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Myoma UteriOB-GYN Rotation
Quirino Memorial Medical Center
Lazaro, Tonyrose C.San Beda College of Medicine
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General Data
• A.E.• 44 y/o female• G3P3• Admitted for the second time at QMMC - June
13,2011
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Chief Complaint
• Vaginal Bleeding
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History of Present Illness2yrs PTA– (+) hypogastric pain, 5/10 , shearing/compressing– Occ minimal intermenstrual vaginal bleeding– Used 1-2pads/day– (+) palpable mass at hypogastric area – tennis ball
size– No consult, no meds
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6 months PTA– Intermenstrual bleeding and occ hypogastric pain
persisted– Progressive enlargement of the mass approx.
double the size of a tennis ball– No consult, no medications
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1 ½ month PTA– (+) profuse vaginal bleeding with blood clots for 2
weeks– Used 3 fully soaked pedia diaper/day– Hypogastric pain became severe, 9/10
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1 month PTA– Consulted at QMMC OB-GYN OPD– CBC- low hemoglobin– Elevated blood glucose– Admitted for correction of anemia, 2 weeks– Transfused 5 u PRBC w/c corrected anemia
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• Transvaginal ultrasoundMyoma Uteri (intramural with
submucosal component)
• Endometrial biopsyProliferative Endometrium with necrosis
and chronic inflammation
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TRANSVAGINAL ULTRASOUND (5/16/2011)
The uterus is anteverted with smoothe contour and heterogenous echopattern measuring 14.8x12.8x13.1cm. There is a well-circumscribed heterogenous mass seen at posterior wall measuring 12.3x12.9x10.4cm (intramural with submucosal.) Cervix measures 3.40x2.12x2.35cm. Endometrium is hyperechoic measuring 0.4cm.
The left ovary measures 3.11x2.63x2.72cm. the right ovary not seen.
Impression: Myoma Uteri (intramural with submucous
component); Normal Left Ovary
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HISTOPATH RESULT: ENDOMETRIAL BIOPSY (5/26/2011)Gross and Microscopic Description:
Specimen consists of several tan brown soft irregular tissue fragments aggregately measuring 3.0x2.5x0.5cm. All tissues processed.
Section discloses irregularly shaped endometrial glands lined by tall columnar cells having aligned cigar shaped nuclei surrounded by a fibrous stroma infiltrated by lymphocytes and plasma cells and focal areas of necrosis.
Diagnosis: Proliferative Endometrium with necrosis and Chronic Inflammation.
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• Discharged improved, advised weekly ff up• Prescribed FeSO4 TID, Tranexamic acid OD
x7days, Ascorbic acid• Continue Metformin 500mg TID• Advised elective surgery (TAHBSO) after 2
weeks or once hgb and glucose become stable
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On the day of admission– Hgb stable – Glucose controlled– Claimed ready for surgery– Scheduled for OR– admitted
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OB-GYN History
• LMP: April 25, 2011• G3P3 (3003)
G1 1995 CS Private hosp at Montalban
Post term/ Breech presentation
No fetomaternal complications
G2 1997 CS Montalban Term No fetomaternal complications
G3 1999 CS Montalban Term No fetomaternal complications
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Menstrual History
• Menarche- 13 y/o• interval 25-28 days• Lasting 3-4days• Using 3-4 soaked pads/day• With occasional dysmenorrhea
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Sexual History
• First intercourse- 29y/o• Only 1 partner (husband)• No contraceptive used• No STD• No recent sexual activity
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Past Medical History
• Feb 2009- DM, hospitalized and diagnosed at Montalban, Metformin 500mg TID.
• No history of HPN, lung diseases, kidney diseases, cardiac diseases, psychiatric disorders.
• No allergies to foods and medications.
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Family Medical History
• No history of Diabetes Mellitus, Lung diseases, kidney diseases, cardiac diseases, and psychiatric disorders.
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Personal/Social History
• widow • Lives in a single abode with her 3 children.• non-smoker• non-alcoholic beverages drinker• denied illicit drug used
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Review of Systems
• General: no weight loss, no easy fatigability, fever• CNS: occasional headache, no loss of consciousness• Respiratory: no difficulty of breathing, no colds, no
cough• Cardio: no chest pain, no palpitation, no orthopnea• GIT: no constipation, no diarrhea, no vomiting
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• GUT: no dysuria, no polyuria, no hematuria, no urinary urgency
• Extremities: no weakness, no numbness
• M/S: no limitation of movement, no joint pain
• Psychiatric: no mood changes, depression or suicidal attempts.
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Physical Examination
GENERAL SURVEY• Patient is conscious and coherent, alert, ambulant;
oriented to time, person, and place; not in cardiorespiratory distress.
VITAL SIGNS• Blood pressure: 120/80• RR: 18/min• HR: 85 bpm• Temperature: 36.4°C
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Skin• Patient’s skin is fair in color, no discolorations, moist and
warm to touch, no masses, no lesions HEENT: anicteric sclera, slightly pale palpebral conjunctiva
Chest/Lung: symmetrical chest expansion, clear breath sound, no retractions
Heart: adynamic precordium, normal rate and rhythm, no murmur
Extremities: full pulses, pink nailbeds
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Abdomen: globular, uterus enlarged to 18x18x10 cm, doughy, slightly movable, non-tender
Speculum Exam: pink and smooth cervix, no
erosions, no discharge
Internal Exam: cervix short, firm, closed; uterus asymmetrically enlarged, non-tender on deep palpation, doughy, slightly movable.
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ADMITTING DIAGNOSIS
• G3P3 (3003) Abnormal Uterine Bleeding, Myoma Uteri, Proliferative Endometrium, s/p LTCS 3x malpresentation and repeat
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Plan
• Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAHBSO)
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Course in the Wards/Pre-operative Work ups
RESULTS REFERENCE RANGERBC 4.31 4.20-5.40 x10^12/LHemoglobin 113 120-160 g/dLHematocrit 0.38 0.36-0.47 %Platelet 335 150-450 x10^9/LWBC 7.8 5-10x10^9/LNeutrophils 0.439 0.500-0.700Lymphocytes 0.197 0.200-0.700Eosinophils 0.312 0.000-0.060Monocytes 0.049 0.000-0.020
COMPLETE BLOOD COUNT (6/13/2011)
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BLOOD CHEMISTRY (6/15/2011)TEST NAME RESULT REFERENCE RANGE
Glucose 5.52 4.1- 5.9Creatinine 45.11 53-115 umol/LSGPT 9.3 7-35 u/LBlood Urea Nitrogen 2.53 2.50-6.40 mmol/LUric Acid 302.82 155-428 umol/LCholesterol 4.74 0-5.20 mmol/LTriglycerides 1.34 0-2.26 mmol/LHDL Cholesterol 0.74 0-1.5 mmol/LLDL 3.4 26-4.1 mmol/LVDLD 0.61 --1.0mmol/LSodium 135 low 136-145 mmol/LPotassium 3.8 3.5-5.1 mmol/LHbA1C 5.1 4.8-6.0%
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COAGULATION PANEL (6/15/2011)
Parameters Results Reference range
Prothrombin time (PT)
10.6 10-14 secs
APTT 40.3 28-44 secs
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CHEST X-RAY (6/15/2011)
• Clear lungs. No other significant findings.
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MEDICATIONS
• Cefuroxime 1 cap BID x7days• Mefenamic acid 500mg/ cap TID• FeSO4 1 tab OD • Ascorbic acid OD• Bisacodyl 1 tab TID• Bisacodyl 2supp/rectum @ HS• Metronidazole 500mg/tab
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PRE-OPERATIVE DIAGNOSIS:
Abnormal Uterine Bleeding Secondary to Myoma Uteri,Proliferative Endometrium, S/P CS 3x Malpresentationand Repeat, Bilateral Tubal Ligation, DM Type II
Controlled
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OPERATION/PROCEDURE PERFORMED (6/17/2011 at 7:00am):
TAHBSO + ADHESIOLYSIS/GEA
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INTRAOPERATIVE FINDINGS
• Uterus enlarged to 20x22x14cm with submucous myoma on cut section measuring 18x15x6cm.
• Cervix 3x3x3cm• Normal- both ovaries• Normal- both FTs• Liver edge smooth• Omentum not matted
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POST OPERATIVE DIAGNOSIS
Abnormal Uterine Bleeding Secondary to Myoma Uteri, Proliferative Endometrium, S/P CS 3x Malpresentation and Repeat, Bilateral Tubal Ligation, DM Type II Controlled.
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POST-OPERATIVE MEDICATIONS:
• Nalbuphine 10mg IV q4 x 6doses• Ketorolac 30mg IV loading then 15mg q6 x
4doses• Omeprazole 40mg IV OD• Cefoxitin 1gm IV q8
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Uterine Leiomyoma
• “fibroids”• “uterine myomas”
• benign proliferations of smooth muscle cells of the myometrium.
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Pathogenesis
• Cause of uterine leiomyomas is unclear• Fibroids are monoclonal• Each tumor resulting from propagation of a single
muscle cell
• Proposed etiologies include development from --smooth muscle cells of the uterus or the uterine arteries ,from metaplastic transformation of connective tissue cells, and from persistent embryonic rest cells
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• Hormonally responsive to estrogen and progesterone
• Pregnancy- grow quickly and to huge proportions
• Menopause- stop growing and atrophy in response to naturally ↓ endogenous estrogen levels.
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Classification by locations Submucosal- beneath the endometrium, commonly assoc w/
heavy of prolonged bleeding• intramural- in the muscular wall of the uterus, MC• subserosal -beneath the uterine serosa
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Epidemiology
• 30% of all American women and 50% of African American women will develop leiomyoma by age 40
• highest prevalence occurring during the fifth decade
• Rare before puberty
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Risk Factors
• increasing age• early menarche• low parity• tamoxifen use• Obesity• 2.5x more likely develop fibroids-1st degree relatives• and in some studies a high-fat diet.
• Smoking has been found to be associated with a decreased incidence of myomata
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Clinical Symptoms of Uterine LeiomyomasBleeding (MC symptom)Longer, heavier periodsEndometrial ulceration
PressurePelvic pressure and bloatingConstipation and rectal pressureUrinary frequency or retention
PainSecondary dysmenorrheaAcute infarct (especially in pregnancy)Dyspareunia
Reproductive difficultiesInfertility (failed implantation/spontaneous abortion)Fetal malpresentationIntrauterine growth restriction (IUGR)Premature labor and delivery
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Clinical manifestations
• 50-65% have no clinical symptoms• Abnormal uterine bleeding- MC symptom• Menorrhagia- presents as increasingly heavy
periods of longer duration• Metrorrhagia- bleeding between periods• Menometrorrhagia- heavy irregular bleeding• Chronic IDA, dizziness, fatigue
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Physical Examination
• Depending on their location and size
• uterine leiomyomas can sometimes be palpated on bimanual pelvic examination or on abdominal examination
• nontender irregularly enlarged uterus with “lumpy-bumpy” or cobblestone protrusions that feel firm or solid on palpation.
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Diagnostic Evaluation
• Pregnancy test- all women• History and PE• Ultrasound (pelvic/transvaginal) – MC means
of diagnostics
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Treatment
• Most cases of uterine fibroids do not require treatment
• Px with actively growing fibroids- ff up every 6months to monitor size and growth
• Treatment- severe pain, heavy or irregular bleeding, infertility, or pressure symptoms; extremely rapid growth
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• Treatment depends on the patient’s– Age– Pregnancy status– Desire for future pregnancies– Size and location of the fibroids
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Medical Therapies
• Medroxyprogesterone- shrink fibroids by decreasing circulating estrogen levels
• GnRH agonists- shrink fibroids by decreasing circulating estrogen levels; stop bleeding, and increase the hematocrit prior to surgical treatment of uterine fibroids.
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Uterine artery embolization (UAE)
decrease the blood supply to the fibroid, thereby causing ischemic necrosis, degeneration, and reduction in fibroid size
• No to women planning to become pregnant after the procedure
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Surgical Intervention
• Myomectomy- surgical resection of one or more fibroids from the uterine wall; preserve fertility; increase risk of recurrence- 50%
• Hysterectomy- DEFINITIVE TREATMENT.
• Because of the potential for hemorrhage, surgical intervention should be avoided during pregnancy, although myomectomy or hysterectomy may be necessary at some point after delivery.
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Indications for Surgical Intervention for Uterine Leiomyomas
Abnormal uterine bleeding, causing anemiaSevere pelvic pain or secondary amenorrheaUterine size (>12 weeks) obscuring evaluation of
adnexae• Urinary frequency, retention, or hydronephrosis• Growth after menopause• Recurrent miscarriage or infertilityRapid increase in size