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

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.

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.

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.

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.

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

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.

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

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

Magnetic resonance imaging

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

DISCUSSION

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

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

What is the incidence? At least 20% of women in the reproductive age group

Whether fibroid is hormone dependant? Fibroid is hormone dependant. Predominantly oestrogen dependant. Other hormones implicated are growth hormone, human placental lactogen

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

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

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

What are the synonyms of fibroid? Fibromyoma Leiomyoma myoma

What are the types of fibroid?

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)

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.

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.

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.

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.

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.

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

Hysteroscopy

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 dont cause intermenstrual bleeds other than when there is ulceration or it is submucous or cervical fibroid

DISCUSSION

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

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

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

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

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

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

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.

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.

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.

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.

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