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Management Of Fibroids

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Management Of Fibroids

  1. 1. MANAGEMENT OF FIBROIDS Hari Dev 2008 MBBS
  2. 2. Bimanual Examination
  3. 3. HEMATOLOGICAL INVESTIGATIONS• Hemoglobin• Total count, differential count• Bleeding time, clotting time• Blood sugar• TFT- thyroid function test• Renal function test
  4. 4. IMAGING MODALITIES• Ultrasound• Sonohysterography• Hysteroscopy
  5. 5. IMAGING MODALITIES ULTRASOUND• Confirm Diagnosis• Size , Number• To detect small submucous fibroids• Detect distorsion of the cavity• Rule out ovarian tumour , adenomyosis• Ascitis?• Assess kidney and ureters..
  6. 6. ULTRASOUND SCAN
  7. 7. TREATMENTSmall, asymptomatic fibroids do not require removal, observed every 6 months.
  8. 8. EXPECTANT MANAGEMENT- CRITERIA
  9. 9. DRUGS USED
  10. 10. PROBLEMS…..
  11. 11. SURGICAL Management- Indications
  12. 12. MYOMECTOMY• Victor Bonney• Option for those who desire further child bearing or wish to preserve uterus• Women presenting with infertility and miscarriage – other causes should be ruled out.• Best for intramural and submucous fibroids
  13. 13. How to limit blood loss??
  14. 14. SURGICAL PROCEDURE• Anterior incision in uterus..• Bonney’s hood incision – single posterior fibroid.
  15. 15. OPEN MYOMECTOMY
  16. 16. Hysteroscopic Laparoscopic Submucous fibroids Subserous, intramural Pedunculated fibroids easliy removed. Less hospital stay Preoperative TVS & Sonohysterography Less postop pain ideal.Myomas < 5cm and of which >50% cosmetic advantageprojecting into cavity Vaginal – pedunculated submucosal myomas
  17. 17. Complications
  18. 18. HYSTERECTOMY - AbdominalSteps1.Opening abdomen – Pfannensteil incision, uterus elevated with left hand , forceps placed on either side of cornua.2.First pedicle – round ligament [ 0/1 vicryl], if needed trace ureter. - if ovaries removed – infundibulopelvic lig. - if ovaries retained –tube & ovarian lig. cut
  19. 19. 3. Bladder dissection – dissect bladder from anterior cervix, bladder pushed down4. Second pedicle - uterine vessels seletonised, clamped, cut and ligated. Clamp placed perpendicular to uterine artery at CU junction.5. Third pedicle - cardinal ligaments and uterosacrals clamped , cut ligated.6. Vaginal angles and vaginal edges- 2 clamps used to clamp across vagina.suture taken thru lt. vaginal clamps and uterosacrals.7. Closure of abdomen.
  20. 20. Complications
  21. 21. Vaginal vault closed anteropsteriorly with interrupted mattress or continous suture with 0 vicryl.
  22. 22. Complications1.Immediate – haemorrhage - injury to bladder / rectum2.Late – reactionary & secondary haemorrhage. - haematoma, abscess - vesicovaginal , uterovaginal or rectovaginal fistulae.3.Sequelae - Vault prolapse
  23. 23. Uterine artery embolisation (UAE)• Symptomatic women who don’t want surgery• Prerequisites – Accurate diagnosis – No suspicion of malignancy – Patient warned of failure – Informed consent
  24. 24. • C/I – Pregnancy – Pelvic infection – Pelvic malignancy – Contrast medium allergy – Adenomyosis – Pedunculated submucous fibroids – Pedunculated subserous fibroids – Infertility
  25. 25. • Technique – Aim to occlude both uterine arteries to induce ischemic necrosis of fibroids – Done in the immediate postmenstrual period – Transfemoral approach on the right side – Embolisation using polyvinyl alcohol particles – B/l done – Discharge after 24-48 hrs – Follow up clinically and sonologically
  26. 26. Complications– Failure to cannulate– Local haematoma– s/v pain due to infarction– Menorrhagia decreases by 90% Postembolisation syndrome – fever, N,V– Infection reduction in fibroid volume by 50-70% &– Exposure to radiation– Persistent vaginal discharge– Pedunculated submucous fibroids expelled vaginally– Pedunculated subserous fibroids become infected– Non target organ embolisation

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