UTERINE FIBROIDS

Bashi Mwewa

INTRODUCTION

• Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing age.

• It can grow inside, outside or within the uterine wall they can also be attached to the uterus by the stem like structure.

• A single cell divides repeatedly, eventually creating a firm, rubbery mass distinct from nearby tissue. The growth patterns of uterine fibroids vary — they may grow slowly or rapidly, or they may remain the same size. Some fibroids go through growth spurts, and some may shrink on their own.

DEFINITION

• These are benign tumor of the smooth muscles of the uterus characterised by menstrual disturbances and enlargement of the abdomen.

INCIDENCE

Fibroids are most common tumors of female pelvis. They occur in female aged 35-50 years.

fibroids rarely occur before menarche.

PATHOLOGY

• The tumour arises from the myometrium and grows slowly though sudden spurt of growth.the tumour are relatively avascular but carries its blood supply from the pseudo capsular layer. since the entire blood supply is derived from the pseudo capsular layer.thegrowth of tumour often outdstrips its blood supply ,and avascular degeneration of the tumour arises.

CAUSES OF FIBROIDS

• Idiopathic

• Hereditary

• Race

• Infertility

• Age

COMMON SITES OF UTERINE FIBROIDS

CLASSIFICATIONS

• SUBMUCOSAL-These grow just underneath the inner uterine lining (endometrium)

• INTRAMURAL-These grow within the muscular wall of the uterus in between layers of the muscle(myometrium).

• SUBSEROSAL- These grow on the out side of the uterus.

• CERVICAL-These are located in the wall of the cervix.

SIGNS AND SYMPTOMS

Menorrhagia due to increased endometrial surface overlying the fibroids

Inter menstrual bleeding

Enlargement of the abdomen due to enlargement of the fibroids

Frequency, urgency and incontinence urine

dysuria

Backache

Dyspeurania

SIGNS AND SYMPTOMS CONT….

Rectal pressure leading to constipation

Habitual abortion

On palpation the uterus feels bigger with irregular shapes equivalent to pregnant uterus

Vaginal bleeding after menopause

Abdominal clamps

Pelvic pain

DIAGNOSIS

• History taking

• Laparoscopy

• Pelvic ultra scan

• MRI-This is more accurate than u/s and shows the number of fibroids and their location

COMPLICATIONS

Infertility-when the uterine cavity is dislodged by tumourAnaemia-from continuous bleedingPossible intestinal obstruction-if tumours are

large or twist nearby organ.Spontaneous AbortionEctopic PregnancyPremature laborDystociaCancer

TREATMENT

• Treatment can be medically or Surgically

MEDICAL MGT

• Give Gonadotrophin Releasing Hormone- This help in decreasing the size of fibroids before surgery.

• This drug also gives an opportunity for a surgeon to select optimal surgical intervention

• The maximum effect is about 12 weeks after starting the treatment.

• The fibroid can reoccur 6 months after discontinuing the drug.

SIDE EFFECTS

• Osteoporosis

• Mood changes

• Vaginal dryness

SURGICAL MANAGEMENT

1. HYSTEROSCOPY RESECTION-This is the removal of the submucosal fibroids using instruments inserted through the vagina and cervix into your uterus.

2. ENDOMETRIAL ABLATION-They use this to remove submucosal fibroids using cautry laser.

3. MYOMECTOMY-This is the surgical removal of submucous fibroids. It can be performed through laparascopy or laparatomy

SURGICAL MGT CONT….

4.HYSTERECTOMY-This is the surgical removal of the uterus together with the fibroids

PRE OPARETIVE CARE

AIMS

To prepare the patient physically and psychologically for surgery

To prevent intra and post operative complication

To alley anxienty

Admission

• Patient is admitted 48-72 hours before surgery in order to carry out all the necessary preparation ordered by the surgeon and also to orient the patient

Psychological care

• introduce yourself to establish good rapport

Psychological care cont…

• Explain the condition to both the patient and the family members so that they can understand the complication that may arise if not treated.

• Explain the type of operation to both the patient and the family members,if in doubt invite the surgeon to explain fully

Psychological care

• Stress the importance of surgical treatment as a helpful option , to help client develop confidence in the surgical approach to treatment.

• Explain to the patient that pain management during and after surgery will be done using strong analgesics to alley the fear related to pain

Psychological care

• Allow the patient to ask questions and answer them correctly to help express her fears and anxiety about surgery

• Explain the possibility for blood transfusion to avoid imposing treatment on the patient or infringing on the patients religion beliefs

Informed consent

• after giving psychological care and the patient the patient understand the condition and type of surgery to be done

• Allow the patient to sign a consent form and explain to her that its legal document allowing the surgeon to carry out a surgical procedure on her.

PHYSICAL PREPARATION

NUTRITION

• Patient should have good nutrition status before surgery

• Give protein and vitamin supplement to promote quick healing of the wound post operatively.

• Give food rich in roughage to prevent constipation

PHYSICAL PREPARATION

INVESTIGATION

• Ultra sound to visualise the location of fibroids

• Urinalysis is done in order to rule out diabetismellitus and other complications

• Blood should be collected for haemoglobin/haematocrit estimation to rule out anaemia

• Bleeding and clotting time to rule out bleeding disorders, HB

• Blood for grouping and x-matching incase of need for blood transfusion

SKIN PREPARATION

• Clean the skin around the operating site with soup and water to prevent microorganism from entering the operating site during surgery

• Shave or trim the hair according to the surgeons preference

BOWEL PREPARATION

• This is done to prevent constipation

• Give enema

• Give food rich in roughage

• Encourage oral fluid after meal

BLADDER CARE

• Encourage patient to empty the bladder before going to theatre to avoid urine incontinence during surgery

• Insert the urine catheter so that the bladder is ever empty to prevent damage during operation.

PRE MEDICATION

• Give prescribed pre medication 30min to 1 hour before operation such as Diazepam to reduce anxiety , Atropin to dry up secretion

• Insert an iv line and administer intra venous fluid to rehydrate and to keep the vein open

HYGIEN

• If the patient is ambulant allow her to take a bath to promote blood circulation

• Allow her to brush the teeth

OBSERVATION

• Check vital signs to act as baseline data to compare with intra and post operative vital signs

• observe general condition of the whether fit for surgery or not.

JEWELLARIES

• Remove all jewelaries and put in the sisters cupboard for safe keeping

• Cover the wedding ring with strapping if it can not be removed.

DENTURES

Remove the dentures if any and put them in cup with water to prevent dislodging during intubation and cause airway obstruction

I will label and store in the sisters cupboard for safe keeping to avoid loosing then

If patient has loose teeth,I will inform the anaesthetist to ensure care during intubation

IDENTITY

I will put an identity band on the hand or forehead

Stating the name , age ,sex , procedure , bed number , ward and diagnosis

This are done so that patient can be easily identified

GOWNING

• Remove patient’s clothes and dress her in a theatre gown to prevent cross infection

• I will also cover patients hair to prevent cross infection

TRANSPORTATION TO THEATRE

• Collect all documents for the patient eg case record , investigation results

IEC

• Educate patient that physical activities will be restricted for at least 2 months

• Heavy lifts and gardening , cooking restricted for 2 months

• Educate patient that sexual intercourse should be avoided until wound heals

POST OPERATIVE CARE

AIMS

• To ensure that patient recovers fully from the effect of surgery and Anaesthesia

• To relieve pain

• To prevent complications such as haemorrhage

ENVIRONMENT

• I will prepare necessary equipments such as iv pole , suction machine , oxygen machine and emesis bowl ready for use in case need arise

• I will nurse my patient in a warm and well ventilated roomy to promote free air circulation.

• I will ensure that the room is quiet to promote rest this will be achieved by playing radios and TVs at low volume, oiling squeaking trollies and answering phone promptly.

• The room will be well light for easy observation

POSITION

• While in anaesthesia ,I will nurse the patient in a semi prone position to facilitate free drainage of secretions

• After the patient recover from anaesthesia I will nurse her in a position of comfort to reduce pain and promote rest

• On the first day post operatively I will prop up the patient in semi fowlers position with head supported by pillow to promote free lung expansion

OBSERVATION

• I will check vital signs temperature, pulse respiration and blood pressure 1/4hrly, 1/2hrly, hrly, 4hrly and twice daily as patient improves to detect any abnormalities

• Elevation in temperature will indicate infection

• Decrease in pulse will indicate internal haemorrhage

• I will examine the operating site and check dressing for any bleeding ,if any I will apply pressure on the dressing to reduce bleeding

• Watch for post op chills and keep the patient comfortably warm to prevent hypothermia and cardiac stress

PAIN RELIEF

• Administer prescribed opiod analgesics e.g. pethidine to relieve post operative pain.

• Later give oral mild analgesic e.g. brufen or diclofenac as prescribed

• I will examine the