Normal and Abnormal Puerperium www.freelivedoctor.com
Synonyms <ul><li>leiomyoma of uterus </li></ul><ul><li>leiomyomas  </li></ul><ul><li>fibromyomas </li></ul><ul><li>myofibr...
Incidence <ul><li>Most common solid pelvic tumors </li></ul><ul><li>Develop in 20 ~ 25% of women during reproductive years...
Correlative Factors <ul><li>An estrogenic milieu may be necessary </li></ul><ul><li>Progesterone function </li></ul><ul><l...
Pathology www.freelivedoctor.com
Gross Appearance <ul><li>Rare only a single , usually many exist </li></ul><ul><li>Well-circumscribed , nonencapsulated </...
<ul><li>Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomy...
Microscopic Appearance <ul><li>Composition : smooth muscle </li></ul><ul><li>connective tissue </li></ul><ul><li>The nonst...
Classification ( 1 ) <ul><li>According to growth location :  </li></ul><ul><li>Myomas on the body of uterus ( 90% ) </li><...
Classification ( 2 ) <ul><li>According to the relation to uterine muscle : </li></ul><ul><li>Submucous ( 10  ~   15% ) </l...
Clinical Manifestation www.freelivedoctor.com
Symptoms <ul><li>menorrhagia and prolonged menstrual period  : common </li></ul><ul><li>Pelvic pain : </li></ul><ul><li>oc...
Signs <ul><li>A palpable abdominal tumour </li></ul><ul><li>Pelvic examination : </li></ul><ul><li>uterus —  enlarged  and...
Degeneration <ul><li>Hyaline degeneration </li></ul><ul><li>Cystic degeneration </li></ul><ul><li>Red degeneration </li></...
Red Degeneration <ul><li>Occasionally seen as a complication of pregnancy ( during pregnancy or immediate postpartum perio...
<ul><li>Here is a very large leiomyoma of the uterus that has undergone degenerative change and is red (so-called &quot;re...
Sarcomatous Change <ul><li>Rare : 0.4% ~   0.8% </li></ul><ul><li>More common at 40 ~   50 years old </li></ul><ul><li>Usu...
Diagnosis <ul><li>History </li></ul><ul><li>Bimanual examination </li></ul><ul><li>Ultrasonography </li></ul><ul><li>( B–u...
Differential Diagnosis <ul><li>Pregnancy </li></ul><ul><li>Ovarian tumour </li></ul><ul><li>Adenomyosis </li></ul><ul><li>...
Treatment www.freelivedoctor.com
Observation and Follow Up <ul><li>Small , asymptomatic fibroids need not be treated , especially near menopause. </li></ul...
Medical Treatment <ul><li>Androgenic agents : testosterone propionate </li></ul><ul><li>GnRH-a : </li></ul><ul><li>induce ...
Surgery Treatment ( 1 ) <ul><li>Indications : </li></ul><ul><li>greater than 10 weeks’ gestational size </li></ul><ul><li>...
Surgery Treatment ( 2 ) <ul><li>Method : </li></ul><ul><li>Myomectomy—conservative therapy </li></ul><ul><li>preserve fert...
Surgery Treatment ( 3 ) <ul><li>Approach : </li></ul><ul><li>trans-abdominal </li></ul><ul><li>trans-vaginal </li></ul><ul...
<ul><li>It is important to individualize the choice of therapy. </li></ul>www.freelivedoctor.com
Uterine Leiomyomas Complicating Pregnancy <ul><li>impact on pregnancy : abortion </li></ul><ul><li>impact on delivery : pr...
Critical Points <ul><li>May be related to superabundant estrogen. </li></ul><ul><li>Well-circumscribed , nonencapsulated. ...
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Normal and abnormal puerperium

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Normal and abnormal puerperium

  1. 1. Normal and Abnormal Puerperium www.freelivedoctor.com
  2. 2. Synonyms <ul><li>leiomyoma of uterus </li></ul><ul><li>leiomyomas </li></ul><ul><li>fibromyomas </li></ul><ul><li>myofibromas </li></ul><ul><li>fibroids </li></ul><ul><li>fibromas </li></ul><ul><li>myomas </li></ul>www.freelivedoctor.com
  3. 3. Incidence <ul><li>Most common solid pelvic tumors </li></ul><ul><li>Develop in 20 ~ 25% of women during reproductive years </li></ul><ul><li>30 ~ 50 years old </li></ul>www.freelivedoctor.com
  4. 4. Correlative Factors <ul><li>An estrogenic milieu may be necessary </li></ul><ul><li>Progesterone function </li></ul><ul><li>Growth factor and their receptor : </li></ul><ul><li>epithelial growth factor ( EGF ) </li></ul><ul><li>Insulin-like growth factor ( IGF ) </li></ul><ul><li>platelet-derived growth factor </li></ul>Puberty Menopause Estrogen Progesterone www.freelivedoctor.com
  5. 5. Pathology www.freelivedoctor.com
  6. 6. Gross Appearance <ul><li>Rare only a single , usually many exist </li></ul><ul><li>Well-circumscribed , nonencapsulated </li></ul><ul><li>A pseudocapsule is present. </li></ul><ul><li>The consistency is usually firm or even hard except when degeneration or hemorrhage has occurred. </li></ul><ul><li>color : light gray or pinkish white </li></ul><ul><li>cut section : an intertwining pattern or </li></ul><ul><li>a whorl-like arrangement ; </li></ul><ul><li>bulgy </li></ul>Pseudocapsule www.freelivedoctor.com
  7. 7. <ul><li>Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the uterus. </li></ul>www.freelivedoctor.com
  8. 8. Microscopic Appearance <ul><li>Composition : smooth muscle </li></ul><ul><li>connective tissue </li></ul><ul><li>The nonstriated muscle fibers are arranged in bundles of various sizes that run in multiple directions. </li></ul>www.freelivedoctor.com
  9. 9. Classification ( 1 ) <ul><li>According to growth location : </li></ul><ul><li>Myomas on the body of uterus ( 90% ) </li></ul><ul><li>Myomas on the cervix of uterus ( 10% ) </li></ul>www.freelivedoctor.com
  10. 10. Classification ( 2 ) <ul><li>According to the relation to uterine muscle : </li></ul><ul><li>Submucous ( 10 ~ 15% ) </li></ul><ul><li>Intramural ( 60 ~ 70% ) </li></ul><ul><li>Subserosal ( 20% ) </li></ul><ul><li>Few leiomyomas are actually of a single “pure” type. </li></ul><ul><li>— hybrids </li></ul>www.freelivedoctor.com
  11. 11. Clinical Manifestation www.freelivedoctor.com
  12. 12. Symptoms <ul><li>menorrhagia and prolonged menstrual period : common </li></ul><ul><li>Pelvic pain : </li></ul><ul><li>occurs in pregnancy if undergoing degeneration or torsion of a pedunculated myoma </li></ul><ul><li>Pelvic pressure : urinary frequency </li></ul><ul><li>bowel difficulty ( constipation ) </li></ul><ul><li>Spontaneous abortion </li></ul><ul><li>Infertility </li></ul>2003-11-3 Menorrhagia Pedunculated spontaneous abortion Infertility www.freelivedoctor.com
  13. 13. Signs <ul><li>A palpable abdominal tumour </li></ul><ul><li>Pelvic examination : </li></ul><ul><li>uterus — enlarged and irregular ; </li></ul><ul><li>hard </li></ul>www.freelivedoctor.com
  14. 14. Degeneration <ul><li>Hyaline degeneration </li></ul><ul><li>Cystic degeneration </li></ul><ul><li>Red degeneration </li></ul><ul><li>Sarcomatous change </li></ul><ul><li>The others : fat degeneration </li></ul><ul><li>calcification </li></ul><ul><li>the secondary infection </li></ul>Result from the diminished vascularity of the connective-tissue element www.freelivedoctor.com
  15. 15. Red Degeneration <ul><li>Occasionally seen as a complication of pregnancy ( during pregnancy or immediate postpartum period ) </li></ul><ul><li>The pathogenesis is unknown , may be the result of the accumulation of blood in the tumour because of venous obstruction. </li></ul><ul><li>The cut surface resembles raw meat. </li></ul><ul><li>Clinical features : a cause of pain ( acute ) </li></ul><ul><li>fever </li></ul><ul><li>rapid growth , tender </li></ul>www.freelivedoctor.com
  16. 16. <ul><li>Here is a very large leiomyoma of the uterus that has undergone degenerative change and is red (so-called &quot;red degeneration&quot;). Such an appearance might make you think that it could be malignant. Remember that malignant tumors do not generally arise from benign tumors. </li></ul>www.freelivedoctor.com
  17. 17. Sarcomatous Change <ul><li>Rare : 0.4% ~ 0.8% </li></ul><ul><li>More common at 40 ~ 50 years old </li></ul><ul><li>Usually occur in intramural fiboids </li></ul><ul><li>grow quickly </li></ul><ul><li>vaginal bleeding </li></ul>www.freelivedoctor.com
  18. 18. Diagnosis <ul><li>History </li></ul><ul><li>Bimanual examination </li></ul><ul><li>Ultrasonography </li></ul><ul><li>( B–ultrasound examination ) </li></ul><ul><li>Hysteroscopy </li></ul><ul><li>Laparoscopy </li></ul><ul><li>Hysterography </li></ul>Hysteroscopy Laparoscopy www.freelivedoctor.com
  19. 19. Differential Diagnosis <ul><li>Pregnancy </li></ul><ul><li>Ovarian tumour </li></ul><ul><li>Adenomyosis </li></ul><ul><li>Malignant tumors of uterus </li></ul><ul><li>sarcoma of uterus </li></ul><ul><li>endometrial carcinoma </li></ul><ul><li>cervical cancer </li></ul>www.freelivedoctor.com
  20. 20. Treatment www.freelivedoctor.com
  21. 21. Observation and Follow Up <ul><li>Small , asymptomatic fibroids need not be treated , especially near menopause. </li></ul><ul><li>Interval : 3 ~ 6 months </li></ul>www.freelivedoctor.com
  22. 22. Medical Treatment <ul><li>Androgenic agents : testosterone propionate </li></ul><ul><li>GnRH-a : </li></ul><ul><li>induce a hypoestrogenic pseudomenopausal state </li></ul><ul><li>not recommended for longer than 6 months </li></ul><ul><li>“ add-back” regimens </li></ul>www.freelivedoctor.com
  23. 23. Surgery Treatment ( 1 ) <ul><li>Indications : </li></ul><ul><li>greater than 10 weeks’ gestational size </li></ul><ul><li>menorrhagia , lead to anemia </li></ul><ul><li>have pressure symptoms </li></ul><ul><li>grows rapidly </li></ul><ul><li>failure of medical treatment </li></ul>www.freelivedoctor.com
  24. 24. Surgery Treatment ( 2 ) <ul><li>Method : </li></ul><ul><li>Myomectomy—conservative therapy </li></ul><ul><li>preserve fertility </li></ul><ul><li>significant risk of recurrence </li></ul><ul><li>Hysterectomy— radical therapy </li></ul><ul><li>Subtotal hysterectomy </li></ul>hysterectomy myomectomy Only true “cure” for leiomyomas www.freelivedoctor.com
  25. 25. Surgery Treatment ( 3 ) <ul><li>Approach : </li></ul><ul><li>trans-abdominal </li></ul><ul><li>trans-vaginal </li></ul><ul><li>laparoscopic or hysteroscopic </li></ul>www.freelivedoctor.com
  26. 26. <ul><li>It is important to individualize the choice of therapy. </li></ul>www.freelivedoctor.com
  27. 27. Uterine Leiomyomas Complicating Pregnancy <ul><li>impact on pregnancy : abortion </li></ul><ul><li>impact on delivery : premature labour </li></ul><ul><li>fetal malpresentation </li></ul><ul><li>retained placenta </li></ul><ul><li>placenta previa </li></ul><ul><li>need for operative delivery </li></ul><ul><li>( birth canal obstruction ) </li></ul><ul><li>postpartum hemorrhage </li></ul><ul><li>Conservative treatment </li></ul>2003-11-3 www.freelivedoctor.com
  28. 28. Critical Points <ul><li>May be related to superabundant estrogen. </li></ul><ul><li>Well-circumscribed , nonencapsulated. </li></ul><ul><li>Have a pseudocapsule. </li></ul><ul><li>Can be classified into submucosal 、 intramural and subserosal types. </li></ul><ul><li>Different types have different features. </li></ul><ul><li>Menorrhagia is common. </li></ul><ul><li>Four degeneration types </li></ul><ul><li>Individualized treatment , include observation 、 medical treatment and surgical treatment. </li></ul>2003-11-3 www.freelivedoctor.com
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