Uterine fibroids

Introduction

Age 35 -45 yrs

Marital status more common in nulliparous women

Presentation

Menstrual abnormalities
Menorrhagia (submucosal fibroids increasing endometrial surface area)
Intermenstrual bleeding (necrosis and sloughing of submucosal fibroid)
Dysmenorrhea (submucosal fibroids & submucosal polyps)
Lump at vulva
Pregnancy related
Subfertility
Miscarriage
Red degeneration (severe sudden onset pain with localized uterine tenderness, pyrexia
and leukocytosis)
Non-engaged head at term
Mal-presentation
Dysfunctional labour
PPH (due to inefficient uterine contractions)
Pressure symptoms
Urinary (frequency, retention, hydronephrosis)
Leg oedema
Varicose veins
Abdominal distension
Complications due to fibroids
Torsion of the pedunculated fibrioid (lower abdominal pain)
Infection of fibroid (fever , lower abdominal pain, offensive discharge)
Haemorrhage (rupture of large veins on the surface)
Pseudo-Meigs syndrome

Menstrual Hx
Past Gyn Hx

Last cervical smear

Past obs Hx

Number of pregnancies, children, ages, birth weight

History of miscarriages
Preterm delivery, IUGR, abnormal presentation, abnormal lie
PPH
Patients wishes to preserve fertility

Asiri Gamage (ME/2006/034) Batch 19

Sexual & contraceptive Hx

Hx of discomfort, pain or bleeding during intercourse

Use of hormonal contraceptive method. (hyperoestrogenic effect increase the size of the
fibroid)

Past medical Hx

Obesity
DM, HT

Past surgical Hx

Myomectomy

Allergic Hx
Drug Hx

GnRH agonists
OCP

Family Hx

Fibroids

Social Hx

Smoking

Examination
General

Built: obesity is a risk factor for fibroids.

Pallor
Polycythaemia (due to erythropoietin secretion by the fibroid)
Varicose veins

Abdomen Examination
-

She has a symmetrically distended abdomen. No striae, scars or linea nigra. Umbilicus is
normal.
Abdomen is soft and non-tender.
I can feel a mass, which is intra-abdominal & arising from the pelvis.
It is firm and non-tender and compatible with 36 weeks size of a gravid uterus.
It has irregular margins and smooth surface.
It is mobile in the horizontal plane but the mobility is restricted in the vertical plane.
Percussion
Im checking for margins
Im checking for band of resonance (percuss over the lump)

Asiri Gamage (ME/2006/034) Batch 19

Liver is not palpable (if not palpable no need to percuss the upper border)
Spleen
Kidney
Im checking for flank dullness(check only one side)

Summary
There is an intra-abdominal mass arising from pelvis of a size of 30 weeks of gravid uterus. It is firm
and non-tender. It has regular margins, smooth surface. It is mobile in horizontal plane and
restricted mobility in vertical plane. No hepatomegaly or free fluids. No bands of resonance.
DD for symmetrically enlarged uterus

Pregnancy
Adenomyosis
Single submucosal or intramural fibroid
Pyometron
Haematometra

DD for pelvic mass

Pregnancy
Ovarian mass

Discussion
Aetiological factors for fibroids
Familial clustering
Occurrence during the reproductive years.
- Hormonal
- Nullipaity
- Obesity
Types of uterine fibroids
Submucosal
Intra-cavity
Intramural
Subserosal
Pedunculate

Asiri Gamage (ME/2006/034) Batch 19

Macroscopic features of fibroid

-

Spherical multiple smooth appearance

Cut surface: spherical whorled appearance, and bulges out with a pale center.

What is a parasitic fibroid?

-

After torsion of a pedunculated fibroid, it is implanted in the broad ligament and survive
by taking blood supply from the broad ligament.

Investigations

To confirm the diagnosis

- USS abdomen and pelvis
Enlarged uterus
Hypoechoeic masses
Exclude ovarian mass
Image the renal tract (exclude hydronephrosis and hydroureter)
Serial USS To assess the response to medical treatment
Detect complications
- FBC : anaemia

Management

Treatment will depend on the symptoms, age, fertility wishes, and the size
of the uterus.
1) Asymptomatic small fibroids
- Watchful waiting
- Repeat USS and clinical assessment in 6-12 months
2) Fibroids causing menstrual problems
- Menorrhagia
o Menorrhagia tranexamic acid, mefanemic acid, progesterone preparations
(norethiesterone)
-

Polyp , intermenstrual bleeding, subfertility

o Need to do a surgery
o Surgery will depend on the age, fertility wishes of the patient

Preserve fertility

Family is completed but yet not

reached menopause

Myomectomy
Hysterectomy

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Myomectomy

Increased risk of bleeding

Increased risk of blood transfusion
Increased risk of another surgery.

myomectomy

Vaginal

* for submucosal, smooth

fibroids

Abdominal

* Done by hysteroscopy

* open
* laparoscopic

Preperation for myomectomy

Informed written consent (explain about the rare possibility of hysterectomy during the
myomectomy due to haemorrhage. So the consent for hysterectomy also taken.
Reserve 3-4 packs of cross matched blood.
Ix:
FBC Hb, PLT
BU/SE, S.Creatinine
SGOT/PT
ECG
CXR
Overnight fasting
Bowel preparation with Polyethelene glycol (kleen prep)
Premedication : Diazepam 10mg
On-table antibiotics: ampicillin 1g and metronidazole IV 500mg

Complications of myomectomy
1) Anaesthetic complications
- Hypotension
- Bradycardia
- Arrhythmia
- Aspiration
2) Surgical complications
- Primary haemorrhage (surgical site at the time of Sx)
- Injury to bladder
- Reactional haemorrhage
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3) Infections cannula, catheter, chest infections, surgical site

4) 2ry haemorrhage (due to infection)
5) Scarred uterus
Post-op care

Monitor PR, BP, RR (1/4 hr for 2 hours , 1/2hr for 2hrs, 1rhly for 4 hr)
QHT
Observe for bleeding PV
IV fluids 2 units overnight
Pain relief IM pethidine 75mg, diclofenac suppository 100mg SOS
Keep NBM until bowel sounds appear
Mobilize the patient in day 1
Bath on day 1
Check post-op Hb

Medical management of uterine fibroids

Drugs are given with the intention of reducing the size of the fibroid.
GnRH analogues
Reduce the bulk and vascularity of
Danazol
the fibroid.

Indications
- Submucosal fibroids when become < 5cm can be removed hysteroscopically. So to shrink
the fibroid these drugs are given.
- Huge fibroid going for myomectomy, the above drugs are given to shrink the fibroid to
enable Pfannenstiel incision rather than a laparotomy.

Why GnRH analogues cannot be given more than 6 months?

It induces artificial menopause

So that the cardiovascular and other risks increase.

Discuss the place of Oophorectomy at the time of hysterectomy?

Ovaries are removed if there is an indication such as future risk of ovarian CA,
endometriosis.
Early removal of ovaries in a premenopausal woman will lead to early menopause. So has to
be on HRT. HRT has its own complications.
Ovaries can fail earlier than expected after hysterectomy.
Trapped ovarian syndrome
- After hysterectomy ovaries are trapped in by post surgical adhesions.
- This will cause cyclical pain with ovulation.
- When ovaries are trapped around the vagina it will cause dyspareunia
Remnant ovarian syndrome
- After surgery some ovarian tissue is left behind. It can develop follicles
- This residual in pelvic pain /pelvic mass.

Asiri Gamage (ME/2006/034) Batch 19