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Myoma Uteri OB-GYN Rotation Quirino Memorial Medical Center

Myoma Uteri OB-GYN Rotation Quirino Memorial Medical Center. Lazaro, Tonyrose C. San Beda College of Medicine. General Data. A.E. 44 y/o female G3P3 Admitted for the second time at QMMC - June 13,2011. Chief Complaint. Vaginal Bleeding. History of Present Illness. 2yrs PTA

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Myoma Uteri OB-GYN Rotation Quirino Memorial Medical Center

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  1. Myoma UteriOB-GYN Rotation Quirino Memorial Medical Center Lazaro, Tonyrose C. San Beda College of Medicine

  2. General Data • A.E. • 44 y/o female • G3P3 • Admitted for the second time at QMMC - June 13,2011

  3. Chief Complaint • Vaginal Bleeding

  4. History of Present Illness 2yrs 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

  5. 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

  6. 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

  7. 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

  8. Transvaginal ultrasound Myoma Uteri (intramural with submucosal component) • Endometrial biopsy Proliferative Endometrium with necrosis and chronic inflammation

  9. 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

  10. 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.

  11. 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

  12. On the day of admission • Hgb stable • Glucose controlled • Claimed ready for surgery • Scheduled for OR • admitted

  13. OB-GYN History • LMP: April 25, 2011 • G3P3 (3003)

  14. Menstrual History • Menarche- 13 y/o • interval 25-28 days • Lasting 3-4days • Using 3-4 soaked pads/day • With occasional dysmenorrhea

  15. Sexual History • First intercourse- 29y/o • Only 1 partner (husband) • No contraceptive used • No STD • No recent sexual activity

  16. 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.

  17. Family Medical History • No history of Diabetes Mellitus, Lung diseases, kidney diseases, cardiac diseases, and psychiatric disorders.

  18. Personal/Social History • widow • Lives in a single abode with her 3 children. • non-smoker • non-alcoholic beverages drinker • denied illicit drug used

  19. 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

  20. 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.

  21. 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

  22. 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

  23. 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.

  24. ADMITTING DIAGNOSIS • G3P3 (3003) Abnormal Uterine Bleeding, Myoma Uteri, Proliferative Endometrium, s/p LTCS 3x malpresentation and repeat

  25. Plan • Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAHBSO)

  26. Course in the Wards/Pre-operative Work ups COMPLETE BLOOD COUNT (6/13/2011)

  27. BLOOD CHEMISTRY (6/15/2011)

  28. COAGULATION PANEL (6/15/2011)

  29. CHEST X-RAY (6/15/2011) • Clear lungs. No other significant findings.

  30. 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

  31. PRE-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

  32. OPERATION/PROCEDURE PERFORMED (6/17/2011 at 7:00am): TAHBSO + ADHESIOLYSIS/GEA

  33. 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

  34. 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.

  35. 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

  36. Discussion

  37. Uterine Leiomyoma • “fibroids” • “uterine myomas” • benign proliferations of smooth muscle cells of the myometrium.

  38. 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

  39. 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.

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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.

  45. Diagnostic Evaluation • Pregnancy test- all women • History and PE • Ultrasound (pelvic/transvaginal) – MC means of diagnostics

  46. 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

  47. Treatment depends on the patient’s • Age • Pregnancy status • Desire for future pregnancies • Size and location of the fibroids

  48. 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.

  49. 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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