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1. Case presentation(AUB) Dr. Reddymalla Divya Final year JR Department of OBG Osmania medical college Nilofur hospital, Hyderabad

2. A 30 yrs Mrs. sk. Rafia, wife of Mohammed Akhtar, who is a housewife by occupation, resident of Kurnool and belonging to lower socioeconomic class according to Modified Kuppuswamy scale came to the NILOUFER HOSPITAL OPD with a complaint of Heavy Menstrual Bleeding (HMB) for 1year. Chief complaints: Heavy menstrual bleeding for 1 year Pain in lower abdomen for 6 months Generalised weakness and fatigue for 2 months. LMP: 21/11/25

3. History of presenting illness She was apparently asymptomatic and had normal cycles until 1 year ago. From then she had an increase in frequency, flow and quantity of menstruation. Current MH : 10days/15days/HF (5-6 pads for day) associated with dysmenorrhea and passage of clots. She has pain in lower abdomen for 6 months, starts 1-2 days before menstruation and subsides after the end of menstruation. Fatigue and generalized weakness noted, subsides on taking rest.

4. No h/o preceding amenorrhea, inter menstrual bleeding or post coital bleeding. No h/o dyspareunia. No h/o foul smelling discharge P/V and fever. No h/o any drug intake. No h/o breathlessness or palpitation. No h/o excessive heat or cold intolerance, constipation, weight gain or loss. No h/o increased frequency of micturition or feeling of incomplete evacuation of bladder. No h/o easy bruisability, bleeding from nose, gums or any other site. No h/o chronic cough, evening rise of fever and night sweats. No h/o weight loss or loss of appetite. No h/o previous blood transfusions.

5. Menstrual history Menarche at 13yr s Previous Regular cycles : 3-4days/28days/Normal flow with no clots / dysmenorrhoea - absent Currently since 1 year : 10days/15days/HF. Ass with clots and changes 5-6 pads per day/ dysmenorrhea present No similar complaint in the past

6. Obstetric history P4L4 with previous NVDs Tubal ligation done 8years back LCB : 9 yrs No obstetrics complications noted Marital history Marital life 14 years No h/o of any contraceptive usage

7. Medical history Not a k/c/o HTN/DM /Thyroid abnormalities /CVA /CAD /Stroke /Epilepsy /Cancer Surgical history H/o Lap appendicectomy 3 years back Family history No h/o HTN/DM /Thyroid abnormalities /CVA /CAD /Stroke /Epilepsy /Cancer

8. Personal history Mixed diet, Normal appetite No addictions Bowel and bladder habits Regular Sleep pattern normal

9. General physical examination Patient was conscious, co-operative and well oriented to time, place and person, comfortably sitting Moderately built and moderately nourished Gait was normal Ht : 156 CMs , Wt : 62 kg , BMI : 27.5 Pallor : ++ No icterus, cyanosis, thyroid swelling, JVP not raised, clubbing, koilonychia No pedal oedema No thyromegaly No lymphadenopathy B/L Breast- normal, no lump or discharge

10. Vital data Temperature : Afebrile PR: 88 beats/min, regular RR:16 cycles/min BP:120/80 mm of Hg SPO₂: 98% on room air

11. SYSTEMIC EXAMINATION CVS : S1&S2 heard, no audible murmurs RS : B/L normal vesicular breath sounds ,no added sounds CNS : no focal neurological deficits

12. Per abdomen Inspection: Contour was normal, all quadrants moving equally with respiration, umbilicus inverted, no engorged veins , visible pulsations or peristalsis Sub umbilical laparoscopic appendicectomy scar seen Palpation : All the inspectory findings are confirmed No tenderness, guarding, or rigidity No palpable organomegaly No palpable masses or hernias. Percussion: Tympanic note present over most of the abdomen (due to gas in intestines). No shifting dullness or fluid thrill (indicating absence of ascites). Auscultation: Normal bowel sounds present No bruit over abdominal aorta or renal arteries. No venous hum or friction rubs.

13. Local examination External Genitalia: Healthy Per speculum : Cervix hypertrophied, circum oral erosions present Vagina healthy Bimanual pelvic examination : Uterus: Anteverted, enlarged to 12-14wks size, firm consistency, side to side mobility +,non-tender, mobile, fornices free ,no fornicial tenderness.

14. SUMMARY A 30 yrs Mrs. sk. Rafia,P4L4 with previous NVDs, with tubectomiesed status came with complaints of heavy menstrual bleeding for 1 year, pain in the lower abdomen for 6 months associated with generalized weakness and fatigue for 2 months. O/E: Pallor ++ On bimanual examination : Uterus enlarged to 12-14 wks. size, mobile, non tender, fornices free and no fornicial tenderness Provisional diagnosis: 30 yrs,P4L4 with previous NVDs and tubectomy done 8yrs back with heavy menstrual bleeding with moderate anemia(possibly AUBL)

15. LAB EVALUATION Complete blood count: Hb-9.1,TLC-7400, Platelets-3.48 TFT: T3-127,T4-8.5,TSH-1.2 Blood sugar: Fating-88,PLBS-110 LFT, RFT: Normal Viral markers: NR Blood group: A+VE PAP Smear: Negative for intraepithelial lesion/malignancy with dense inflammation Endometrial sampling: Deferred I/V/O ET< 2mm

16. USG pelvis: Uterus bulky, anteverted, ET measuring 3-4mm,evidence of well defined large heterogeneously hypoechoic lesion measuring 65*58*66 mm in the posterior myometrium with peripheral vascularity indenting the ET anteriorly likely posterior intramural fibroid. B/L ovaries normal.

17. MRI pelvis: Large bilobed intramural well defined mass in the left posterior upper uterine body showing rounded sub endometrial component and flattened sub serosal component causing distortion of endometrial cavity. Uterine fibroid FIGO classification 2-5. Uterus enlarged 107*70*87 mm. ET<2mm. Cervix and endocervical canal normal.

18. Thank you