CASE REPORT

MYOMA UTERINE

Supervised by:

dr. Hesty Duhita Permata, Sp.OG

Presented by:

Niki Rizqi Rachmawati

2013730077

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

MUHAMMADIYAH JAKARTA FACULTY OF MEDICINE
RSUD R. SYAMSUDIN SH SUKABUMI
 CHAPTER I
INTRODUCTION

Uterine myoma are benign growths that develops from muscle tissue of the uterus. They
are also called leiomyomas or fibroids. The size, shape, and location or fibroids can vary greatly.
They may be present inside the uterus, on its outer surface or within its wall, or attached to it
by a stem-like structure.
Based on World Health research Organisatioan (WHO) the cause of maternal mortality
due to uterine myoma in the year 2010 as many as 22 cases (1.95%) and year 2011 as many as
21 cases (2.04%) on all treated obstetric patients. Mioma uteri more commonly found in black
women compared with white women. In Indonesia, the incidence of uterine myoma is found
from 2.39 to 11.7% in all gynecologically treated patients. The number of incidents of this
disease in Indonesia ranks second after cervical cancer. Rarely, myoma is found in women aged
20 years, at most at the age of 35-45 years (approximately 25%).
Myoma are classified base on their location and direction of growth (subserosal myoma,
pedunculated myoma, parasitic myoma, intramural myoma, and submucous myoma). At times,
a subserous myoma becomes parasitic and derives its blood supply through the highly
vascularized omentum.
Treatment of symptomatic myomas consist of analgesia and observation. The modality
that we can use to treat this disease is drug therapy (Nonsteroidal Anti-Inflamatory Drugs,
Hormonal Therapy, Androgens, GnRH Agonist, Antiprogestins and GnRH Antagonis), Uterine
Artery Embolization (UAE), and surgical management (Hysterectomy and Myomectomy).

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 CHAPTER II
CASE REPORT

2.1. Patient’s Identity

Name : Mrs. N
Date of birth / Age : August, 01-1974 / 43 years-old
Nationality : Indonesian
Address : Kp. Kabandungan, Tugu Bandung
Marital status : Married
Occupation : Housewife
Religion : Moslem
Date of admission : November 9, 2017
Date of examination : November 11, 2017

Husband Identity
Name : Mr. A
Age : 52 years-old
Nationality : Indonesian
Address : Kp. Kabandungan, Tugu Bandung
Occupation : Farmers
Religion : Moslem

2.2. History Taking

Chief Complaint
Heavy and painful bleeding from the genital that worsened since 1 month
before admission to the hospital. And abdominal mass.

History of Present Illness

Patient was referred from RSUD Sekarwangi because of her heavy and painful
bleeding from the genital and abdominal mass. And the patient did physical and
ultrasonography examination. Before she went to RSUD sekarwangi, she did not feel
any mass in her abdomen. She just feel if it was fat. And had no felt abdominal pain.
The patient had felt limp and dizzy. Patient had no felt trouble defecating and
urinating. Difficult bowel movements and pain in the chapter is not felt by the patient.
she did not have complain of decreased appetite or weight loss.
She also had a 7-10 days menstrual cycle, but she always feel dysmenorrhea
during each menstruation period.

History of Past Illnesses

History of chronic hypertension : yes
History of trauma : denied
History of diabetes mellitus : denied

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 History of asthma : denied
History of allergy : denied
History of surgery : denied

Familial History
History of hypertension : denied
History of asthma : denied
History of diabetes mellitus : denied
History of allergy : denied

Menstruation History
Menarche :12 years old
Menstrual cycle : regularly, 28 days of cycle, 7 to 10 days
duration, with dysmenorrhea
Amount of menstrual blood : 3-4 normal pads / day ( ± 60 cc )
LMP : October 5, 2017

Contraception History
She doesn’t took any contraception since first married.

Marital History
Married once, for 28 years.

Obstetric History
She never got pregnant

2.3. Physical Examination

General condition : mildly ill appearance
Consciousness : compos mentis
Blood pressure : 170/100 mmHg
Heart rate : 88 bpm
Respiratory rate : 21x/minute
Temperature : 36,5°C
Weight : 76kg
Height : 156 cm
BMI : 31,6 kg/m2 (obesitas)

General Examination
Eyes : anemic conjunctiva +/+, icteric sclera -/-, edema palpebra -/-
Mouth : wet oral mucosa membrane
Neck : thyroid enlargement (-), trachea is in the middle
Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in breathing

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 Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, ronchi -/-, wheezing -/-

Abdomen
Inspection : convex, mass in lower abdomen
Auscultation : bowel sound (+) 6 times/minute
Palpation : palpable solid mass on the lower of abdomen, from symphisis
pubis to umbilicus, with smooth surface and strictly defined
borders, no tenderness, no fluctuation
Percussion : dull on mass area, but tympani on other areas

Extremities : warm, edema -/-/-/-, CRT < 2 seconds

Gynecologic Examination
Abdomen
Inspection : convex, mass in lower abdomen
Auscultation : bowel sound (+) 6 times/minute
Palpation : palpable solid mass on the lower of abdomen, from symphisis
pubis to umbilicus (gravida 20 weeks), with smooth surface and
strictly defined borders, no tenderness, no fluctuation

Percussion : dull on mass area, but tympani on other areas

Genital
 Inspection
 Vulva : within normal limit
 Vagina : within normal limit
 Inspeculo
 Portio : bleeding from serviks, there is no sign of inflammation,
 Vaginal Toucher :
- V/V : within normal limit
- Portio : thick and soft
- Corpus uteri : gravida 20 weeks
- Right/left adnexa : mass (-),tenderness (-/)

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2.4 Laboratory (November 9,2017)

Types Results Units Normal Value

Hematology
Hemoglobin 7.1 g/dL 12 – 16
Hematocrit 24 % 37-47
Leucocytes 7.500 /uL 4000 – 10000
Platelets 434.000 Thousands/uL 150000-450000
Eritrocyte 3.8 Millions/ uL 3.8-5.2

2.5. USG examination (November 3rd 2017)

USG result
 USG image shows an enlarged uterus

2.7. Working Diagnosis

Mrs. N, 43 years old, myoma uterine with anemia dan hipertension.

2.8. Management
 Observe general condition, vital signs, and bleeding
 Transfuse with PRC until Hb>10 g/dL, check post transfusion Hb

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  Tranexamic acid 3x500 mg IV
 Mefenamic acid 3x500 mg PO
 Amlodipine 2x5 mg PO
 Planning for surgery (Histerectomy)

2.9. Follow Up

Date Subjective Objective Assessment Planning

09/11 Bleeding (+),  General condition : Mrs. N, 43  observation of
/2017 Dizzy (+), limp mildly ill years old, general
(+)  Level of consciousness: condition, vital
myoma
CM signs, bleeding
 Vital Sign : uterine with  IVFD Futrolit
 Blood Pressure : anemia dan  Transfusion 2
170/100 mmHg bags PRC
hipertension.
 Heart Rate : 88x/minute  Give tranexamic
 Respiratory Rate : 21x/ acid 3x500 mg
minute IV
 Body Temperature:  Give mefenamic
36,5°C acid 3x500 mg
 Conjunctiva anemis +/+ PO
 Lab :  Give amlodipine
- Hb 7.1 2x5mg PO
- Ht 24
- Leu 7500
- Trom 434.000

10/09 Bleeding (-),  General condition : ill Mrs. N, 43  observation of

/2017 dizzy (+), limp  Level of consciousness: years old, general
(+) CM condition, vital
myoma
 Vital Sign : signs, bleeding
 Blood Pressure : 150/90 uterine with  IVFD Futrolit
mmHg anemia dan  Transfusion 2
 Heart Rate : 83x/minute bags PRC
hipertension.
 Respiratory Rate : 20x/  Give tranexamic
minute acid 3x500 mg
 Body Temperature: IV
36,6°C  Give mefenamic
 Conjunctiva anemis +/+ acid 3x500 mg
 Lab : PO
- Hb 7.1

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 - Ht 24  Give amlodipine
- Leu 7500 2x5mg PO
- Trom 434.000

11/11 Bleeding (-),  General condition : does Mrs. N, 43 Patient was discharged
/2017 dizzy (-), limp not look ill years old, from the hospital
(-)  Level of consciousness:
myoma
CM
 Vital Sign : uterine with
 Blood Pressure : 130/80 anemia dan
mmHg
hipertension.
 Heart Rate : 80x/minute
 Respiratory Rate : 20x/
minute
 Body Temperature:
36,6°C
 Conjunctiva anemis -/-
 Lab :
- Hb 10.8
- Ht 32
- Leu 7400
- Trom 314.000

2.7. Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : ad malam
Quo ad sanationam : dubia ad bonam

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 CHAPTER III
CASE ANALYSIS

3.1. Problems

1. How to diagnose Myoma uterine ?

Theory Case
History Taking History Taking
1. Menstrual abnormalities, including 1. Patient complained about menstrual
menorrhagia. cycle 7 to 10 days duration, with
2. Pelvic pain and pressure dysmenorrhea.
3. Abdominal pain 2. Patient doesn’t complain about
4. Urinary tract obstruction pelvic pain and pressure
5. Constipation 3. Patient doesn’t complain about
6. Smoking abdominal pain
7. Family history of uterine fibroid tumors 4. There was no history of urinary track
8. Nulliparity obtraction
9. Obesity 5. Patient complain about of irregular
10. Prolonged use of oral contraceptives bowel habits for the past nine
months.
6. Patient doesn’t smoking
7. There was no history of family with
myoma uterine
8. Nullipara
9. Patient is obesity
10. Patient doesn’t took any
contraception since first married

Theory
Physical Examination
Abdominal Examination:
Inspection: abdominal lump or swelling
Palpation:
Firm mass, maybe cystic in cystic
degeneration.
Margins are well-defined.
Surface is nodular; may be
uniformly enlarged in a single
fibroid.
Case
Physical Examination
1. Abdominal Exemination :
Inspection: convex, mass in lower abdomen
Auscultation: bowel sound (+) 4 x/minute
Palpation:
palpable solid mass on the lower
of abdomen, from symphisis
pubis to umbilicus
strictly defined borders
smooth surface
no tenderness

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 Mobility is restricted from above no fluctuation
downwards but can be moved from Percussion: dull on mass area, but tympani
side to side. on other areas
Percussion: swelling is dull.

Laboratory Exemination Laboratory Exemination

Hematology results would show an anemic state
in which there will be low hemoglobin, Hb 7.1 g/dL ()
hematocrit, and erythrocyte because of the Ht 24% ()
bleeding. Erythrocyte 3.8 mil/mL ()

Digital Exemination Digital Exemination

Uterine contour is enlarged and USG image shows an enlarged uterus.

distorted.
Depending on the amount of
connective tissue or smooth muscle
proliferation, fibroids are of
different echogenecity-hypoechoic
or hyperechoic.
Vascularization is at the periphery of
the fibroid.
Central vascularization indicates
degenerative changes.

2. How to management treatment for this case?

Theory Case
OBSERVATION Observe general condition, vital
MEDICAL THERAPY signs, and bleeding
Sex Steroid Hormones (anti- Transfuse with PRC until Hb > 10
progesterone e.g. Mifepristone, g/dL, check post transfusion Hb
SPRM e.g. ulipristal acetate, Tranexamic acid 3x500 mg IV
androgens e.g. danazol and Mefenamic acid 3x500 mg IV
gestrinone) Amlodipine 2x5 mg PO
GnRH Agonists (Leuprolide Planning to surgery
acetate, goserelin, luporelin,
buserelin or nafarelin)
Non-Hormonal Options
(Tranexamic acid, NSAIDs, WB
or PRC transfusion)
SURGICAL THERAPY

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 CHAPTER IV
CONCLUSION

1. This Patient Mrs. N, 43 years old, myoma uterine with anemia and hypertension.
Patient was referred from RSUD Sekarwangi because of her heavy and painful
bleeding from the genital and abdominal mass. And the patient did physical and
ultrasonography examination. Before she went to RSUD sekarwangi, she did not
feel any mass in her abdomen. She just feel if it's fat. And had no felt abdominal
pain. The patient had felt limp and dizzy. Patient had no felt trouble defecating an
urinating. Difficult bowel movements and pain in the chapter is not felt by the
patient. she did not have complain of decreased appetite or weight loss. She also had
a 7-10 days menstrual cycle, but she always feel dysmenorrhea during each
menstruation period. In abdominal examination there was mass palpated in the
lower abdomen. Ultrasonography examination result USG image shows an enlarged
uterus.
2. In this case the management for this patient is observation. Patients get treatment
for bleeding, blood high pressure and anemia. And planning for surgery if the
general condition is good.

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 REFERENCES

1. SOGC Clinical Practice Guideline. The Management of Uterine Leiomyomas. J

Obstet Gynaecol Can 2015;37(2):157–178
2. Bagian Obstetri dan Ginekologi FK UNPAD. Tumor Alat Kandungan . Ginekologi edisi
2 , 2010 . Bandung : Elstar Offset. Hal : 154 – 161

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