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These are firm, benign tumours of muscular and fibrous tissue, ranging in size from the very small to very large.
TYPES OF FIBROID
Cont..
LABOUR: Malpresentation Uterine inertia Premature labour Dystocia Post partum hemorrhage Manual removal of placenta Difficult caesarean section.
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PURPERIUM : Sub involution. Secondary PPH. Puerperal sepsis. Inversion : fundal submucous fibroid may cause inversion of uterus
Cont..
Tenderness and rigidity over the tumour Sometimes foetal parts are not easily palpated or FHS are not auscultated properly. Size of uterus may be more than the weeks of gestation. Rarely acute symptoms due to red degeneration or torsion can occur.
Cont..
Naked eye appearance of the tumour shows dark red areas with cut section reveals raw-beef appearance often containing cystic spaces. The odour is often fishy. The colour is due to presence of haemolysed red cells and haemoglobin. Microscopically, evidences of necrosis are present. Vessels are thrombosed but extravasation of blood is unlikely.
DIAGNOSTIC TEST
History: Patient may be elderly primi or known case of fibroid, there may be history of infertility or bad obstetric history. Confirmation is commonly and easily done by ultrasound. Blood count shows leucocytosis. The diagnosis is often made only on laparotomy.
TREATMENT
In asymptomatic and uncomplicated patients no treatment is required. Only frequent antenatal visits are mandatory and counseling of patient about complications which may occur. Conservative treatment should be followed. Patient is put to bed. Ampicillin 500 mg capsule thrice daily for 7 days is given. Analgesic and sedative are frequently needed.
Cont..
In complicated and symptomatic patient treatment is given according to complication. In impaction one should manually remove the impaction. In retention of urine self retaining catheterization should be done. In red degeneration treatment is always conservative i.e. bed rest, higher antibiotics, analgesics, and sedation.
Cont..
Torsion of subserous pedunculated fibroid It causes acute abdomen and laparotomy with myomectomy is indicated.
RISK FACTORS
Human papillomavirus (HPV) infection Sexual behaviour Smoking. Pregnancy Social class Cervical smear tests
TYPES
Squamous cell carcinoma Adenocarcinoma.
DIAGNOSIS
Cont..
Colposcopy allows the cervix to be visualised with a powerful light source and examined microscopically to reveal the extent of the lesion. Staging : Same as in non-pregnant patient. But wrong staging is possible due to increased vascularity & softening of pregnant state.
MANAGEMENT
DURING PREGNANCY CIN : Only follow up during pregnancy, definitive treatment 6 weeks after delivery to rule out invasion colposcopy detected biopsy is taken. Micro invasive : Cone biopsy is done to rule out deeply invasive cancer. If cone biopsy shows micro invasion than definitive treatment 6 week after delivery.
INCIDENCE
Simple cysts : 1 in 50 to 1 in 80. Benign ovarian tumours : 1 in 1000 to 1 in 1500 Ovarian carcinoma : 1 in 12000 to 1 in 50000 (rare)
DIAGNOSIS
In early pregnancy on P/V examination palpable mass in adnexal region or pouch of douglas separate from uterus may be felt. USG in first trimester (TVS) is very helpful for diagnosis. USG also helps in differentiating benign from malignant tumour by tumour MRI if available is very helpful in diagnosis of dermoid.
MANAGEMENT
Early pregnancy Late pregnancy DURING LABOUR
DURING PUERPERIUM
On occasion, the diagnosis is made following delivery. The tumour should be removed as early in puerperium as possible. Following operation the specimen is sent for histological examination.
When the long axis of the uterus is directed backwards during pregnancy, the uterus is said to be retroverted.
ETIOLOGY
Presence of factors preventing spontaneous rectification.They are : Old adhesions, pelvic tumours & projecting sacral promontory with unusually deep concave sacrum preventing upward displacement of uterus. Idiopathic.
UNFAVOURABLE:
In the minority, spontaneous rectification fails to occur between 12-16 weeks. The developing uterus gradually fills up the pelvic cavity and becomes incarcerated.
EFFECTS ON PREGNANCY
Consequences of incarcerated gravid uterus Urethra : Due to upward and forward displacement of cervix & stretching of anterior vaginal wall, there is elongation & distortion of urethra occurs.
Bladder : Due to acute retention of urine, bladder becomes markedly distended reaching up to umbilicus. Long standing cases edema of bladder wall and cystitis occur
Uterus : Sometimes a portion of the uterus remains imprisoned in the pelvis, while remainder part enlarges and extends higher in abdomen called sacculation of uterus.
With sacculation of uterus following can occur Abortion Preterm labour Malpresentation Nonengagement of head & Rupture of uterus during labour.
SIGNS P/A :- tense tender swelling (distended bladder) reaching up to umbilicus, which disappears after catheterization. Per rectum : Confirms the retroverted position of uterus.
P/V :- Cervix often difficult to feel or felt higher up due to forward and upward displacement. On bimanual examination soft, pulsatile gravid uterus felt posteriorly in pouch of douglas. As uterus becomes impacted it is often difficult to pass a finger beyond the swelling.
DIAGNOSTIC TEST
The diagnostic features of retroverted gravid uterus are History of amenorrhoea Non accessibility of the cervix with its upward and forward direction Swelling is due to full bladder Ultrasonography
TREATMENT
Before the symptoms of incarceration: In case of symptoms of threatened incarceration, with retroverted gravid uterus, following measures are undertaken. Patient is asked to empty her bladder frequently. Patient is asked to lie down in prone or semi prone position.
After the symptoms of incarceration If spontaneous correction fails Manual correction by pushing the uterus
In obstinate cases, when the above method fails due to adhesions, laparotomy may have to be done. Adhesiolysis is to be attempted failing which termination of pregnancy may be indicated. In diagnosed cases of anterior sacculation of the uterus, delivery by Caesarean section is the method of choice.
Pregnancy with 1st degree uterine prolapse with mild cystorectocele is common. Pregnancy, is, however, unlikely when the cervix remains outside the introitus and continuation of pregnancy in 3rd degree prolapse is an extremely rare event
Vaginal discharge may be copious and decubitus ulcer may develop when the cervix remains outside the introitus. There is chance of incarceration, if the uterus fails to rise above the pelvis by 16th week of pregnancy.
LABOUR: Early rupture of membranes. Prolonged labour due to delayed dilatation of cervix and due to sagging cystorectocoele. Cervical dystocia. PUERPERIUM : Puerperal sepsis. Subinvolution.
TREATMENT
If the cervix is outside the introitus
The cervix is to be replaced inside the vagina and is kept in position by a ring pessary The patient is to lie in bed with the foot end raised by about 20 cm.
To relieve oedema and congestion of the prolapsed mass, it should be covered by gauze soaked with glycerine and acriflavine. Perineal exercises. The treatment is continued until 18-20th week of pregnancy till the prolapsed mass is reduced in size and replaced inside the vagina.
If reposition is not possible and there is incarceration, termination of pregnancy may be indicated. If the cervix remains outside the introitus even in the later months, it is preferable to admit the patient at 36th week.
DURING LABOUR
The patient should be in bed, not only to prevent early rupture of the membranes but also to facilitate replacement of the prolapsed cervix inside the vagina. Intravaginal plugging soaked with glycerine and acriflavine not only helps in reduction of cervical oedema but also facilitates its dilatation.
Prophylactic antibiotic, in cases of premature rupture of the membranes or when the cervix remains outside, should be administered. Hylase injection in the substance of cervix to soften it can be tried. It helps in dilatation
Manual stretching of the cervix or pushing up the cystocele or rectocele past the presenting part during uterine contractions facilitates progressive descent of the head
If the head is deeply engaged with the cervix remaining thin but undilated, delivery maybe facilitated by Duhrssen's incision at 2 and 10 O'clock positions followed by ventouse extraction or forceps application. If the head is high up and/or the cervix remains oedematous, thick or undilated Caesarean section is a safe procedure
Surgery for prolapse is contraindicated in antepartum and post partum period. Definitive surgery is done only after 6 months of delivery and preferably after the patient starts menstruating. If there is history of sling surgery, some prefer LSCS to prevent recurrence after delivery but usually vaginal delivery is allowed.