Transcript BLOOD CHEMISTRY (6/15/2011)

Myoma Uteri
OB-GYN Rotation
Quirino Memorial Medical Center
Lazaro, Tonyrose C.
San Beda College of Medicine
General Data
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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
– (+) 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
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
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
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
• Transvaginal ultrasound
Myoma Uteri (intramural with submucosal
component)
• Endometrial biopsy
Proliferative Endometrium with necrosis
and chronic inflammation
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
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.
• 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
On the day of admission
– Hgb stable
– Glucose controlled
– Claimed ready for surgery
– Scheduled for OR
– admitted
OB-GYN History
• LMP: April 25, 2011
• G3P3 (3003)
G1
1995
CS
Private hosp at Post term/ Breech
Montalban
presentation
No
fetomaternal
complications
G2
1997
CS
Montalban
Term
No
fetomaternal
complications
G3
1999
CS
Montalban
Term
No
fetomaternal
complications
Menstrual History
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Menarche- 13 y/o
interval 25-28 days
Lasting 3-4days
Using 3-4 soaked pads/day
With occasional dysmenorrhea
Sexual History
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First intercourse- 29y/o
Only 1 partner (husband)
No contraceptive used
No STD
No recent sexual activity
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.
Family Medical History
• No history of Diabetes Mellitus, Lung diseases,
kidney diseases, cardiac diseases, and
psychiatric disorders.
Personal/Social History
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widow
Lives in a single abode with her 3 children.
non-smoker
non-alcoholic beverages drinker
denied illicit drug used
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
• 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.
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
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
Abdomen: globular, uterus enlarged to
18x18x10 cm, doughy, slightly movable, nontender
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.
ADMITTING DIAGNOSIS
• G3P3 (3003) Abnormal Uterine Bleeding,
Myoma Uteri, Proliferative Endometrium, s/p
LTCS 3x malpresentation and repeat
Plan
• Total Abdominal Hysterectomy and Bilateral
Salpingo-Oophorectomy (TAHBSO)
Course in the Wards/
Pre-operative Work ups
COMPLETE BLOOD COUNT (6/13/2011)
RBC
Hemoglobin
Hematocrit
Platelet
WBC
Neutrophils
Lymphocytes
Eosinophils
Monocytes
RESULTS
4.31
113
0.38
335
7.8
0.439
0.197
0.312
0.049
REFERENCE RANGE
4.20-5.40 x10^12/L
120-160 g/dL
0.36-0.47 %
150-450 x10^9/L
5-10x10^9/L
0.500-0.700
0.200-0.700
0.000-0.060
0.000-0.020
BLOOD CHEMISTRY (6/15/2011)
TEST NAME
RESULT
REFERENCE RANGE
Glucose
5.52
4.1- 5.9
Creatinine
45.11
53-115 umol/L
SGPT
9.3
7-35 u/L
Blood Urea Nitrogen
2.53
2.50-6.40 mmol/L
302.82
155-428 umol/L
Cholesterol
4.74
0-5.20 mmol/L
Triglycerides
1.34
0-2.26 mmol/L
HDL Cholesterol
0.74
0-1.5 mmol/L
LDL
3.4
26-4.1 mmol/L
VDLD
0.61
--1.0mmol/L
135 low
136-145 mmol/L
Potassium
3.8
3.5-5.1 mmol/L
HbA1C
5.1
4.8-6.0%
Uric Acid
Sodium
COAGULATION PANEL (6/15/2011)
Parameters
Results
Reference range
Prothrombin
time (PT)
APTT
10.6
10-14 secs
40.3
28-44 secs
CHEST X-RAY (6/15/2011)
• Clear lungs. No other significant findings.
MEDICATIONS
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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
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
OPERATION/PROCEDURE
PERFORMED (6/17/2011 at 7:00am):
TAHBSO + ADHESIOLYSIS/GEA
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
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.
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
Discussion
Uterine Leiomyoma
• “fibroids”
• “uterine myomas”
• benign proliferations of smooth muscle cells
of the myometrium.
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
• Hormonally responsive to estrogen and
progesterone
• Pregnancy- grow
proportions
quickly
and
to
huge
• Menopause- stop growing and atrophy in
response to naturally ↓ endogenous estrogen
levels.
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
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
Risk Factors
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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
Clinical Symptoms of Uterine Leiomyomas
Bleeding (MC symptom)
Longer, heavier periods
Endometrial ulceration
Pressure
Pelvic pressure and bloating
Constipation and rectal pressure
Urinary frequency or retention
Pain
Secondary dysmenorrhea
Acute infarct (especially in pregnancy)
Dyspareunia
Reproductive difficulties
Infertility (failed implantation/spontaneous abortion)
Fetal malpresentation
Intrauterine growth restriction (IUGR)
Premature labor and delivery
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
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.
Diagnostic Evaluation
• Pregnancy test- all women
• History and PE
• Ultrasound (pelvic/transvaginal) – MC means
of diagnostics
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
• Treatment depends on the patient’s
– Age
– Pregnancy status
– Desire for future pregnancies
– Size and location of the fibroids
Medical Therapies
• Medroxyprogesterone- shrink fibroids
decreasing circulating estrogen levels
by
• GnRH agonists- shrink fibroids by decreasing
circulating estrogen levels; stop bleeding, and
increase the hematocrit prior to surgical
treatment of uterine fibroids.
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
Surgical Intervention
• Myomectomy- surgical resection of one or
more fibroids from the uterine wall; preserve
fertility; increase risk of recurrence- 50%
• Hysterectomy- DEFINITIVE TREATMENT.
• Because of the potential for hemorrhage, surgical
intervention should be avoided during pregnancy,
although myomectomy or hysterectomy may be
necessary at some point after delivery.
Indications for Surgical Intervention for Uterine
Leiomyomas
Abnormal uterine bleeding, causing anemia
Severe pelvic pain or secondary amenorrhea
Uterine size (>12 weeks) obscuring evaluation of
adnexae
• Urinary frequency, retention, or hydronephrosis
• Growth after menopause
• Recurrent miscarriage or infertility
Rapid increase in size
Thank You..