GYNAECOLOGY CASE SYMPTOMATIC FIBROID -1.pptx

An overview of uterine fibroid

1. GYNAECOLOGY CASE SYMPTOMATIC UTERINE FIBROIDS: ABDOMINAL MYOMECTOMY

2. PATIENT’S BIODATA NAME ​​​​​​ : ​​ Mrs. Kaka Indi Muhammad AGE ​​​​​​ : ​​ 43 years HOSPITAL NO ​​​​ : ​​ 792503 ADDRESS ​​​​​ : ​​ Ngomari Airport, Maiduguri OCCUPATION ​​​​ : ​​ House wife MARITAL STATUS: Widow ETHNIC GROUP ​​​​ : ​​ Kanuri RELIGION ​​​​​ : ​​ Muslim PARITY ​​​​​ : ​​ P4 +0 A4 LMP ​​​​​​ : ​​ 15 th November, 2024 LCB ​​​​​​ : ​​ 2011 DATE OF ADMISSION ​​​ : ​​ 22 nd November, 2024 DATE OF OPERATION ​​​ : ​​ 25 th November, 2024 DATE OF DISCHARGE ​​​ : ​​ 29 th November, 2024

3. PRESENTING COMPLAINT Heavy menstrual bleeding of 3 years duration. Abdominal pain of 2 years duration.

4. HISTORY OF PRESENTING COMPLAINT Patient was in her usual state of health until 3 years prior to presentation when she started experiencing heavy menstrual bleeding associated with dysmenorrhea, passage of clot, she uses about 3 fully soaked pads daily as against the previous 2 barely soaked pads. About a year after the onset of her symptoms, she started having lower abdomen pain which was insidious in onset, colicky in nature, radiates to the lower back and worsened progressively. There was no known aggravating factor, however, it was said to be relieved by over the counter pain medications, whose details could not be ascertained. Pain was severe enough to prevent her from standing upright and undertaking her daily activities. No postcoital or intermenstrual bleeding, palpitation, headache, dizziness, easy fatiguability. There was no associated history of abdominal distention, constipation, passage of loose stool, no history of vomiting or dysuria. But there was history of in creased urinary frequency. No history of similar illness in the past.

5. GYNAECOLOGICAL HISTORY She attained menarche at the age of 16 years and menstruates for 5-7 days in regular cycles of 28-30 days with associated dysmenorrhea. However, no history of dyspareunia, no contraception use. Patient was aware of Pap smear, but never had it done, she was therefore adequately counselled.

6. PAST OBSTETRIC HISTORY 1 st pregnancy was in 2005, carried to term , supervised at nursing home, pregnancy labour and peuperium (PLP) were uneventful, had vaginal delivery of a live female neonate who is alive and well 2 nd pregnancy was in 2007 carried to term, also supervised at nursing home, had vaginal delivery of a live male neonate who is alive and well 3 rd and 4 th pregnancies were in 2008 and 2012 respectively, both carr ied to term and supervised in a private hospital, PLP uneventful, had vaginal delivery of live male neonates whom are all alive and well

7. PAST MEDICAL & SURGICAL HISTORY S he is a known hypertensive, regular with medications She is not a known diabetic, sickle cell disease or asthmatic patient. No previous history of surgery, hospitalization or blood transfusion.

8. FAMILY & SOCIAL HISTORY No family history of similar illness. There was history of hypertension in mother, no family history of diabetes mellitus, sickle cell disease or asthma. Patient is a widow, holds a diploma certificate and works at PHC (primary health center). She was married in a monogamous setting until the death of her husband, time and cause of death was not documented. She neither smokes nor consumes alcoholic beverages.

9. DRUG ALLERGY She has no known drug allergy.

10. EXAMINATIONS GENERAL PHYSICAL EXAMINATION She was a Middle-aged woman , fully conscious and alert, afebrile, with axillary temperature of 36.8C, not pale, anicteric, acyanosed , not dehydrated, no peripheral lymphadenopathy, no pedal oedema. Weight – 85kg H eight –1.5m BMI – 37.7Kg/m 2

11. VTAL SIGNS Blood Pressure – 120/90 mmHg Respiratory Rate – 18 cycles/min Pulse Rate – 80 beats/min Temperature – 36.6 c

12. ABDOMINAL EXAMINATION The abdomen was full, moved normally with respiration, soft, no area of tenderness, uterus was 16 weeks size, liver and spleen not palpable, kidneys not ballotable.

13. RESPIRATORY EXAMINATION Her respiratory rate was 20 cycles per minute, regular and the lung fields were clinically clear.

14. CARDIOVASCULAR EXAMINATION Her pulse rate was 82 beats per minute, regular and of normal volume. Her blood pressure was 120/80mmHg. First and second heart sounds heard and there were no cardiac murmurs.

15. PELVIC EXAMINATION The external genitalia appeared normal. Cervix was posterior,2cm long, firm, OS was closed. The uterus was approximately 18 weeks size on bimanual examination, anteverted, with multiple nodular masses on the anterior and posterior surface, no adnexal mass or tenderness. Examining gloved finger stained with normal vaginal discharge.

16. RECTAL EXAMINATION There was good perianal hygiene The anal verge was normal with normal sphincteric tone. The rectum was empty and the rectal mucosa was freely mobile. A bimanual exam revealed a non-tender, firm and irregular mass palpated along the anterior rectal wall.

17. CLINICAL IMPRESSION Symptomatic Uterine fibroid.

18. INVESTIGATION & RESULTS FBC ​ PCV ​​​​ - ​ On presentation ( 34%) ​ WBC ​​​​ - ​ 4.3 x 10 9 /L ​ Neutrophils ​​​ - ​ 55% ​ Lymphocytes ​​​ - ​ 36% ​ Eosinophils ​​​ - ​ 2% ​ Monocytes ​​​ - ​ 7% ​ Plateletes ​​​ - ​ 375,000/mm3 Blood group ​​​​ - ​ AB Rhesus ‘ D ’ positive Electrolytes, urea and creatinine ​ - ​ Normal Urinalysis ​​​​ - ​ Normal

19. PELVIC USS ​ The uterus is bulky with ​​​​​​​ AP diameter of 8.3 cm. There are w ell circumscribed hypoechoic masses of varying sizes with echogenic margins involving both anterior and posterior uterine walls. Largest measuring 5.9 x 4.8 cm in diameter. Both ovaries appeared normal. This was consistent with multiple uterine fibroid. ​​​​​​

20. PREOPERATIVE PREPARATIONS The patient was then appropriately counselled on fibroid, its consequences and the options of management. She opted for open abdominal myomectomy and was planned for an abdominal myomectomy She was asked to provide 2 units of cross matched blood for the surgery. Patient was reviewed by anesthetist and was said to be fit for anesthesia; ASA 1

21. OPERATIVE FINDINGS ​ Multiple (25) uterine myomas on the anterior and posterior uterine walls largest measuring 6x4cm Grossly normal tubes and ovaries Estimated blood loss @ 200mls.

22. POST OPERATIVE MANAGEMENT Her recovery from anesthesia was satisfactory. Her vital signs remained stable and normal. Her urinary output was adequate. Urine was clear about 100mls. IV infusion of 5% dextrose in water 1L 8 hourly for 24 hours, with the return of bowel activity. Post operative analgesia was provided with IM pentazocine 60mg 8 hourly for 24 hours. IV ceftiazone 1g BD. × 48 hours IV Metronidazole 500mg 8 hourly × 48 hours IM Diclofenac 75mg 12 hourly × 48hours The parenteral medications were discontinued and converted to tablets Tabs amoxiclav 625mg B.D × 1/52 Tabs Metronidazole 400mg 8 hourly × 1/52 Tabs Diclofenac 50mg 8 hourly × 5/7 Tabs PCM 1g 8 hourly × 3/7

23. The indwelling urethral catheter was removed on the first post operative day when she was encouraged to ambulate. Her Packed cell volume(PCV) was 32% on the second post operative day and the wound was cleaned with well apposed edges. The surgical wound was redressed. On the 4 th day, she was found to be stable and was discharged home on her oral medications. She was requested to come for stitch removal on the 7 th post operative day

24. FOLLOW-UP CLINIC (13/12/2024) She was well and had no complaints. She was neither pale nor jaundiced. Her blood pressure was 120/80mmHg and PCV was 34%. The abdominal wound had healed by primary intention.

25. HISTOPATHOLOGY REPORT On macroscopy, sample showed 23 firm grey nodules, with the largest measuring 5 x 3.5 x 2.5cm and the smallest measuring 0.5 x 0.5 x 0.2cm. The cut sections were similar and revealed grey white whorled appearance. The microscopic examination showed leiomyomata composed of interlacing bundles of smooth muscle cells which had oval to elongated nuclei with moderate eosinophilic cytoplasm with tapered ends. There were areas of hyalinization, dystrophic calcification and infarction noted. There was no evidence of malignancy. DIAGNOSIS – Uterine Masses - Leiomyomata.

26. SUMMARY A 43 year old P4 +0 A4 who presented with heavy menstrual bleeding and abdominal pain, she was managed as a case of symptomatic uterine fibroid and subsequently had abdominal myomectomy with satisfactory post operative recovery

27. Outline Introduction Epidemiology Risk factors Types of uterine fibroid Clinical presentation Investigations Treatment Complication Conclusion References

28. LEIOMYOMATA ​ ​ Leiomyomata, commonly called uterine fibroids, are oestrogen -dependent benign neoplasms of the uterus that arises from the smooth muscles of the myometrium Fibroids are one of the important causes of menorrhagia in women of reproductive age Fibroids are the most common gynaecological disorder classically requiring surgery when symptomatic

29. EPIDEMIOLOGY They constitute the commonest tumors commonly found in women of reproductive age with a prevalence varying from 20-50 % of women depending on age, ethnicity, parity and method used to assess their presence Studies from Nigeria showed that the incidence of fibroids is 6.4% in Abuja, 3.1% in Kano, 7.8% in Zaria, 8.4% in Ilesa, 9.5% in Ile-Ife , 9.8% in Lokoja, and 9% in Maiduguri

30. R ISK FACTORS Risk factors for uterine fibroid in Mrs. K. I . M. were; Age (Commonly 3 rd & 4 th decade) Race ( 3-9 times more common in blacks than in caucasian women) Obesity (Increased conversion of androgens to oestrogen ) Hypertension Other risk factors not seen in her are: Nulliparity No use of Contraceptives or smoking , both of which are protective against the development of uterine fibroids. . As women who smoked have lower risk of developing uterine fibroid due to decreased oestrogen sensitivity compared to non-smokers

31. Types of uterine fibroid ANATOMICAL TYPES OF FIBROID Intramural (70%) Subserous or Pedunculated (15%) Submucous (5%) Cervical (1-2%) The patient had intramural and subserous uterine fibroids.

32. CLINICAL FEATURES The clinical features are variable, depending on their anatomic type, site and size. Majority are asymptomatic (75%) especially when small. Symptoms consistent with uterine fibroid in this patient include: menorrhagia, dysmenorrhea and lower abdominal pain, pressure symptoms (urinary frequency) Pain with uterine fibroids may result from secondary changes including degeneration, infection, atrophy, necrosis, vascular, or sarcomatous changes. Hyaline degeneration is the most common degenerative change accounting for 65%, which was seen in Mrs. K. I. M. Other degenerative changes not seen in Mrs K. I. M. include cystic, fatty, and red (cancerous) degeneration, Other symptoms include dyspareunia, leg swelling, haemorrhoid .

33. Examination General physical examination ; Palor Abdominal examination Abdominal mass with or without tenderness Vaginal examination Bimanual examination will also help in determining a uterine mass Other systemic examination

34. Investigations Full blood count Electrolytes, urea and creatinine Urinalysis Grouping and crossmatching Pregnancy test Ultrasound scan MRI Hysteroscopy

35. INVESTIGATIONS ULTRASOUND SCAN Used to assess size of uterus, Number, size & location of fibroids To assess endometrial thickness To look for adnexal pathology To differentiate adenomyoma from fibroids.

36. DIAGNOSIS Following history, examinations and investigations

37. TREATMENT Treatment for fibroid is based on the following; Patient ’ s a ge Severity of symptoms Desire for future fertility Patient’s preference Treatment options include; Conservative or expectant management Medical management Surgical management Radiological management

38. TREATMENT Expectant Management Indicated in asymptomatic fibroid in post menopausal age group Low dose Combined Oral Contraceptive pills: causes endometrial atrophy and decreased prostaglandin production. It reduces bleeding. Medical Management: Not curative, only temporary therapy. Commonly used drugs include; NSAIDs e.g Mafenamic acid Tranexemic acid Low dose Combined Oral Contraceptive pills Newer drugs include: Selective estrogen receptor modulators e.g Raloxifene

39. TREATMENT Surgical Management Myomectomy Hysterectomy Surgery is definitive treatment for fibroid. Indication for surgical management of fibroid Symptomatic fibroid – Menorrhagia, pain, pressure symptoms, anemia due to blood loss Failure to respond to medical management Infertility Patient preference

40. TREATMENT Myomectomy- is a term used for the removal of the fibroid alone while preserving the uterus. Which was the procedure Mrs. K. I. M. had. It is usually indicated for women who: desire to retain their uterus (Just like Mrs. K. I. M. who has not completed her family size) Younger age group When invitro feralization is indicated (if fibroid distorts uterine cavity)

41. COMPLICATIONS EARLY; Bleeding leading to anaemia W ound infection, B urst abdomen, P rolonged hospital stay LATE; P ostoperative adhesions, Reoccurrence, R isk of rupture of myomectomy scar in labour . Mrs. K. I. M. did not develop any of the complications because efforts were made to avoid endometrial breach, reduce blood loss and obliterate all dead spaces at surgery.

42. Antibiotics and analgesics were administered, E vacuation of blood clot from the pelvis and less tissue handling and peritoneal lava r ge were applied as measures to reduce the risk of infection and pelvic adhesions ​ She was also counselled on the possibility of recurrence as the recurrence rate of fibroids is about 30-50%.

43. CONCLUSION Uterine fibroid is a common uterine tumor in women of reproductive age. Treatment depends on the presenting symptoms and desire for fertility and it ranges from expectant to medical and surgical interventions. Early detection and personalized care are crucial for managing fibroids effectively, ensuring the best possible outcome for affected women.

44. REFERENCES 1. Obed JY, Bako B, Usman DJ. Uterine fibroids: risk of recurrence after myomectomy in a Nigerian population. Arch Gynecol Obstet. 2011:283; 311-315. 2. Michal Ciebieraa Uterine Fibroids: current research on novel drug targets and innovative therapeutic strategies Volume 28. Issue 8, 2024. 3. Yangq , Cie Biera , Bariani M.V etal . Comprehensive review of Uterine fibroids: Developmental origin, pathogenesis and treatment. Endocr Reviewed 2022 4 . Bosch TV. Benign disease of the Uterus In: Edmonds DK (Eds) Dewhurst ’ s Textbook of Obstetrics and Gynaecology for Postgraduates, 9th edition. Blackwell Publishing, London. 2018: 823-834. 5. Mohammed Z, Yakasai IA &Abdulrahman A. Surgical Management of Uterine Fibroids at Aminu Kano Teaching Hospital, Kano, Nigeria; A 5 year review. Trop J Obstect Gynaecol , 30(2), August 2013. 6. Mairiga AG., Bako BG., Kawuwa MB. Uterine fibroids: A 5-year clinical experience at the University Teaching Hospital Maiduguri. BOMJ 2006; 3(2): 3-6. 7 . Dougherty MP, Decherney AH. Benign disorders of the uterine corpus. In: Decherney AH, Nathan L, Laufer N, Roman AS (eds). Current Obstetrics and Gynaecology Diagnosis and Treatment. 12th edition. McGraw Hill, 2019: 421-446. 8 . Fasubaa OB, Sowemimo OO, Ayegbusi OE, etal . Contributors of uterine fibroid to infertility at Ile-Ife, South Western Nigeria. Trop J Obstect Gynaecol , 2018; 38, 266 9. Geidam AD, Lawan ZM, Chama C, Bako BG. Indications and outcome of abdomenal myomectomy in University of Maiduguri Teaching Hospital: Review of ten years. Nigeria MedJ . 2011; 52(3): 158-162. 10. Setchell T, Miskry T. The Uterus. In Setchell EM, Shepard JH. (Eds) Shaw ’ s textbook of operative Gynaecology 7th edition, EIH Unit Ltd. Press. Manesar. 2013:158-191. 11 0bed JY, Bako B, Kadas S, Usman JD, Kullima AA, Moruppa JY. The benefit of myomectomy in women aged 40 years and above: Experience in an urban teaching hospital in Nigeria. Niger Med J 2011;52: 158-62.