Home GUT and OBG Fibroid Uterus
Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References

CLINICAL HISTORY

A 36year old female patient came to the clinic with complaint of enlargement of abdomen for 2 weeks and a sudden increase in weight from 60 kgs to 65.7 kgs in 2 weeks.

MENSTRUAL HISTORY 

  • Normal menstrual cycle 
  • No dysmenorrhea 
  • No menorrhagia 
  • No clots passed 

OBSTETRIC HISTORY 

  • Obstetric score –   G2P2A0L2 – Both LSCS 
  • Last Child – 14 years old
  • LMP – 6/11/20

            21/10/20

            7/9/20

PAST HISTORY

The patient has no significant past history

No previous history of surgeries 

She has no history of diabetes mellitus, hypertension, thyroid, respiratory, cardiac or connective tissue abnormalities 

General physical examination 

The female patient was conscious, alert, cooperative and was well nourished, moderately built was well oriented to time, place and person. 

  • No Pallor 
  • No Icterus
  • No Cyanosis
  • No Clubbing
  • No Lymphadenopathy
  • No Oedema 
  • Blood pressure-110/80 
  • Pulse – 85 beats / min 

SYSTEMIC EXAMINATION

CVS – S1, S2 heard

RS- B/L normal 

PER ABDOMEN 

On Inspection – No Bulge was seen

On Palpation – Firm lump from pelvis till epigastrium was felt

Bowel sounds are normal

P/V examination – NAD

CNS – No FND

LOWER ABDOMEN USG –


USG revealed a large solid mass along the posterior uterine wall from the cervix to the epigastrium as described, ovarian in origin D/D large serosal uterine fibroid.

Ultrasound of lower abdomen excluded ovarian tumor 

Fibroid uterus 

Differential diagnosis 

Ovarian tumour 

Endometrial cancer  

Endometriosis 

Patient underwent myomectomy under spinal anesthesia 

Pre Surgery
Fibroid
Fibroid with uterus
Uterus with fallopian tube and ovaries

Uterine leiomyomas (fibroids or myomas) are benign tumors of the uterus and clinically apparent in a large part of reproductive aged women.

Clinically, they present with a variety of symptoms: 

  •  excessive menstrual bleeding,
  •  dysmenorrhoea and intermenstrual bleeding
  •  chronic pelvic pain
  •  pressure symptoms such as a sensation of bloatedness,
  •  increased urinary frequency
  •  bowel disturbance

In addition, they may compromise reproductive functions,

  •  possibly contributing to subfertility
  •  early pregnancy loss
  •  later pregnancy complications.[1]

Treatment

  • Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. 
  • Treatment of women with uterine leiomyomas must be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the therapist. 
  • In women who do not wish to preserve fertility and/or their uterus and who have been counselled regarding the alternatives and risks, hysterectomy by the least invasive approach possible may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. 
  • Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. 
  • Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with the help of appropriate imaging. 
  • When morcellation is necessary to remove the specimen, the patient should be informed about possible risks and complications, including the fact that in rare cases fibroid(s) may contain unexpected malignancy and that laparoscopic power morcellation may spread the cancer, potentially worsening their prognosis. 
  • Anemia should be corrected prior to proceeding with elective surgery. (II-2A) Selective progesterone receptor modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. 
  • Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be considered. 
  • Uterine artery occlusion by embolization or surgical methods may be offered to selected women with symptomatic uterine fibroids who wish to preserve their uterus. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted. 
  • In women who present with acute uterine bleeding associated with uterine fibroids, conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention may be considered, but hysterectomy may become necessary in some cases. In centres where available, intervention by uterine artery embolization may be considered.[2]

Attempts at a nonsurgical treatment of uterine leiomyomas probably began hundreds of years ago, but scientifically validated modalities became available only some 40 years ago.During this relatively short period of time, several regimens were introduced using different categories of drugs. Today, the most promising belong to two categories: PR modulators and orally active GnRHR blockers.[3]

  1. Andrea Ciavattini, Jacopo Di Giuseppe, Piergiorgio Stortoni, Nina Montik, Stefano R. Giannubilo, Pietro Litta, Md. Soriful Islam, Andrea L. Tranquilli, Fernando M. Reis, Pasquapina Ciarmela, “Uterine Fibroids: Pathogenesis and Interactions with Endometrium and Endomyometrial Junction”, Obstetrics and Gynecology International, vol. 2013, Article ID 173184, 11 pages, 2013. https://doi.org/10.1155/2013/173184
  1. Vilos GA, Allaire C, Laberge PY, Leyland N; SPECIAL CONTRIBUTORS. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015 Feb;37(2):157-178. doi: 10.1016/S1701-2163(15)30338-8. PMID: 25767949.
  1. Farris M, Bastianelli C, Rosato E, Brosens I, Benagiano G. Uterine fibroids: an update on current and emerging medical treatment options. Ther Clin Risk Manag. 2019;15:157-178. https://doi.org/10.2147/TCRM.S147318

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