Nursing Management of MYOMATOUS/UTERINE FIBROIDSPresented by Horace WilliamsMScN, BScN, Cert. Psychiatry. Dip. RNDepartment of NursingNCU
Objectives
Key Terminologies
DEFINITON & INCIDENCE OF FIBROIDS
What is a leiomyomaIt is a benign neoplasm of the muscular wall of the uterus composed primarily of smooth muscle Can be solitary or multiple in the lining (intracavitary), muscle wall (intramural) and outside (serosal) surface of the uterus
(Smeltzer et al., 2010)
What is the incidence of leiomyomasThey are the most common pelvic tumorsIt is found in 25% of white women & 50% of black womenOccur in 20-40% of women during reproductive lifeGenetically predisposed and most times benignUsually develop in women between 25-43 years oldFibroids are a common reason for hysterectomy due to menorrrhagia which can be difficult to control(Smeltzer et al., 2010)
ETIOLOGY AND PATHOPHYSIOLOGY OF FIBROIDS
UnknownEach individual myoma is unicellular in origin Estogens a possible factor no evidence that it is it has been implicated in growth of myomasMyomas contain estrogen receptors in higher concentration than surrounding myometrium
Myomas may increase in size with estrogen therapy & in pregnancy & decrease after menopauseThey are not detectable before pubertyProgestrone increase mitotic activity & reduce apoptosis resulting in increased sizeThere may be genetic predisposition
PATHOPHYSIOLOGYFibroid are frequently multiple
They may reach 15 cm in size or even larger
They are usually Firm, spherical or irregular lobulated
Usually encoated within a false capsule
Can be easily enucleated from surrounding myometrium
CLASSIFICATION OF FIBROIDS
Submucous leiomyomaPedunculated submucousIntramural or interstitialSubserous or subperitonealPedunculated abdominalParasiticIntraligmentaryCervical
CLINICAL MANIFESTATIONS
1-SYMPTOMSSymptomatic in only 35-50% of patients
Symptoms depend on location, size, changes & pregnancy status
1-Abnormal uterine bleeding
The most common 30% of patients
Heavy / prolonged bleeding (menorrhagia) leads to iron deficiency anemia
1-Abnormal uterine bleeding Submucous myoma produce the most pronounced symptoms of menorrhagia, pre & post-menstrual spotting
Bleeding is due to interruption of blood supply to the endometrium, distortion & congestion of surrounding vessels or ulceration of the overlying endometrium
Pedunculated submucous results in areas of venouse thrombosis & necrosis on the surface leading to intermenstrual bleeding
2-PAINVascular occlusion results in necrosis, infectionTorsion of a pedunculated fibroid leads to acute painMyometrial contractions to expel the myomaRed degenration results acute painHeaviness fullness in the pelvic area lead to feeling a massIf the tumor gets impacted in the pelvis this results in pressure on nerves leading to back pain radiating to the lower extremitiesDysparunea if it is protruding to vagina
3-PRESSURE EFFECTS
If myoma is large it may distort or obstruct other organs like ureters, bladder or rectum leading to urinary symptoms, hydroureter, constipation, pelvic venous congestion & LL edema
Rarely a posterior fundal tumor results in extreme retroflexion of the uterus distorting the bladder base leading to urinary retention
Parasitic tumor may cause bowel obstruction
Cervical tumors results in serosanguineous vaginal discharge, bleeding, dyspareunia or infertility
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4-INFERTILITYThe relationship is uncertain 27-40% of women with multiple fibroids are infertile but other causes of infertility are presentEndocavitary tumors affect fertility more
5- SPONTANEOUS ABORTIONSincidence before myomectomy 40%after myomectomy 20%More with intracavitary tumors
DIAGNOSTIC TESTS USED TO DETECT FIBROIDS
EXAMINATIONMost myoma are discovered on routine bimanual pelvic exam or abdominal examinationRetroflexed retroverted uterus obscure the palpation of myomas
LABORATORY FINDINGSAnemiaDepletion of iron reserveRarely erythrocytosis results in pressure on the ureters leading to back pressure on the kidneys results in increased erythropoietin
Acute degeneration & infection results in increased ESR, leucocytosis and fever
IMAGINGPelvic ultrasound is very helpful in confirming the diagnosis & and excluding pregnancy / particularly in obese patientsSaline hysterosonography (HSG) can identify submucous myoma that may be missed on ultrasoundHSG will show intrauterine leiomyoma
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Magnetic Resonance Imaging (MRI): highly accurate in delineating the size, location and numbers of myomas , but not always necessary
Intravenous Pylegram (IVP) : will show ureteral dilatation or deviation and urinary anomalies
Hystroscopy : for identification and removal of submucous myomas
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COMPLICATIONS OF FIBROIDS
1-COMPLICATIONS IN PREGNANCY Less than 2/3 of women with fibroids and unexplained infertility conceive after myomectomy
Red degeneration In the 2nd or 3rd trimester of pregnancy rapid increase in size leads to vascular deprivation results in degeneration
Causes pain & tendernessMay initiate preterm laborManaged conservatively with bedrest & narcotics and tocolytics if indicatedAfter the acute phase pregnancy will continue to termDURING LABORUterine inertiaMalpresentationObstruction of the birth canalCervical or isthmeic myoma necessitate CSPost Partum Hemorrhaging
COMPLICATIONS IN NON PREGNANT WOMEN
Heavy bleeding with anemia is the most commonUrinary or bowel obstruction from large parasitic myoma is much less commonMalignant transformation is rareUreteral injury or ligation is a recognized complication of surgery for Cx myomaNo evidence that COCP increase the size of myomas
Postmenopausal women on Hormone Replacement Therapy must be followed up with pelvic exam or ultra sound every 6 months
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MEDICAL MANAGEMENT OF FIBROIDS
MANAGEMENT DEPENDS ON:AgeParityPregnancy statusDesire for future pregnancyGeneral healthSymptomsSize Location
(Smeltzer et al., 2010)
EMERGENCY TREATMENT- ABlood transfusion/ PRBC to correct anemia
Emergrncy surgery indicated for: - infected myoma -acute torsion -intestinal obstruction
Myomectomy is contraindicated during pregnancy
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SPECIFIC MEASURES - BMost cases asymptomatic NEEDS no treatmentPostmenopausal NEEDS no treatmentOther causes of pelvic mass must be excludedThe diagnosis must be certainInitial follow up every 6 months to determine the rate of growth of the myomaSurgery is contraindicated in pregnancyThe only indication for myomectomy in pregnancy is torsion of a pedunculated fibroid
Myomectomy is not recommended during Caesarian Section (CS)Pregnant women with previous multiple myomectomy / especially if the cavity was entered should be delivered by CS to reduce risk of scar rupture in labor
PHARMACOTHERAPY GNRH AGONISTS (Leuprolide)Treatment results in: 1- Reduced size of the myomas by a maximum of 50% 2- This shrinkage is achieved in 3 months of treatment 3-Amenorrhea & hypoestrogenic side-effects occur 4-Osteopososis may occur if treatment last greater 6 months
SUPPORTIVE MEASURES - CPAP smear & endometrial sampling for all patients with irregular bleedingBefore surgery-Correct Hemoglobin levels-Prophylactic antibiotics-Mechanical & antibiotic bowel preparation if difficult surgery is anticipatedProphylactic heparin postoperative
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SURGICAL MEASURES - D1- Evaluation for other neoplasia2 - MyomectomyFor symptomatic patient who wish to preserve fertility Open myomectomyLaparoscopic myomectomyHysteroscopic myomectomy (Smeltzer et al., 2010)3-HysterectomyVaginal hysterectomyAbdominal hysterectomy4 - Uterine artery embolisation (Dutton, Hurst, Mcpherson et al., 2007)
Nursing management post hyesterctomy/myomectomy up coming lecture
41 year old G3P3 AAF presents to clinic with c/o abdominal bloating, pelvic pain, and pressure. C/o feeling her uterus through her abdomen as if she was pregnant, but she had a BTL 8 yrs ago. Menses are q28days with heavy bleeding and large clots, lasting 9 days. Exam reveals a 14-week irregular shape, mobile uterus and normal adnexa bilaterally.