Uterine fibroid - Case scenarios and Discussion

1. UTERINE FIBROID CASE SCENARIOS & DISCUSSION By Dr. K. Haynes Raja, Junior Resident, Rajah
Muthiah Medical College & Hospital, Annamalai University.

2. PREFACE This presentation is prepared to meet out the undergraduate medical student needs
especially to understand the practical aspects of uterine fibroid and to rapidly revise some important
viva questions. DEDICATION Dedicated to my Great Teachers in the Dept. of Obstetrics & Gynaecology
Dr. Lavanya Kumari and Dr. Sangeereni, Inspiring Friends Dr. Paulin Benedict, Dr. Jeyakumar Meyyappan
and Dr. Hannah Jane and our REVELLIONZ 08’ batch.

3. CASE SCENARIO - 1 A 36 Year old woman has noticed abdominal swelling for 10 months. She has to
wear large clothes and people asked her if she is pregnant, which she finds distressing having been
trying to conceive.

4. She has no abdominal pain and her bowel habit nauseated is normal. when she She eats feels large
amounts. She has urinary frequency but no dysuria or haematuria.

5. Her periods are regular, every 27 days and have always been heavy, with clots and flooding on the
second and third days. She has never received any treatment for her heavy periods.

6. She has been with her partner for 7 years and despite not using contraception she has never been
pregnant.

7. Examination The woman has a very distended abdomen. A smooth firm mass is palpable extending
from symphysis pubis to midway between the umbilicus and the xiphisternum (equivalent to a 32 week
pregnancy). It is non-tender and mobile. It is not fluctuant and it is not possible to palpate beneath the
mass.

8. On speculum examination it is not possible Bimanual to visualise examination the cervix. reveals a
non-tender firm mass occupying the pelvis.

9. Investigations Haemoglobin 6.3 g/dL Mean cell volume 68fl White cell count 4.9 * 109/L Platelets 267
* 109/L

10. Magnetic resonance imaging

11. Diagnosis The woman has a large uterine fibroid. This is causing menorrhagia and hence the
microcytic anaemia from iron deficiency. It is also likely that fibroid is infertility history. accounting for
her

12. DISCUSSION

13. What is the differential diagnosis? Uterine fibroids Pregnancy Full bladder Haematometra/pyometra
Adenomyosis Bicornuate uterus Bilateral tubo-ovarian masses Ectopic pregnancy Pelvic Endometriosis
Endometrial carcinoma Uterine sarcoma Ovarian neoplasms

14. What is fibroid? Fibroid is the commonest benign tumour of uterus Arises from smooth muscle
cells and hence called as Leiomyoma

15. What is the incidence? At least 20% of women in the reproductive age group
16. Whether fibroid is hormone dependant? Fibroid is hormone dependant. Predominantly oestrogen
dependant. Other hormones implicated are growth hormone, human placental lactogen

17. What are the hyperoestrogenic states? Nulliparity Obesity Polycystic Ovarian syndrome
Endometrial hyperplasia

18. Explain the Anatomy & pathology of fibroid? Derived from smooth muscle cell rests, either from
vessel walls or uterine musculature Well circumcised, firm, round tumours with a pseudocapsule
They become soft and cystic when degenerative changes occur They may be single or multiple

19. Explain the Anatomy & pathology of fibroid? Usually arises from body of uterus and less commonly
from cervix The vessels which supply lie in capsule and send radial branches, so innermost part
receives least blood supply The innermost part is the first to undergo degeneration whereas the
outermost part is the first to calcify Cut surface shows whorled appearance

20. What are the synonyms of fibroid? Fibromyoma Leiomyoma myoma

21. What are the types of fibroid?

22. What are the types of fibroid? Uterine Body of uterus Extrauterine Cervix Ovary Subserous (10%)
Broad ligament fibroid Intramural(75%) 1. True (originates in broad Submucous (15%) ligament) 2. False
(arises in uterus & grows into broad ligament)

23. What is parasitic fibroid? Rarely, a extruded fibroid gets detached from uterus and attaches to a
vascular organ (omentum or bowel). This fibroid is called parasitic fibroid or wandering fibroid.

24. CASE SCENARIO - 2 A 32 year old woman complains of increasingly long and heavy periods over the
past 5 years. Previously she bled for 4 days but now bleeding lasts up to 10 days. The periods still occur
every 28 days. She experiences intermenstrual bleeding between most periods but no postcoital
bleeding.

25. The periods were never painful previously but in recent months have become extremely painful with
intermittent cramps. She has had four normal deliveries and had a laparoscopic sterilization after her
last child.

26. Her smear tests have always been normal, the most recent being 4 months ago. She has never had
any previous irregular bleeding or other gynaecological problems.

27. Examination: The abdomen is soft and nontender with Speculum no palpable examination mass.
shows a normal cervix. On bimanual palpation, the uterus is bulky (approximately 8 week size), mobile
and anteverted. There are no adnexal masses.

28. Investigations Haemoglobin 9.2 g/dL Mean cell volume 75 fl White cell count 4.5 * 109/L Platelets
198 * 109/L

29. Hysteroscopy

30. Diagnosis This woman has a Submucosal fibroid. Submucosal fibroids are a common cause of
menorrhagia and can cause, as in this case, intermenstrual bleeding. “Fibroids usually don’t cause
intermenstrual bleeds other than when there is ulceration or it is submucous or cervical fibroid”
31. DISCUSSION

32. What are the clinical manifestations? Menorrhagia, polymenorrhoea, metrorrhagia Infertility,
recurrent abortions Pain – spasmodic dysmenorrhoea, backache, due to pyelitis Pressure symptoms –
bladder, ureter, rectum Abdominal lump or mass protruding at introitus Vaginal discharge As many as
50% women are asymptomatic

33. How do they cause menorrhagia? Increased surface area of endometrium Hyperoestrogenism
Intramural fibroid prevents adequate contraction and retraction of uterus Associated pelvic
inflammatory disease

34. Can fibroids cause polycythaemia? Yes. Huge fibroid compresses renal artery Reduced renal
perfusion Hypoxia activation of Renin- angiotensin aldosterone Renal erythropoietin secretion
increases polycythaemia

35. How do they cause infertility? Cervical fibroid does not allow nidation of sperms Fibroid in
Cornual end does not allow fertilised ovum to enter uterine cavity Increased chances of abortion is
seen with submucous fibroid due to improper implantation Associated infertility Hyperoestrogenic
state can cause

36. When do fibroids present as emergency? When do they cause pain? Acute torsion of a
pedunculated fibroid or degeneration are the main causes of pain Intracapsular haemorrhage Rarely,
a submucous fibroid trying to get expelled from the cervix will produce pain

37. CLINICAL SCENARIO - 3 A 33 Year old women complains of worsening abdominal pain for 4 days. She
is 16 week pregnant in her third pregnancy. She has a 10 year old son, by normal delivery and a
miscarriage 8 years ago. Her pregnancy has been uneventful until now with unremarkable first trimester
scan. an

38. The pain is in the left lower abdomen and is constant and sharp. She has taken paracetamol with
little effect and she is unable to sleep due to pain.

39. She has had no vaginal bleeding and reports urinary frequency since the beginning of the pregnancy.
She is mildly constipated and has no nausea and vomiting. There is no history of trauma. She has not felt
the baby moving yet.

40. EXAMINATION The woman is apyrexial and pulse rate is 125/min, with blood pressure 110/68 mm
Hg. The uterus is palpable just above the umbilicus. There is significant tenderness over the left uterine
fundal region, where it also feels firm. The abdomen is otherwise soft and non-tender.

41. There is voluntary guarding but no rebound tenderness. Bowel sounds are normal. Speculum
examination shows a normal, closed cervix and no blood. The fetal heart beat is heard with hand-held
Doppler.

42. Investigations Haemoglobin 10.6 g/dL Mean cell volume 79 fl White cell count 7.2 * 109/L Platelets
378 * 109/L C-reactive protein <5 mg/L

43. Diagnosis The patient has fibroid undergoing Red degeneration. The uterine size is larger than dates
and the localised uterine tenderness are the important features in making this diagnosis. “Red
degeneration happens exclusively in pregnancy” almost
44. DISCUSSION

45. What are the obstetric complications of fibroid? a) Increased risk of Abortions b) Threatened
preterm labour c) Premature delivery d) Abruptio placenta. e) IUGR f) Intrapartum problems if fibroid
large & located in the lower uterine segment. Cervical fibroid caesarean delivery. g) Interference with
propagation of myometrial contractility uncoordinated uterine contraction or PPH.

46. What are the general complications of fibroid? Degeneration Torsion Inversion of uterus
Capsular haemorrhage Infection Associated endometrial carcinoma

47. What are the secondary changes in fibroid? Atrophy Hyaline/cystic/fatty degeneration
Calcareous degeneration Red degeneration Sarcomatous degeneration

48. What is red degeneration? Occurs most frequently during pregnancy Becomes tense and tender
and causes severe abdominal pain with constitutional upset and fever. Fibroid becomes reddish with a
particular fishy smell. Leucocytosis and raised ESR may be present but this is an aseptic condition
Examination of fibroid shows thrombosed vessels

49. Differential diagnosis and management for red degeneration Differential Diagnosis: Acute
appendicitis Torsion of ovarian cyst Acute pyelonephritis Accidental haemorrhage Treatment:
Self limiting and resolves by itself

50. When do fibroids grow rapidly? In sarcomatous degeneration (not more than 0.5%)

51. What are the investigations to do? General Investigations: Blood investigations: Haemoglobin &
Haematocrit to rule out anaemia Random Blood sugar to know the diabetic status Blood grouping
and Rh typing for transfusion if necessary Serum urea and Creatinine for assessing the renal function
Urine Examination: albumin, sugar and deposit

52. What are the investigations to do? Special investigations: Intravenous pyelogram: To trace the
course of ureter to avoid injury during surgery To rule out renal abnormalities (Eg. pelvic kidney)
Ultrasound abdomen: To know the site and number of fibroid

53. Other investigations Hysterosalpingography and sonosalpingography Hysteroscopy Dilatation

and curettage to rule out endometrial cancer Magnetic resonance imaging

54. When do you treat a fibroid? Indications for treating an asymptomatic fibroid are Infertility
caused by cornual blocking or abortion caused by submucous fibroid Fibroid more than 12 weeks size
or a pedunculated fibroid which can undergo torsion Fibroid causing pressure on ureter Rapidly
growing fibroid If the nature of tumour cant be assessed clinically

55. When do you treat a fibroid? All symptomatic fibroid needs treatment which can be Medical or
surgical

56. How will you manage Medically? Iron therapy for anaemia Surgery is the definitive treatment
modality but the use of medical management is to control menorrhagia and to improve haemoglobin
before surgery Drugs can also be used in women nearing menopause or who are not fit for surgery
Drugs used are low dose OCPs(have minimal oestrogen), mifepristone(RU analogues like leuprolide 486),
GnRH
57. What are the indications for use of GnRH agonists in women with leiomyomas? Preservation of
fertility before attempting conception or preoperative treatment before myomectomy Treatment of
anaemia to allow recovery of normal haemoglobin levels before surgical management or allowing
autologous blood donation Treatment of women approaching menopause in an effort to avoid surgery
Preoperative treatment of large leiomyomas to make vaginal hysterectomy, hysteroscopic resection or
ablation, or laparoscopic destruction more feasible Treatment of women with Medical
contraindications to surgery

58. What are the advantages and disadvantages of GnRH analogues? GnRH analogues causes rapid
shrinkage of tumour and reduces vascularity Hence it decreases the need of surgery in young women
with infertility for cornual blockade It also facilitates vaginal hysterectomy or surgery with minimal
blood loss The main disadvantage is cant be extended beyond 6 months (causes osteoporosis), fibroid
capsule becomes thin and enucleation is difficult, recurrence of fibroid is high.

59. What are the potential indications of surgery? Abnormal uterine bleeding with resultant anemia,
unresponsive to hormonal or other conservative management Chronic pain with severe
dysmenorrhea, dyspareunia, or lower abdominal pressure or pain Acute pain, as in torsion of a
pedunculated leiomyoma or prolapsing submucosal fibroid

60. What are the potential indications of surgery? Urinary symptoms or signs such as hydronephrosis
after complete evaluation Infertility with leiomyomas as the only abnormal finding Recurrent
pregnancy loss with distortion of endometrial cavity Markedly enlarged uterine size with compression
symptoms or discomfort

61. What are the surgical management options? Myomectomy – Laparotomy / Laparoscopy /
Hysteroscopy Hysterectomy – Abdominal / vaginal / laparoscopic Uterine artery embolization

62. What is myomectomy? Removal of fibroids leaving behind the uterus Indicated in infertile
women or a women desirous of childbearing and wishing to retain uterus

63. What are the preoperative requisites of myomectomy? Haemoglobin should be restored In
infertility cases, other causes should have been excluded SIGNATURE FOR HYSTERECTOMY IS
REQUIRED IN DIFFICULT CIRCUMSTANCES Should be performed in preovulatory period Endometrial
cancer to be ruled out by D&C

64. Explain the steps of myomectomy Patient in supine position The abdomen is draped and opened
by pfannenstiel incision Confirm the feasibility of myomectomy Anterior uterine wall is incised and
as many fibroids are removed by tunneling incisions Haemorrhage is controlled by myomectomy
clamp The capsule should be incised and fibroid enucleated with the help of myoma screw Following
enucleation, cavity is obliterated with catgut Release the clamp and secure haemostasis

65. What are the complications of myomectomy? Haemorrhage – primary, secondary and reactionary
Trauma to adjacent structures – ureter, bladder, bowel Infections Adhesions and intestinal
obstruction Recurrence of fibroids and persistent menorrhagia

66. When do you employ laparoscopic myomectomy? Pedunculated fibroid Subserous fibroid not
exceeding 10 cm in size and not more than 4 in number
67. What are the advantages of subtotal hysterectomy over total hysterectomy? Cervix is retained for
sexual function Vault prolapse is less Less surgical morbidity

68. Will you remove ovaries during hysterectomy for fibroid? Ovaries should be retained to avoid
menopausal symptoms in a premenopausal woman provided they look normal.

69. What is panhysterectomy? Removal of uterus, cervix and ovaries

70. What is LAVH? Contraindications for this procedure? LAVH stands for Laparoscope assisted vaginal
hysterectomy. Contraindications are Uterus more than 14 – 16 weeks size Fibroid located in broad
ligament, cervical fibroid and extensive pelvic adhesions, endometriosis

71. What are the complications of hysterectomy? Haemorrhage – Primary, secondary and reactionary
haemorrhage Trauma to adjacent organs – bladder, ureter, bowel and ureter Postoperative infection
and Sepsis Anaesthetic complications Paralytic ileus, intestinal obstruction or chronic abdominal pain
due to postop adhesions Thrombosis, pulmonary embolism, chest infection Burst abdomen, scar,
hernia Residual ovarian syndrome Dyspareunia

72. Explain about uterine artery embolization? Through percutaneous femoral catheterisation,
Polyvinyl alcohol (PVA), gel foam particles or metal coils are injected. This reduces vascularity and
size(40% at 6 weeks and 75% at 1 year) Contraindications: Subserous, submucous and pedunculated
fibroids Infertility and desire of pregnancy

73. Explain about uterine artery embolization?

74. Explain about uterine artery embolization? Advantages: No major surgery, intraoperative
bleeding, adhesions Short hospital stay 75 – 80% women are satisfied

75. Can fibroids grow beyond Menopause? Yes. If the woman is on hormone replacement therapy.

76. Polypectomy