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CASE REPORT

UTERINE LEIOMYOMA
Supervised by:
dr. Hj. Hesty Duhita Permata, Sp.OG

Created by:
Yosefine Ivanda T (2016-061-031)
INTRODUCTION

Uterine leiomyoma/fibroid/myoma benign


neoplasms that arised from the uterine smooth
muscle tissue (myometrium)
Commonest gynecological cancer, prevalence 70-
80% in women age 50s, peak at 40s
Risk factors including age (late reproductive years),
early menarche, African-American ethnicity,
nulliparity, and obesity
Clinically apparent in 25% women
CASE
REPORT
PATIENTS IDENTITY

Name : Mrs. I
Age : 47 years old
Nationality : Indonesian
Marital Status : Married
Occupation : Shop owner
Religion : Moslem
Address : Kp.Cikedok, RT 03/RW
04
Date of Admission : July 12th, 2017
Date of Examination : July 12th, 2017
CHIEF
COMPLAINT :
Heavy and painful bleeding from the genital that worsened
since 10 days before admission to the hospital.
HISTORY OF PRESENT
ILLNESS
Heavy and painful menstrual bleeding
5 years Bled 2x/month, duration 10-15 days, used 4-5 pads a
day
before admission Palpable solid mass in lower abdomen, slowly getting
bigger

3 months Patient started having trouble defecating and urinating


before admission

Bleeding worsened
10 days Bright red, with a few dark red lumps, 24 pads/day, full
Abdominal mass (+)
before admission No abdominal/pelvic pain
HISTORY OF PAST ILLNESS

Miscarriage 17 years ago (3 month pregnant),didnt undergo


curettage, bled for 3 months
After the miscarriage, patient couldnt be pregnant again
even though shed tried with her husband
Chronic illnesses : denied
Trauma : denied
Allergy : denied
Past surgery : denied
FAMILY HISTORY

Chronic illnesses : denied


Trauma : denied
Allergy : denied
Malignancy : denied
MENSTRUATION HISTORY

Menarche : 12 years old


Menstrual cycle : irregularly, twice a month, with duration
of 10-15 days, dysmenorrhea (+)
Total pads : 12-24 pads/day (240-480 cc)
First day of last menstrual period : July 2nd, 2017
CONTRACEPTION HISTORY

The patient never used any kind of contraception.


MARITAL HISTORY

Married once, been married for 18 years now.


OBSTETRIC HISTORY

Gestational
No. Year Labor History
Age
1. 2000 3 months Abortus
PHYSICAL EXAMINATION
General condition : appeared moderately ill
Conciusness : compos mentis

Vital Signs Nutritional Status


BP : 110/80 mmHg Weight : 48 kg
HR : 102 bpm Height : 148 cm
RR : 20 x/min BMI : 21,9 kg/m2 (normal)
Temp : 36,6oC
PHYSICAL EXAMINATION

Head : normocephaly, deformity (-)


Eyes : anemic conjunctiva +/+, icteric sclera -/-
Ear and Nose : no abnormalities
Mouth : dry and anemic oral mucous membrane
Neck : thyroid enlargement (-), lymph node
enlargement (-)
Thorax
Heart : regular 1st and 2nd heart sounds, murmur (-),
gallop (-)
Lung : symmetric, vesicular breath sounds +/+, regular,
rhonchi -/-, wheezing -/-
PHYSICAL EXAMINATION

Abdomen
Inspection : convex, mass in lower abdomen
Auscultation : bowel sound (+) 4 times/minute
Palpation : palpable solid mass on the center of
abdomen, from symphisis pubis to two fingers above umbilicus,
with smooth surface and strictly defined borders, no tenderness,
no fluctuation
Percussion : dull on mass area, but tympani on other
areas

Extremities : cold, CRT <2s, edema -/-/-/-


PHYSICAL EXAMINATION

Gynecological Examination
Vulva: normal, no edema, no lesion
Vagina : normal, no lesion
Bimanual Pelvic Examination:
palpable firm, irregularly enlarged uterus
can be moved from side to side
the cervix moves with the movement of the mass felt per
abdomen
Cavum Douglasi: empty.
LABORATORY EXAMINATION
(June 12th, 2017 09.53)

Normal
Types Result Unit
Value
Hematology
Hemoglobin 4,0 g/dL 12-14
Hematocrit 16 % 37-47
Leukocyte 5.700 /mL 4.000-10.000
150.000-
Platelets 299.000 /mL
450.000
Erythrocyte 2,8 millions/mL 3,8-5,2
MCV 57 fL 80-100
MCH 15 pg 26-34
MCHC 25 g/dL 32-36
TRANSABDOMINAL
ULTRASOUND
USG image shows an enlarged uterus with
hyperechoic lesion.
WORKING
DIAGNOSIS :
Mrs. I, 47 years old, with uterine leiomyoma and anemia.
MANAGEMENT

Observe general condition, vital signs, and bleeding


Transfuse with PRC until Hb>10 g/dL, check post transfusion
Hb
Give tranexamic acid 3x500 mg IV
Give mefenamic acid 3x500 mg PO
FOLLOW UP (JULY 13 ,
TH 2017)
SUBJECTIVE OBJECTIVE THERAPY
Bleeding (+) 45 cc General condition: looks IVFD Futrolit
moderately ill
Patient had trouble BP: 110/70 mmHg 3 bags PRC
defecating. HR: 84 bpm
transfusion
RR: 20 x/min
Still weak. Temp: 36,5oC
Anemic conjunctiva+/+
Tranexamic acid
Abdomen: palpable solid mass 3x500 mg
above symphisis, smooth
surface, no tenderness on Mefenamic acid
palpation 3x500 mg
Hb: 7,0 g/dL
Ht: 23%
RBC: 3,5 mil/mL
WBC: 6.300/ mL
Platelets: 230.000/ mL
MCV: 67 fL
MCH: 20 pg
MCHC: 31 g/dL
FOLLOW UP (JULY 14 ,
TH 2017)
SUBJECTIVE OBJECTIVE THERAPY
Minimal bleeding General condition: looks IVFD Futrolit
mildly ill
Still weak. 4 bags PRC
BP: 100/60 mmHg
HR: 82 bpm transfusion
RR: 21 x/min
Temp: 37,2oC Tranexamic acid
Anemic conjunctiva+/+ 3x500 mg
Abdomen: palpable solid
Mefenamic acid
mass above symphisis,
smooth surface no
3x500 mg
tenderness on palpation
FOLLOW UP (JULY 15 ,
TH 2017)
SUBJECTIVE OBJECTIVE THERAPY
Minimal bleeding General condition: stable, does IVFD Futrolit
not look ill
Patient felt difficulty BP: 120/90 mmHg 1 bag PRC
breathing HR: 84 bpm
transfusion
RR: 20 x/min
Patient said she had Temp: 36,6oC
clear vaginal discharge Anemic conjunctiva -/-
Tranexamic acid
Abdomen: palpable solid mass 3x500 mg
Patient had defecated above symphisis, smooth
surface, no tenderness on Mefenamic acid
palpation 3x500 mg
Hb: 8,4 g/dL
Ht: 28%
RBC: 4,0 mil/mL
WBC: 6.600 /mL
Platelets: 222.000 /mL
MCV: 71 fL
MCH: 21 pg
MCHC: 30 g/dL
FOLLOW UP (JULY 16 ,
TH 2017)
SUBJECTIVE OBJECTIVE THERAPY
Patient has no General condition: stable, Patient was
complaint does not look ill discharged from the
BP: 130/80 mmHg hospital
HR: 82 bpm
RR: 20 x/min
Temp: 36,2oC
Anemic conjunctiva -/-
Abdomen: palpable solid
mass above symphisis,
smooth surface, no
tenderness on palpation
Hb: 10,1 g/dL
WBC: 10.100 /mL
Platelets: 229.000/mL
CASE
ANALY
SIS
RISK FACTORS
THEORY CASE
Age (late reproductive
47 years old
years)
Early menarche Menarche at 12 years old
African-American ethnicity Asian ethnicity
Nulliparity Nulliparous
Obesity BMI 21,9 kg/m2 (normal)
DIAGNOSIS
THEORY CASE
SYMPTOMS:
menstrual abnormalities (menorrhagia, menorrhagia (+), the patient used 24 pads a
metrorrhagia) day, for 10-15 days
metrorrhagia (+), patient doesnt know her
menstrual cycle, only that it happens twice a
month
dysmenorrhea dysmenorrhea (+)
dyspareunia dyspareunia (-)
infertility Patient has secondary infertility
pressure symptoms Pressure symptoms (+), has trouble
defecating and urinating
recurrent pregnancy loss (miscarriage,
Patient had miscarriage in 2000
preterm labor)
lower abdominal or pelvic pain abdominal/pelvic pain (-)
abdominal enlargement Patient has abdominal enlargement since 5
years ago.
DIAGNOSIS
THEORY CASE
PHYSICAL EXAMINATION:
General examination reveals varying General condition: moderately ill
degrees of pallor Vital signs are all in normal limit
Hypovolemic shock in severe bleeding Anemic conjunctiva +/+
Dry and anemic oral mucous membrane
Abdominal Examination: Abdomen
Inspection: abdominal lump or swelling Inspection: convex, mass in lower abdomen
Palpation: Auscultation: bowel sound (+) 4 x/minute
Firm mass, maybe cystic in cystic Palpation:
degeneration. palpable solid mass on the center of
Margins are well-defined. abdomen, from symphisis pubis to two
Surface is nodular; may be uniformly fingers above umbilicus
enlarged in a single fibroid. strictly defined borders
Mobility is restricted from above smooth surface
downwards but can be moved from side to no tenderness
side. no fluctuation
Percussion: swelling is dull. Percussion: dull on mass area, but tympani on
other areas
DIAGNOSIS
THEORY CASE
PHYSICAL EXAMINATION:
Bimanual Pelvic Examination: Bimanual Pelvic Examination:
uterus irregularly enlarged by the swelling palpable firm, irregularly enlarged uterus
felt per abdomen. can be moved from side to side
That the swelling is uterine is evidenced by: the cervix moves with the movement of
Uterus is not felt separated from the swelling the mass felt per abdomen.
and as such a groove is not felt between the
uterus and the mass
The cervix moves with the movement of the
tumor felt per abdomen.
LABORATORY EXAMINATION:
Hematology results would show an anemic Hb 4.0 g/dL ()
state in which there will be low hemoglobin, Ht 16% ()
hematocrit, and erythrocyte because of the RBC 2.8 mil/mL ()
bleeding.
DIAGNOSIS
THEORY CASE
ULTRASOUND IMAGING:
Uterine contour is enlarged and distorted. USG image shows an enlarged uterus with
Depending on the amount of connective hyperechoic lesion.
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.
MANAGEMENT

THEORY CASE
OBSERVATION Observe general condition, vital signs, and
bleeding
MEDICAL THERAPY Transfuse with PRC until Hb > 10 g/dL, check
Sex Steroid Hormones (anti-progesterone post transfusion Hb
e.g. Mifepristone, SPRM e.g. ulipristal Give tranexamic acid 3x500 mg IV
acetate, androgens e.g. danazol and Give mefenamic acid 3x500 mg IV
gestrinone)
GnRH Agonists (Leuprolide acetate,
goserelin, luporelin, buserelin or nafarelin)
Non-Hormonal Options (Tranexamic acid,
NSAIDs, WB or PRC transfusion)

SURGICAL THERAPY
LITERA
TURE
REVIE
W
DEFINITION

UTERINE LEIOMYOMA

Benign neoplasms that arised from the uterine smooth


muscle tissue (i.e. the myometrium), composed of
disordered myofibroblasts buried in abundant
quantities of extracellular matrix that accounts for a
substantial portion of tumor volume .

-Society of Obstetricians and Gynecologists of Canada


EPIDEMIOLOGY

Commonest gynecological tumors


70-80% in women age 50s
Prevalence increases along reproductive age, peaking at 40s
Significant morbidity and impact on the womens QoL and
productivity.
RISK FACTORS

Age (late reproductive years)


CLASSIFICATION
SYMPTOMS
PHYSICAL EXAMINATION

General examination reveals varying degrees of pallor.


Hypovolemic shock in severe bleeding.
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.
Mobility is restricted from above downwards but can be moved
from side to side.
Percussion: swelling is dull.
PHYSICAL EXAMINATION

Bimanual pelvic examination: uterus irregularly enlarged by


the swelling felt per abdomen

That the swelling is uterine is evidenced by:


Uterus is not felt separated from the swelling and as such a
groove is not felt between the uterus and the mass
The cervix moves with the movement of the tumor felt per
abdomen.
ULTRASOUND IMAGING

Uterine contour is enlarged and 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.
OTHER DIAGNOSTIC
METHODS

Saline Infusion Sonography (SIS)


MRI
Laparoscopy
Histeroscopy
Histerosalphyngography
MANAGE
MENT
Observation
Medical Therapy
Surgical Therapy
OBSERVATION

Generally slow growing


Asymptomatic women with large leiomyomas can be
managed expectantly.
Symptomatic conception attempts closely follow surgery,
if possible, to limit tumor recurrence before conception.
MEDICAL THERAPY

Symptomatic leiomyomas long-term medical therapy OR


short-term preoperative adjunct.
Sex Steroid Non-Hormonal
Typically GnRH
regress Agonists
postmenopausally to relieve symptoms
Hormones Options
in anticipation of menopause.
COC and progestin Leuprolide acetate Tranexamic acid
Antiprogesteron Goserelin NSAIDs (e.g.
(e.g. Mifepristone) Nafarelin mefenamic acid)
SPRM (e.g. WB/PRC
ulipristal acetate) transfusion
Androgens (e.g.
danazol,
gestrinone)
SURGICAL THERAPY

Hysterectomy

Definitive and most common surgery.

Myomectomy
Uterus-preserving surgery that excises myomas and is
considered or women who desire fertility preservation or who
decline hysterectomy.
CONCLUSION
The diagnosis was made correctly by
the attending physician.
The management was only
symptomatic.
It is recommended to use COC and/or
leuprolide acetate if possible because
it would help shrink the leiomyoma
volume and improve bleeding
symptoms, while waiting for
menopause.
REFERENCES

1.Chapter 9: Pelvic mass. In: Hoffman BL, Schorge JO, Bradshaw KD,
Halvorson LM, Schaffer JI, Corton MM, ed. Williams Gynecology 3rd
edition. McGraw-Hill. 2016;3:202-12.

2.Chapter 19: Benign lesions of the uterus. In: Dutta DC, Konar H, ed. DC
Duttas Textbook of Gynecology 6th edition. Jaypee Medical Publisher.
2013;6:272-83.

3.Delacruz MSD, Buchanan EM. Uterine fibroids: diagnosis and treatment.


Am Fam Physician. 2017;95(2):100-7.