Uterine Fibroid.pptx

Uterine Fibroid.pptx

• 1.
  Uterine Fibroid Gaya 
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  ‘Benign tumours (myoma/leiomyoma) arising from the uterus’ Etiology unknown but they are estrogen dependent and undergo atropy after menopause More common in nulliparous women
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  Types • Subserosal –growin outer surface of uterus • Pedunculate – when they grow out of the uterus on pedicles • Intramural / interstitial – grow inside the myometrium will enlarge the entire body of the uterus
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  • Submucosal –grow beneath the endometrium .they can distort the cavity. These fibroid can grow in to the uterine cavity and known as fibroid polyps • Broad ligament fibroids - grow in to broad lig. • Cervical – arise from the cervix
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  Symptoms • Majority odfibroid are asymptomatic ,detect during USS or laparoscopy 1)Menorrhagia – Usually with submucosal and interstitial fibroid Due to increase of endometrial surface and impaired contractility and increasing vasularity and pelvic congestion.
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  2)Intermenstrual bleeding – dueto ulceration of a submucosal or fibroid polyps 3)Dysmenorrhoes – Cause by submucosal fibroid or fibroid polyps. Those are interfere with the uterine contractility during menses in attemp to expel it through the cervical canal
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  4)Subfertility – Due toimpaired of uterine and tubal mortility due to heaviness of uterus ,defective implantation ,mechanical obstruction of tubal and problem in migrating of the sperm occur 5) Acute pain can occur –due to red degeneration of torsion of pudunculate fibroid
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  Complications • If canaffect POD and acute retention of urine can be happen • Pedunculated fibroid can undergo twisting and necrosis • Infection can occur in submucus fibroid following delivery or miscarriage same can happen in interstitial fibroid following caesarian section if the uterine incision extend inti myoma • Malignant changes are rare
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  Types of degenerationoccur in fibroid • Hyaline degeneration – commonest type and more common in larger fibroid. degenration occur in the central part and tumour become soft in consistency .common in menopause • Cystic degeneration – following hyaline d. and cavitation formation occur at the central part
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  • Red degeneration– commonly occurs during pregnancy and puerperium, increased vascularity of the uterus and tumour become painful and tender • Calcification - occur in postmenopausal women and is due to deposition of Calcium carbonate and phosphate .also called womb stones
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  Complication in pregnancy •Early stage –repeat miscarriage (in submucus fibroid specially) • Late stage –premature labour ,pain due to red degeneration ,abnormal lies and presentation , fetal growth restriction • During labour –obstructed labour and increased incidence of caesarian delivery .lower segment fibroid incision need to do in upper segment in c- section • Post partum period- higher incidence of post partum haemorrage
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  Examination • General examinationalways look foe anemia • Abdominal examination – When the uterus is larger than a pregnant uterus of 12-14 week size it become palpable abdominally in the suprapubic region DD s are : Full bladder , pregnancy , ovarian tumours ,adenomyosis ,tubo-ovarian masses
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  Investigation • FBC –toexclude anemia • USS - main stay of diagnosis • 3D vaginal sonography – used in evaluating the uterine cavity specially with regard to submucus fibroid and fibroid polyps • CT and MRI • Laparoscopy –to detect small fibroid and exact location • Hysteroscopy –to diagnosis submucosal and fibroid polyps
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  Management • Conservatively • Surgical •Medical • Uterine artery embolization
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  Conservative (expectant) • Asymptomaticfibroid that detect during routine examination are managed conservatively • Risk of sarcomatous 1 in 1000 • Conservative management indicate in pregnancy and puerperium. • Regular follow up (with 6-12 month) with USS in necessary to detect any sudden enlargement or change in the echogenicity • Spontaneous regression of the fibroid is expected after menopause
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  Surgical management The choiceof surgical treatment is determined by the presenting complaint and the patient’s aspirations for menstrual function and fertility Indicate to:  Symptomatic fibroid  When fibroid become palpable abdominally (large enough 12 week gestation size or 5-6cm on USS measurement )  Subfertility when other method fail
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  Surgical procedures are oMyomectomy o Hysterectomy Indication for myomectomy over hysterrectomy are :
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  • Woman hasnot complete family • Fibroid causing subfertility • Desire to retain uterus Advantages of hysterectomy : • Recurrence of myoma does not exist • It is easier to achieve hemostasis during surgery • Risk of post operative adhesion formation low
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  • Menorrhagia associatedwith a submucous fibroid or fibroid polyp should be treated by hysteroscopic removal • Where a bulky fibroid uterus causes pressure symptoms, the options are myomectomy with uterine conservation, or hysterectomy. • Myomectomy will be the preferred option where preservation of fertility is required.
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  • An importantpoint for the preoperative discussion during the consent process is that there is a small but significant risk of uncontrolled life threatening bleeding during myomectomy, which could lead to hysterectomy performed as a life saving measure. • This has to be explain to the patient before surgery and consent need to be taken
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  • Disadvantages ofmyomectomy  Haemorrhage in to myoma cavity  Sepsis  Postoperative adhesion –can involve omentum and bowel and leads to subacute bowel obstruction  Recurring
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  • Myomectomy canbe done laparoscopy or open surgery • Open myomectomy –incision may become suprapubic transverse but in large fibroid extending above the umbilicus and midline incision may become necessary • Laparoscopic myomectomy will cause fewer adhesion but become technically difficult in removing large fibroid
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  • Morcellator needto take fibroid out from the abdominal cavity once removed.
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  • Laparoscopic MyomaScrew Used to stabilize and manipulate nondegenerating myomas, fibroids, or other tissues intended for removal during laparoscopic procedures.
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  Medical treatment • medicaltreatment for heavy menstrual bleeding (tranexemic acid, mefenamic acid, combined oral contraceptive pill) tend to be ineffective. • The only effective medical treatment is to use gonadotrophin progressreleasing hormone (GnRH) agonists and Danazol . • While very effective in shrinking fibroids, when ovarian function returns, the fibroids regrow to their previous dimensions.
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  • Need prolongtreatment at least 6-9 month • Menopausal symptoms due to hypoestrogenic state and osteoporosis are side effects .
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  Hysterectomy and myomectomycan be facilitated by GnRH agonist pretreatment over a three-month period to reduce the bulk and vascularity of the fibroids. Useful benefits of this approach are to enable a suprapubic (low transverse) rather than a midline abdominal incision, or to facilitate vaginal rather than abdominal hysterectomy, both of which are conducive to more rapid recovery and fewer postoperative complications. GnRH agonist pretreatment can obscure tissue planes around the fibroid making surgery more difficult but, on the positive side, blood loss and the likely need for transfusion are reduced.
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  Uterine artery embolization •Uterine artery embolization (UAE) is a newer technique performed by interventional radiologists. • It involves embolization of both uterine arteries under radiological guidance with a small incision in the femoral artery performed under local anesthesia. • The current evidence indicates that the overall shrinkage of fibroids and reduction in menstrual blood loss is around 50 per cent, although long-term follow- up data beyond 18–24 months are not available.
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  • patients usuallyrequire admission overnight because of pain following arterial occlusion • Requiring opiate analgesia. • Complications include fever, infection, fibroid expulsion and potential ovarian failure. • Women wishing to retain their fertility should be counselled carefully before undergoing UAE as the effects are not known, although there have been pregnancies reported in the literature.
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  Management The management isby hysteroscopic (transcervical) resection of the fibroid (TCRF). This can be performed as a day case under general anaesthetic (or even local anaesthetic if the fibroid is small). The important points in counselling the patient are as follows. • Description of the procedure: the procedure involves stretching (dilatation) of the cervix and insertion of an endoscope into the uterus (hysteroscopy) to view the fibroid. The fibroid is ‘shaved’ away with a hot wire loop (diathermy). Fluid is circulated through the uterine cavity to enhance the view and allow cooling. • What are the risks? • bleeding: it is rare to bleed heavily but in the extreme situation blood transfusion could be required, or even a hysterectomy to control the loss • infection • fluid overload: during the procedure, irrigation fluid is absorbed into the circulation. Excessive absorption can cause breathing difficulties (pulmonary oedema) and the need for hospital admission • uterine perforation: rarely the hysteroscope perforates the wall of the uterus and if this occurs or is suspected then laparoscopy is needed immediately to confirm it, secure any bleeding and check for damage to surrounding bowel or bladder. • What to expect afterwards: most women experience bleeding, discharge and passing of ‘debris’ for up to 2 weeks after the procedure.