Date post: | 02-Jun-2015 |
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Fibroid uterus
• Disease is prevalent in one among every four women as per studies
The commonest benign tumour of uterus
Commonest benign solid tumour in female
Terminology & Definition
• “womb stone” • “scleromas” • “Fibroid”• “myoma” Benign tumors Arising from the
myometrium or muscles of its vessel walls Composed of smooth muscles interspersed with varying amounts of fibrous tissue
myoma, fibromyoma, leiofibromyoma, fibroleiomyoma, and fibroma
origin of uterine leiomyomas is
incompletely understood But cytogenetic studies have yielded
some clues Each tumor develops from a single
muscle cell – a progenitor myocyte Cytogenetic analysis has demonstrated that myomas have multiple chromosomal abnormalities.
Aetiology & Pathogenesis
• Twenty percent of abnormalities involve translocations between chromosomes 12 and 14.
• Seventeen percent involve a deletion of chromosome 7. • Twelve percent involve a deletion of chromosome 12. • oestrogen and progesterone receptors are found in higher
concentrations in uterine myomas.• There also appear to be similarities between fibroids and
keloid formation
Sites
CLASSIFICATION OF UTERINE FIBROIDS
BODY(CORPOREAL) CERVICAL
INTERSTITIAL(75%) SUBSEROUS (15%) SUBMUCOUS(5%)
SESSILE PEDUNCULATED
SUBSEROUS BROAD LIGAMENT WANDERING (PSEUDO) (PARASITIC)
ANTERIOR POSTERIOR CENTRAL LATERAL
MORPHOLOGY
BODY/CORPOREAL FIBROIDS
GROSS APPEARANCE CIRCUMSCRIBED DISCRETE ROUND FIRM,GRAY WHITE
TUMORS
SIZE VISIBLE NODULES TO MASSIVE TUMOR
CUT SECTION
SMOOTH AND WHITISH
WHORLED APPEARANCE
Secondary changes
Degenaration atrophy hyaline change calcification cystic degenaration red degenaration Torsion Infection Sarcomatous change – 0.2%
egg shell calcification
tvs
AtrophicHyaline yellow, soft gelatinous areas
Cystic liquefaction follows extreme hyalinization
Calcific circulatory deprivation precipitation of ca carbonate & phosphate
Septic circulatory deprivation necrosis infection
Myxomatous (fatty) uncommon, follows hyaline or cystic degenration
1-BENIGN DEGENERATION
Red (carneous) degenerationCommonly occurs during pregnancy Edema & hypertrophy impede blood supply
aseptic degeneration & infarction with venous thrombosis & hemorrhage
Painful but self-limitingMay result in preterm labor & rarely DIC
2-MALIGNANT TRANSFORMATIONTransformation to leiomyosarcomas occurs in
0.1-0.5%
Asymptomatic Abnormal uterine bleeding---- 30% Pain abdomen --- Mass per abdomen
symptom
Abnormal uterine bleeding• The most common symptom is menorrhagia
• Heavy / prolonged bleeding (menorrhagia) iron deficiency anemia
• But intermenstrual spotting and disruption of a normal pattern are other frequent complaints
• location of the myomas, submucous versus intramural, is not related to bleeding symptoms
• symptoms of bleeding were related to the size of myomas
• The older theory that the amount of menorrhagia is directly related to an increase of endometrial surface area has been disproven.
PAIN
• Dull aching pain of Feeling a mass
• RED DEGENERATION
• TORSION HAEMORRHAGE,
• ACUTE INFECTION
• EXPULSION OF A SUBMUCOUS FIBROID
• Back pain radiating to the lower extremities
• Dysparunea
PRESSURE EFFECTS
• If large may distort or obstruct other organs like ureters, bladder or rectum urinary symptoms, hydroureter, constipation, pelvic venous congestion & LL edema
• Rarely a posterior fundal tumor extreme retroflexion of the uterus distorting the bladder base urinary retention
• Parasitic tumor may cause bowel obstruction
• Cervical tumors serosanguineous vaginal discharge, bleeding, dyspareunia or infertility
INFERTILITY
“Woman postpones her pregnacy later fibroid postpones it”
• The relationship is uncertain
• Myomectomy is indicated only in long-standing infertility and recurrent abortion after all other potential factors have been investigated and treated.
• submucous myomas that distort the uterine cavity are the myomas that may affect reproduction
VICTOR BONNEYINVENTOR: MYOMECTOMY CLAMP AND SCREW
“ …in my early years as a
gynaecological surgeon, a
case occurred which
profoundly affected my
outlook. A lady, recently
married, wishing above all
things to have a child,
underwent a subtotal
hysterectomy on account of a
single sub‐mucous fibroid.”
Master pelvic surgeon and pioneer of
conservative surgery for the ovary and
fibroids
Clinical Examination
Clinically, the diagnosis of uterine myomas is usually confirmed by physical examination. Upon palpation, an enlarged, firm, irregular uterus may be felt.
The three conditions that commonly enter into the differential diagnosis include pregnancy, adenomyosis, and an ovarian neoplasm.
The discrimination between large ovarian tumors and myomatous uteri may be difficult on physical examination, because the extension of myomas laterally may make palpation of normal ovaries impossible during the pelvic examination.
The mobility of the pelvic mass and whether the mass moves independently or as part of the uterus may be helpful diagnostically.
INCIDENCE OF CLINICALLY DETECTABLE FIBROIDS IN PREGNANCY VARIES FROM 1 IN 500 TO 1 IN
1000.
Effect of pregnancy on fibroid
INCREASE IN SIZE– oestrogen and progestrone
RED DEGENERATION – charecterised by rapid enlargement of fibroid, acute onset of pain over the fibroid, mild pain and vomiting……..self limiting……
INFECTION of the fibroid in peuperium
TORSION OF A PEDUNCULATED FIBROID
Position size and type of fibroid determine their effect on pregnancy
Most complications occur when the fibroid is submucous and close to the placental implantation site.
Effect of fibroid on pregnancy
Miscarriage and preterm labour.
Both in first and second trimester
Antepartum
Malpresentations Non-engagement of head Uterine inertia Obstructed labour PPH and retained placenta Difficulty at CS
Intrapartum
Puerperal infection and morbid puerperium
Postpartum
Thanks to VISHNU H LAL & AL VAHSAB