PMD/OLC

UTERINE FIBROID
HAJAR AFIQAH
MBBS 1709-8241
 Identification data

● Name: Miss A.
● Age: 19 years old.
● Race: Malay.
● Nulliparous.
● LMP date: 14 days ago; sure of her dates.
 Chief Complaint

A 19 years old Malay lady, nulliparous presented with

progressively worsening heavy menstrual bleeding for
the last 3 months.
 History of presenting illness
Menorrhagia Associated with
● Sudden onset, started 1 year ago. ● Progressively increasing lower abdominal
● Progressively worsening for the last swelling of 8 months duration.
3 months. ● Dysmenorrhea
● Uses an average of 6 sanitary pads ○ Onset: 1 year ago.
per day as against her usual 3, fully ○ Duration: Starts at beginning of menses,
soaked, with passage of clots size lasts throughout the whole period length,
20-50 cents, no foul odour. resolves when period ends.
● Duration of menstrual flow increases ○ Character: Continuous, crampy in nature.
from 7 days to 14 days. ○ Radiation: No.
● No spotting between menses. ○ Severity: Disturbs her daily activities and
sleep (P/S: 6/10).
○ Aggravating: Movement.
○ Relieving: Rest.
 History of presenting illness
● Bulk-related symptoms
○ Increase in urination frequency: 5-7 times per day, little amount for the last
2 months.
○ Urine retention present.
○ Otherwise, no hematuria, nocturia, dysuria or pain in the flank (indicating
ureteral compression & hydronephrosis), and constipation (indicating
bowel compression).

● There were occasional episodes of palpitations & dizziness.

 History of presenting illness
Otherwise,
● No fever, chills, fatigue, weakness or loss of weight and appetite
(indicating malignancies).
● No chronic or sharp pelvic pain (indicating adenomyosis).
● No intermenstrual bleeding (indicating endometrial polyps).
● No pain with bowel movements or urination; dyschezia (indicating
endometriosis).
● No SOB, syncopal attack, profuse sweating, nausea or chest pain
(indicating hypovolemic shock).
● No persistent gum bleeding, unexplained epistaxis or easily bruising
(indicating bleeding disorders).
● No fever, foul smelling per-vaginal discharge, dysuria, polyuria or
genital irritation/itchiness (indicating cervicovaginal infection).
 GYNAECOLOGICAL/MENSTRUAL HISTORY
● Menarche at age 10 years old.
● Duration: 7 days.
● Cycle: 28 days, regular.
● Pads used 3 pads per day.
● Content: Fresh blood, no clots.
● LMP date: 14 days ago.
● Associated with slight dysmenorrhea.
● Never done pap smear.
● She is virgo intacta.
Past medical/surgical
Drug history
history
● Past medical history ● Paracetamol for menstrual
unremarkable. pain.
● Past surgical history ● Otherwise, not taking any
unremarkable. supplemental or traditional
● No history of hospital medicines.
admission. ● NKDA/NKFA.
 family history social history
● Her grandmother, mother and two ● She is currently single and an
older sisters had a history of undergraduate student.
uterine fibroids. ● Staying at Cyberjaya with her
● Otherwise, no family history of parents.
chronic diseases or history of ● Does not smoke, take alcohol or
breast, ovarian, endometrial or any illicit drugs.
colon cancer. ● Healthy balanced diet.
● 4-6 hours of sleep.
● Exercises 3 times a week for 30
minutes.
 Case summary
Miss A, a single undergraduate 19 years
old Malay lady with strong family history of
uterine fibroid came with complaint of
progressively worsening heavy menstrual
bleeding since 3 months ago. It was
associated with dysmenorrhea, occasional
palpitations and dizziness, progressive lower
abdominal swelling over the last 8 months and
pressure symptoms since 2 months ago.
 General examination
Patient was lying in supine position with a degree
Vital signs:
of pallor. Otherwise, she is afebrile, alert,
conscious, orientated, breathing comfortably with BP 123/81 mmHg
no signs of respiratory distress and not in any
PR 96 bpm, regular rate & rhythm with
visible pain. good volume

- Hands: Capillary refill time <2 seconds, warm RR 20 breaths/minute

to touch, no peripheral cyanosis.
T 37.3 C
- Eye: Conjunctival pallor.
- Mouth: Good hydration & oral hygiene, no SpO2 98% under room air
angular stomatitis. BMI 21.1 kg/cm^2 (Normal)
- Neck: No palpable masses/nodules.
- Leg: No pedal oedema.
 Abdominal examination
Examination Percussion

● Abdomen symmetrical that moves with respiration. ● Dullness at suprapubic area.

● Umbilicus in centrally located and inverted. ● No shifting dullness or fluid
● No scars or dilated veins seen. thrills.
● Abdominal distension at suprapubic area noted.
Auscultation
Palpation
● Bowel sound was heard.
● A 20 week sized pelvic mass was noted, ● No renal or aortic bruit heard.
non-tender, smooth, firm, regular margin, mobile
with no overlying skin changes.
● No hepatosplenomegaly or ballotable kidneys.
 PELVIC EXAMINATION
Bimanual vaginal examination Speculum examination

● There is palpable mass. ● Closed cervical os.

● No visible mass/protrusion.
● No signs of active inflammation.
 Differential diagnosis
Differentials Points supporting Points against

Uterine fibroid - Menorrhagia. - Peak incidence at 30-40s.

- Dysmenorrhea.
- Increased urinary frequency
& retention.
- RF: early menarche,
nulliparous, family hx of
uterine fibroids.
- PE: Suprapubic mass, firm
consistency, non-tender,
mobile.
 Adenomyosis - Dysmenorrhea. - Chronic pelvic pain.
- Menorrhagia. - PE: No tender uterus,
boggy/bulky, diffuse large
uterus.

Endometrial polyps - Menorrhagia. - Intermenstrual bleeding.

- Irregular cycle.
- Tend to be small and
unlikely to cause an
enlarged uterus.

Endometriosis - Menorrhagia. - Dyschezia.

- Dysmenorrhea. - Pelvic pain.

Endometrial cancer - Menorrhagia. - No constitutional symptoms.

- Uterine mass. - No family history of
malignancy.
- Signs & symptoms of
metastasis (Fatigue, nausea
or vomiting, enlarged LN).
 investigations
Imaging
Lab Investigations
● Pelvic ultrasound
● FBC
○ Anteverted & markedly
○ Hb - 8.6 g/dL [N: 13.5-17.4 g/dL]
enlarged uterus with multiple
○ PCV/Hct - 26% [N: 40.1-50.6%]
well-defined, hypoechoic solid
● Serum electrolyte & creatinine - Normal
masses of varying sizes, the
● Urine beta HcG - Normal
largest measured 13.4 cm x 8.5
● Alpha-fetoprotein levels - Normal
cm located in the fundus.
Subserous and submucous
components were also seen.
 A hypoechoic
lesion at
posterior wall of
the uterus.
DEFINITIVE DIAGNOSIS

Uterine fibroid
(leiomyoma)
management
Pre-operative management Intraoperative finding
● Admit patient. ● 20-week sized fibroid riddled uterus with
● Patient was counselled on different multiple subserous, intramural and
options of management in the submucous fibroids.
presence of her parents, they opted for ● 13 fibroid nodules were enucleated with
an abdominal myomectomy. smallest size measuring 2 cm and the
● They were further counselled on the largest 16 cm.
benefits as well as the associated ● The fallopian tubes and ovaries were
risks, recurrence and future fertility. healthy.
● Informed consent was taken. ● Estimated blood loss was 600 mL.
● Given IV 1L warmed 0.9% NaCl
solution.
● Blood grouping and cross matching of
4 blood units were done.
● Monitor vitals and strict pad chart for
PV bleeding and KNBM 6 hours pre-op.
Post-operative management Patient’s progress
● Monitor vital signs, wound inspection, ● Her immediate post-operative was
any post-op complications and uneventful & vital signs remained stable.
infections. ● Her postoperative PCV was 28.6% while
● Address chronic anemia, proper diet her Hb was 9.5 g/dL.
and supplements (iron, folic acid, ● Her postoperative recovery was
B12). satisfactory.
● Though she was adolescent and not ● Discharged on 4th postoperative day on
sexually active, she was still iron, folic acid and vitamin B
counselled on contraceptive options. supplements.
● Allow discharge with TCA 3 months ● Her f/u visit 2 weeks later, she was
later to review the (HPE) of the asymptomatic & surgical site was well
fibroid. Monitor for recurrence. healed.
● At 4 weeks, PCV 30% and Hb 10 g/dL.
● Histology report confirmed uterine
fibroids.
discussion
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 What is uterine fibroid
Uterine fibroids (aka leiomyomas/myomas)
are benign tumors of the uterus that often
appear during reproductive years and regress Risk factors:
during menopause.
● Age >40 years old.
Pathogenesis is not well defined yet, though ● Early menarche <10 years old.
fibroids are thought to develop from the ● Family history of uterine
myometrium after a smooth muscle cell’s fibroids.
neoplastic transformation, followed by the ● Obesity.
formation of a connective tissue component ● Nulliparity.
and pseudocapsule. ● Race (African descent).
● Alcohol & caffeine intake.
Malignant transformation is extremely rare.
TYPES
COMPLICATIONS
Thank you!!