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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Transcript
UTERINE FIBROID CASE SCENARIOS & DISCUSSION By Dr. K.
Haynes Raja, Junior Resident, Rajah Muthiah Medical College &
Hospital, Annamalai University.
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.
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.
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.
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.
She has been with her partner for 7 years and despite not using
contraception she has never been pregnant.
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.
On speculum examination it is not possible Bimanual to
visualise examination the cervix. reveals a non-tender firm mass
occupying the pelvis.
Investigations Haemoglobin 6.3 g/dL Mean cell volume 68fl White
cell count 4.9 * 109/L Platelets 267 * 109/L
Magnetic resonance imaging
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
DISCUSSION
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
What is fibroid? Fibroid is the commonest benign tumour of
uterus Arises from smooth muscle cells and hence called as
Leiomyoma
What is the incidence? At least 20% of women in the
reproductive age group
Whether fibroid is hormone dependant? Fibroid is hormone
dependant. Predominantly oestrogen dependant. Other hormones
implicated are growth hormone, human placental lactogen
What are the hyperoestrogenic states? Nulliparity Obesity
Polycystic Ovarian syndrome Endometrial hyperplasia
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
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
What are the synonyms of fibroid? Fibromyoma Leiomyoma
myoma
What are the types of fibroid?
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)
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.
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.
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.
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.
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.
Investigations Haemoglobin 9.2 g/dL Mean cell volume 75 fl
White cell count 4.5 * 109/L Platelets 198 * 109/L
Hysteroscopy
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 dont cause
intermenstrual bleeds other than when there is ulceration or it is
submucous or cervical fibroid
DISCUSSION
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
How do they cause menorrhagia? Increased surface area of
endometrium Hyperoestrogenism Intramural fibroid prevents adequate
contraction and retraction of uterus Associated pelvic inflammatory
disease
Can fibroids cause polycythaemia? Yes. Huge fibroid compresses
renal artery Reduced renal perfusion Hypoxia activation of Renin-
angiotensin aldosterone Renal erythropoietin secretion increases
polycythaemia
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
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
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
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.
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.
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.
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.
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