) Inversion of the uterusInversion of the uterus..
  7. 7. Loss of worled appearance ifLoss of worled appearance if degenration occurreddegenration occurred
  8. 8. Risk of MalignancyRisk of Malignancy Incidence of leiomyosarcoma in hysterectomy specimens of women receiving surgical treatment for fibroid 0.1% in reproductive age group 1.7% after age of 60 years
  9. 9. Early menarche (<10 years old) is associated with an increased risk of developing fibroids. Early menarche (<10 years old) is associated with an increased risk of developing fibroids.  Parity (having one or more pregnancies extending beyond 20 weeks) decreases the chance of fibroid formation.  Early age at first birth decreases risk and a longer interval since last birth increases risk  Parity (having one or more pregnancies extending beyond 20 weeks) decreases the chance of fibroid formation.  Early age at first birth decreases risk and a longer interval since last birth increases risk No definit risk with oral contraception No association of fibroid growth with agents for ovulation induction No definit risk with oral contraception No association of fibroid growth with agents for ovulation induction A relationship between fibroids and increasing body mass. The relationship is complex and is likely modified by other factors A relationship between fibroids and increasing body mass. The relationship is complex and is likely modified by other factors
  10. 10. Site of originSite of origin Corporeal fibroid (97% ) Cervical fibroid (3%)
  11. 11. Fibroids are often described accordingFibroids are often described according to their location in the uterusto their location in the uterus
  12. 12. Anatomic LocationsAnatomic Locations
  13. 13. SymptomsSymptoms
  14. 14.  It is the most common symptom.  Menorrhagia is the typical bleeding pattern with myomas .  Intermenstrual bleeding and  postmenopausal bleeding  are NOT characteristic of myomas  EXCEPT IF
  15. 15. Bulk-related symptoms — urinary frequency, difficulty emptying the bladder,urinary obstruction Piles &constipation Hydrourter &hydronephrosis .
  16. 16. Dysmenorrhea — Dysmenorrhea is also reported by many women with fibroids. Leiomyoma degeneration or torsion — fibroids cause acute pain from degeneration (eg, red degeneration) or torsion of a pedunculated tumor.
  17. 17. submucosal or intramural with an intracavitary component) result in:  difficulty conceiving a pregnancy Increase risk of abortion leiomyomas have been associated with adverse pregnancy outcomes eg, placental abruption,  fetal growth restriction, and preterm labor and birth
  18. 18. Signs of cervical fibroidSigns of cervical fibroid A firm fixed pelvic massA firm fixed pelvic mass with thewith the uterus lying on its top.uterus lying on its top. Barrel-shapedBarrel-shaped enlargement of theenlargement of the cervix.cervix. A cervical polyp.A cervical polyp.
  19. 19. Pelvic ExamPelvic Exam AA pelvi-abdominal Or pelvic mass.pelvi-abdominal Or pelvic mass. symmetrical enlargement of the uterus.symmetrical enlargement of the uterus. A symmetrical enlargement of the uterus.A symmetrical enlargement of the uterus. - A pedunculated subserous- A pedunculated subserous - A broad ligament fibroid.- A broad ligament fibroid.
  20. 20. speculum examspeculum exam cervical polypcervical polyp
  21. 21. CERVICAL POLYPCERVICAL POLYP
  22. 22. TAS&TVSTAS&TVS size, sitesize, site andand numbernumber of fibroidsof fibroids differentiatesdifferentiates the tumour from otherthe tumour from other swellings asswellings as ovarian tumourovarian tumour
  23. 23. 2-Saline infusion sonogRaphy2-Saline infusion sonogRaphy
  24. 24. (3) Hysteroscopy(3) Hysteroscopy To visulize a sub mucous fibroid or a small fibroid polyp.
  25. 25. (4) Intra venous pyelogram (IVP)(4) Intra venous pyelogram (IVP) InIn cervicalcervical andand broad ligament fibroidbroad ligament fibroid - Course of ureter.Course of ureter. - Hydroureter & hydroneprosisHydroureter & hydroneprosis - Kidney function.- Kidney function.
  26. 26.  AsymptomaticAsymptomatic  Fibroid small (<12 wk gestational size)Fibroid small (<12 wk gestational size)  Near menopauseNear menopause Treatment is not necessary if….Treatment is not necessary if…. (follow up every 6 months )(follow up every 6 months )
  27. 27. Hormonal tttHormonal ttt COCPsCOCPs DanazolDanazol Gonadotrophin releasing hormone analogueGonadotrophin releasing hormone analogue (agonist)(agonist) Mifepristone:Mifepristone: a progesterone receptora progesterone receptor antagonist It reduces the size of myomas byantagonist It reduces the size of myomas by 50%.50%.
  28. 28. MirenaMirena coil treats menorrhagia, and reducescoil treats menorrhagia, and reduces the size of fibroids + contraception)the size of fibroids + contraception)
  29. 29. MyomectomyMyomectomy Removal of fibroids from the uterusRemoval of fibroids from the uterus Indications:Indications: Young age below 40 yearsYoung age below 40 years Single myomaSingle myoma
  30. 30. Contraindication of MyomectomyContraindication of Myomectomy AgeAge > 40.> 40. Multiple fibroids (leaveMultiple fibroids (leave behind a uselessbehind a useless organ).organ). Cervical fibroidCervical fibroid IfIf malignancymalignancy is suspected.is suspected.  presence of other lesions in the uterus aspresence of other lesions in the uterus as adenomyosis.adenomyosis.
  31. 31. Open myomectomyOpen myomectomy
  32. 32. LaparoscopicLaparoscopic MyomectomyMyomectomy
  33. 33. HysteroscopicHysteroscopic MyomectomyMyomectomy
  34. 34. How to decrease blood lossHow to decrease blood loss during myomectomy ?during myomectomy ?
  35. 35.  Pre operative correction of anemia:Pre operative correction of anemia: – Iron supplementation,Blood transfusionIron supplementation,Blood transfusion Pre operative GnRH agonists treatmentPre operative GnRH agonists treatment Vasopressin(20U in 20 ml NS)Vasopressin(20U in 20 ml NS) -- as effective asas effective as vascular occlusion for controlling blood lossvascular occlusion for controlling blood loss Tourniquets :Tourniquets : Bonney’s myomectomy clampBonney’s myomectomy clamp Ring forcepsRing forceps Elastic rubber catheter(around cervix)Elastic rubber catheter(around cervix)
  36. 36. HysterectomyHysterectomy Indication:Indication: 1)1)Multiple myomaMultiple myoma 2)2)Cervical fibroidCervical fibroid 3)3)Uncontrollable bleedingUncontrollable bleeding during myomectomyduring myomectomy
  37. 37. Cervical fibroidCervical fibroid
  38. 38. Smooth muscle tumors of the uterus are often multiple. Seen hereSmooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of theare submucosal, intramural, and subserosal leiomyomata of the uterusuterus
  39. 39. Embolization of both uterine arteriesEmbolization of both uterine arteries Indicated when patient is unfit or refuseIndicated when patient is unfit or refuse hysterectomy .hysterectomy . < tumour size about< tumour size about 50%.50%. endometritis and pyometraendometritis and pyometra infection of the necrotic fibroids.infection of the necrotic fibroids.
  40. 40. MRI-guided Focused UltrasoundMRI-guided Focused Ultrasound (MRI-FUS(MRI-FUS))
  41. 41. Management Clinical effect Method of Treatment Observation Most Serial Pelvic Exams Pre-surgical Shrinkage Size by 50% GnRH analog 3-6months; regrowth after stopping Myomectomy Preserves fertility Laparotomy, laparoscopy Embolization Preserves the uterus Invasive radiotherapy Hysterectomy Fertility completed TAH,TVH Definitive tx

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