Pre-operative Conference

Presented by:
Sarah Manaloto MD
Patient Profile:
 RD
 43 years old
 G4P4 (4004)
 Married
 Filipino
 Roman Catholic
 City of San Fernando, Pampanga
Chief Complaint:

 Palpable
hypogastric mass
History of Present Illness:
5 years PTC:
Palpable hypogastric mass,
described as fixed, smooth,
non-tender, approximately 5 x
5 cm
No consults done, no
medications taken
5 months PTC:
(+) increase in size of the hypogastric
mass, approximately double the
initial size
Associated with pelvic heaviness,
occasional numbness and
paresthesia at the lower extremities
especially during prolonged standing
or walking
1 month PTC:
 (+) worsening of pelvic discomfort
 Accompanied by constipation,
urinary urgency and frequency
 Consult done with a PMD, TVS was
requested showing:
TVS (07/26/2019)
 Uterus: 6.87 x 6.49 x 9.23 cm, retroverted
 Left anterolateral myoma with cystic degeneration measuring 9.76 x
9.62 x 9.70 cm
 Left lateral posterior mid segment myoma nodule measuring 1.72 x
1.65 x 2.02 cm
 Posterior upper segment myoma measuring 4.98 x 4.87 x 4.45 cm
 Posterior mid segment myoma nodule measuring 0.95 x 1.36 x 1.15
cm
 Right lateral lower segment myoma measuring 3.35 x 2.67 x 2.80 cm
 Posterofundal myoma nodule measuring 1.43 x 2.13 x 1.59 cm
 Anterior upper segment myoma measuring 3.24 x 3.51 x 3.11 cm
 Anterior mid segment myoma nodule 1.49 x 1.57 x 1.47 cm
 Patient was advised for surgery

 Due to financial constraint, patient sought

consult at our institution
Past Medical History:

(-)Hypertension
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Heart Disease
(-) Allergies
(-) Surgery
Family History:
(-) Hypertension
(-) Asthma
(-) Diabetes Mellitus
(-) Cancer
(-) Allergies
(-) Thyroid Disease
(-) Heart Disease
Personal and Social History:

(-) Smoking
(-) Alcohol
beverage drinking
Denies illicit drug
use
BPO agent
OB History:
G4P4 (4004)
G1 1993 FTBG NSD HOSPITAL- MD - NO
DELIVERED ASSISTED COMPLICATIONS
G2 1994 FTBG NSD HOSPITAL- MD - NO
DELIVERED ASSISTED COMPLICATIONS
G3 1996 FTBG NSD HOSPITAL- MD - NO
DELIVERED ASSISTED COMPLICATIONS
G4 2004 FTBB NSD + BTL HOSPITAL- MD - NO
DELIVERED ASSISTED COMPLICATIONS
Menstrual History:
 M – 11 years old
 I – 28-30 days
 D – 7 days
 A – 3 pads per day, moderately
soaked
 S – (+) dysmenorrhea
 LMP: JULY 26, 2019
 PMP: JUNE, 3RD WEEK, 2019
Gyne History:
 Age of first sexual contact: 17 years
old
 No. of sexual partner: 1
 (-) Dyspareunia
 (-) Post coital bleeding
 (+) OCP use – 1993 x 2 months
 (-) Sexually Transmitted Infections
 (+) Pap smear – 1994 (normal findings)
Review of Systems:
 General: no weakness or fatigue, no weight loss
 Skin: no itchiness or dryness, no rashes
 Eyes: no redness, no discharge or pain
 Ears: no discharge, no pain
 Nose and Sinuses: no nose bleeds or discharge
 Mouth and Throat: no swelling, no bleeding gums
Neck: no lumps, no swollen glands
Gastrointestinal: no vomiting, no changes
in bowel habits, no rectal bleeding
Genitourinary: no hematuria, no dysuria
Hematologic: no bleeding, no bruising
Neurologic: no seizures
Physical Examination:
General: conscious, coherent,
ambulatory, not in respiratory distress

Vital signs:
 BP: 100/70 mmHg PR: 80 bpm
RR: 18cpm Temp: 36.8OC
 Current weight: 79 kg
 Height: 1.63 m
 BMI: 29.7 kg/m2 (Obese – Asian)
 HEENT: anicteric sclerae, pink palpebral
conjuntivae
 Lungs: symmetrical chest expansion, (-)
retractions, clear breath sounds
 Heart: adynamic precordium, normal rate and
rhythm, (-) murmurs
 Abdomen: flabby, with normoactive bowel
sounds, non-tender, (+) midline, firm, moveable
hypogastric mass measuring 8 x 9 cm, non-
tender
Pelvic Exam:
GE: normal looking external genitalia, no
lesions or masses noted.

Speculum Exam: Vaginal wall is pink.

Cervix is pink, smooth with no lesions
noted. No foul smelling discharge.
IE: Cervix is short, firm, closed. Uterus
enlarged to 14 weeks size, no
adnexal mass, no adnexal
tenderness

RE: good sphincter tone, collapsed

rectal vault, no blood on examining
finger.
TRANSVAGINAL
ULTRASOUND (08/05/2019)
 The uterus is retroverted with smooth contour and
homogenous echopattern measuring 7.8 x 7.8 x
9.3 cm (the cervix measures 5.1 x 2.9 cm with
homogenous stroma and district endocervical
canal).
 There are 7 well-circumscribed, heterogenous,
myometrial masses seen.
 The endometrium is trilaminar and measures 0.8
cm. The subendometrial halo is intact.
 The right ovary measures 3.8 x 2.7 x 2.2 cm with a
unilocular cyst measuring 1.9 x 1.3 x 1.2 cm with
low level echo fluid within.
 The left ovary measures 2.4 x 2.4 x 1.7 cm . There
are no adnexal masses seen.

 There is no free fluid in the cul-de-sac

 M1: 9.1 x 9 x 9.8 cm anterior isthmus to
midcorpus, intramural with subserous
component with a cystic space measuring
6.8 x 8.0 x 6.3 cm with low level echo fluid
within
 M2: 4.2 x 5.1 x 4 cm posterofundal,
intramural
 M3: 3.4 x 3.5 x 3.9 cm anterofundal,
intramural
 M4: 2.6 x 2.8 x 2 cm posterior isthmus,
intramural
 M5: 1.7 x 1.8 x 1.9 cm posterofundal,
intramural
 M6: 1.3 x 1 x 1.1 cm posterior midcorpus,
Impression:
 Multiple myoma uteri, intramural and intramural
with subserous component with cystic
degeneration

 Proliferative phase endometrium

 Right ovarian cyst, probably an endometriotic

cyst

 Normal left ovary

Salient Features
Pertinent Positives Pertinent Negatives
 43 y/o  No abnormal vaginal bleeding

 Multipara  No menstrual schedule changes

 Enlarging hypogastric mass  No weight loss

 Numbness and paresthesia of the

lower extremities

 Changes in bowel and bladder

habit

 Dysmenorrhea

 OCP use

 Obese
Differential Diagnosis
ASSESSMENT:

 MULTIPLE MYOMA UTERI

 G4P4 (4004)
PLAN:

TOTAL ABDOMINAL
HYSTERECTOMY BILATERAL
SALPHINGECTOMY
THANK YOU!