Cesarean hysterectomy is really two separate operations: cesarean section and hysterectomy. Cesarean hysterectomy can be accomplished through most abdominal wall incisions. A vertical incision provides best exposure, but often when performed as an emergency a transverse incision has been used and may be adequate.

1. Caesarean Section
Hysterectomy
Presented by :
MUKESH SAH
POST-GRADUATE MEDICAL INTERN
GOODSAM MEDICAL CENTER
06/05/2020 1

2. General Data
• Patient J.G
• 41 years old
• Female
• Married
• Born on February 2, 1976
• House wife
• Balungao, Pangasinan
• Admitted on October 10, 2017 for the first time in
R1MC
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3. Chief complaint
Headache
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4. History of Present Illness
• 4 days Prior to admission
 the patient
experienced headache
with associated dizziness,
accompanied by vaginal
spotting
• Consult in a private
institution
• She was noted to have
high Blood Pressure and
was advised for admission
but refused
• Home Medication given
was Methyldopa 250 mg
every 8 hours
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5. History of Present Illness
• The patient had temporary
relief of symptoms until
• 3 hours Prior to admission 
the patient then again
experienced headache and
dizziness with associated
body weakness, (-)
hypogastric pain, (-) blurring
of vision, (-) vomiting, (-)
vaginal bleeding/discharge
• Which prompted consult at
R1MC hence admission
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6. Past Medical History
• Patient has no known allergies to any medication or food no
know history of diabetes
• Patient cannot recall if she had any childhood diseases.
• The patient has no previous Operation
• Patient was diagnosed to have Myoma Uteri (subserous) On
August 7, 2017 via Ultrasound
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7. Family History
• No Heredofamilial disease were recalled by the patient
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8. PERSONAL/SOCIAL HISTORY
• The patient is a college graduate. She’s now a plain housewife
living with her husband and granddaughters. Her diet is
usually composed of meat, vegetables, and rice. She doesn’t
smoke nor drink.
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9. Obstetrics History
Menarche- 12 y/o
Interval- Regular
Duration- 5 days
Amount- 3-5 pads/day
Symptoms- (+) dysmenorrhea
Sexual hx- 17 y/o
No. of partner- 1
Family planning- none
Papsmear – none
PNCU – 5x BHC and
private institution
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10. Obstetrics History
LMP- Dec 8, 2016
EDC- Aug 15, 2017
AOG- 38 5/7 weeks
G3P1(1011)
G1 –2004 , Term, NSD, Home
Delivery , Female, alive
G2 – 2009, Miscarriage
G3 -Present pregnancy
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11. Physical Examination
• Patient is conscious, coherent not
in cardio respiratory distress
– Current BP: 200/ 100 mmHg
– Highest BP:220/100 mmHg
– Goal Bp:176/80 mmHg
– CR:94 bpm RR:20 T:36.5C
• (-)pallor (-) jaundice (-) cyanosis
• Pink palpebral conjunctiva
anicteric sclera, (-) periorbital
Edema
• Symmetrical chest expansion, no
retractions, clear breath sounds
• Adynamic precordium, normal
rate, regular rhythm, no murmur
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12. Physical Examination
Abdomen globular, normoactive bowel sounds, soft nontender,
with palpable nodular masses at periumbilical and infraumbilical
area measuring 10x8 and 8x5cm
Extremities: (+) bipedal edema, pitting, grade 1
FH- 33cm FHT-132 bpm
IE- Cervix closed, uneffaced, (-) SHOW
LM1- Cannot Fully determine due to Presence of Myoma
LM2- Small irregular soft mass at right maternal side, fetal back at
left maternal side
LM3- Round ballotable hard mass
LM4-
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13. Salient features
• Subjective
– Headache
– Dizziness
– Vaginal bleeding
– Gradually
increasing Mass
at abdomen
• Objective
– Elevated Blood
Pressure: 200/100
– Multiple Palpable
Mass at the
periumbilical and
infraumbilical area
– (+) Fetal movement
– (+)Fetal Heart tone
– (+) bipedal edema
– Urinalysis: ++
proteinuria
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14. Admitting Diagnosis
G3P1(1011) PU 38 5/7wks AOG, Cephalic not in Labor, Pre-
eclampsia with severe features, Myoma uteri
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15. On the day of admission
10/10/17 (6:00 am) First Hospital Day
• Admitted at Labor room
• Diagnostics done
-Cbc typing -Urinaysis -FBS
-HbsAg -VRDL/RPR -HBA1c
-Electrolytes -LDH -RBS
-BUN, Crea -SGOT, SGPT
• IVF: D5 LRS 1L x 20ugtts/min
• MgSo4 4 grams SIVP then 5grams deep IM each buttocks
• Hydralazine 5mg IV
• Methyldopa 250mg/tablet 2 tablet q6
• Insert IFC aseptically
• Hooked on O2 at 3-4 lpm via NC
• Position patient to Left lateral decubitus
• Monitored VS, FHT and Progress of Labor
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20. Ultrasonography
• August 7 ,2017
– Within a gravid uterus single Male fetus in breech presentation with good
cardiac activity
– Biometric Measurement
• BPD: 7.49cm= 30 weeks 0 days
• HC: 27.61cm= 30 weeks 1 day
• AC: 26.12cm = 30 wes 2 days
• FL: 5.89 cm = 30 weeks 5 days
• EFW: 1,568 grams
– Expected date of delivery October 14 2017
– Fetal heart rate 144 bpm
– Placenta located anteriorly with grade 2 in maturity
– Hypoechoic nodule in the anterior wall of the Uterus Measuring 2.82 x2.37
cm, 5.49x 3.91 cm, and 5.24 x 4.22cm
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21. On the day of Admission
• 10/10/17 (9:00 am)
– KCL Drip Started (PNSS 1L + 40 Meqs) to run for 6 hours
– Scheduled for LTCS I ( Pre-eclampsia w/ severe features,
Uncontrolled BP)
– Secure Consent
– Notify OR and Anesth on duty
– Cefuroxime 1.5 gm iv (-) ANST now then 750 q 8 hours
– Secure 1 unit PRBC for possible OR use
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22. Course in the Ward
• 10/10/17
– Operation started at 11: 25 am
– Operation ended at 12: 50 PM
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23. Operation done
‘E’ LTCS followed by Total Abdominal
Hysterectomy with Bilateral Salphingo-
oophorectomy
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24. Intra Operative
ANTERIOR
POSTERIOR
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25. Intraoperative
On laparotomy a gravid term size uterus was exposed with
formed lower uterine segment, LTCS was done extracting to a
live baby boy in cephalic presentation; amniotic fluid clear and
adequate with AS 8/9 in 1 and 5 minutes if life. Placenta located
anterofundally. On further exploration, multiple myoma was
noted on the anterior wall, the two largest mass approximately
10x10 cm and at the posterior wall, the largest mass was also
measured about 8x8cm. Both fallopian tubes were normal but a
multiple Endometrial implants were noted in the ovaries. Then
proceeded with total abdominal Hysterectomy with bilateral
salpingo-oophorectomy.
OR started: 12:34pmEnded: 1:52pm
EBL: 800cc UO: 200cc
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26. GROSS FINDINGS
UTERUS -27X20X17CM
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27. M1- 9x6x4cm
M2- 10x8x4 cm
M3- 3x3x3 cm
M1
M2
M3
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28. ENDOMETRIAL CANAL-19CM CERVIX- 6X6X3CM
M1
M2
M3
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29. Gross Examination:
• The uterus measured 27X20X17CM, Multiple Intramural
Masses at the anterior wall M1:9x6x4cm M2: 10x8x4cm M3:
3x3x3 cm, on the posterior wall M1: 8x7x3cm M2: 5x5x3cm,
M3: 3x3x2cm. On cut section of masses it reveals tan colored
with whorl like tissue pattern.
• Endometrial canal: 19 CM Cervix 6x6x3 cm
• Ovary Right: 3x3x1 cm, , fallopian tube right 14x1cm
• Ovary Left: 3x3x1cm, fallopian tube Left 13x1cm
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30. M4 8x7x3 cm
M5 5x5x3 cm
M6 3x3x2 cm
M6
M4 M5
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31. Histopath Result
• Leiomyoma Uteri Multiple, intramural and
Subserosal
• Vascular congestion, Bilateral Fallopian
Tubes
• Cystic follicles, Bilateral Ovaries
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32. Final Diagnosis
• G3P2 (2012) PU term cephalic live birth delivered via LTCS I for
Pre-eclampsia with severe features under SAB to a baby boy
BW2770gm BL51cm AS:8/9 BS: 38wks AGA followed by total
abdominal Hysterectomy with bilateral salpingo-
oophorectomy, Multiple Myoma(Intramural and Subserous),
pelvic endometriosis
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33. UTERINE FIBROIDS
(LEIOMYOMATAS)
Williams Book of Gynecology
Dewhurst’s Textbook of
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34. UTERINE FIBROIDS (LEIOMYOMATAS)
• Uterine fibroids, also known as uterine leiomyomas
• Benign Smooth Muscle Tumor of the Uterus
• They are benign neoplasms composed of disordered
“myofibroblasts”
• the Most Common gynecological tumours
• Occurring in about 30% of women above the age of 30 years.
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35. 06/05/2020 35

36. Epidemiology
• Most frequent pelvic tumors and most common tumor in
women
• Highest prevalence occurring during 5th decade
• In general a third of myomas become symptomatic
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37. Risk Factors
• Increasing age
• Early menarche
• Low parity
• Tamoxifen use
• Obesity
• High fat diet
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38. Pathophysiology
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39. Clinical Presentation
• Pressure due to enlarging pelvic mass
• Dysmenorrhea
• Abnormal uterine bleeding
• Increase in abdominal girth
• Urinary frequency or urgency
• Asymptomatic in over 2/3 of women with uterine myoma
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40. Diagnosis
• History and Physical examination
• Imaging- Ultrasound
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41. Differential Diagnosis
• Causes of symmetrically enlarged uterus:
– Pregnancy
– Subinvolution of the uterus.
– Submucous or interstitial fibroid.
– Adenomyosis uteri.
– Carcinoma or sarcoma of the uterus.
• Causes of asymmetrically enlarged uterus:
– Subserous fibroid.
– Localized adenomyosis.
– Ovarian, tubal, or broad ligamentary swelling.
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42. Management
• Conservative Management
– small asymptomatic fibroid,
– fibroid in pregnancy or puerperium.
• Just keep observation every 6 months.
• Beware of underlying and/or associated
pathology
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43. Medical Treatment:
• Lines of treatment:
– Symptomatic:
• Correction of anemia,
• haemostatics,
• analgesics, and anti-spasmodics (anti-PG).
– Anti-estrogens:
• large dose of progesterone,
• Tamoxifen, Danazol,
• LH-RH analogues
– useful in decreasing the size and vascularity of the tumor by 50%
which is beneficial before myomectomy
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44. Surgical Management
•Indications:
•Symptomatic cases or uterus larger than 12
weeks size.
•Suspected malignancy (rapidly enlarging or
post-menopausal growth).
•Multiple huge fibroids liable to complications.
•Infertility.
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45. Myomectomy VS Hysterectomy
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46. Principle of Myomectomy
•Myomectomy aims at
– removal of all the myomas,
– with conservation of a functioning uterus to preserve
the reproductive function.
•Generally the morbidity is higher than those with
hysterectomy.
– It is associated with much blood loss
– Liability of recurrence of fibroid.
•Myomectomy is better reserved only for those
keen to preserve the reproductive function.
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47. Principle of Hysterectomy
• Patient around 40 years, and completed her family.
• Severe bleeding during myomectomy.
• Major damage of the uterus by myomectomy which
affects its function for pregnancy.
• Recurrent fibroids.
• Asymptomatic myomas wherein uterus reahed size
of 14-16 weeks AOG
• Suspicious of malignancy – rapid growth after
menopause
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48. What is the effect of Fibroid on
Pregnancy and Pregnancy on Fibroid?
eMedMD.
com
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49. What is the effect of Fibroid on Pregnancy and
Pregnancy on Fibroid?• A Fibroid or Fibroids are very often discovered in the womb
(uterus) during a pelvic examination or more frequently during
a routine ultrasound scan when a woman is pregnant.
• It has been found that about a third of fibroids may enlarge
during the first three months (known medically as the first
trimester) of pregnancy.
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50. What is the effect of Fibroid on Pregnancy and
Pregnancy on Fibroid?
• It has been found that between 10% and 30% of women with
fibroids have problems or complications during their
pregnancy.
• It is hypothesised that mechanical obstruction or impaired
distensibility (stretchability) of the uterus may explain some of
the problems caused by fibroids.
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51. What is the effect of Fibroid on Pregnancy and
Pregnancy on Fibroid?
• In early Pregnancy
– Miscarriage
– Bleeding
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52. What is the effect of Fibroid on Pregnancy and
Pregnancy on Fibroid?
• In Late Pregnancy
– Preterm labor and preterm premature rupture of membranes
– Placenta abruption
– Placenta previa
– Fetal growth restriction and fetal anomalies
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53. What is the effect of Fibroid on Pregnancy and
Pregnancy on Fibroid?
• In labor and delivery
– Malpresentation, caesarean section and labour dystocia
– Retained placenta
– Postpartum hemorrhage
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54. 
THANK YOU 
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55. • THANK YOU
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