Fibroid Flashcards
Fibromyomas subtypes
Leiomyoma
Fibroma
Fibroids
Myomas
Evidence in support of oestrogen and progesterone dependence of myomas
. Rarely found before puberty and cease to grow after menopause
. New myomas rarely appear after menopause
. Association with hyperorstrogenism
. Increase in size during pregnancy and ocp use and shrink after delivery
. Treatment with mifepristone shrinks it,gnrh also shrinks it
. Risk factors are early menarche,nullipara and low parity
Unusual forms of leiomyoma
. Intravenous leiomyomatosis
Characterized by polypoid projections of smooth muscle tumours into the veins of the parametrium and broad ligaments. During surgery they appear as worm like cords of benign fibrous tissue when pulled out of the veins. Fragments of tumour emboli can cause obstruction of blood flow from atrium and sudden death.
. Disseminated intraperitoneal leiomyomatosis involving large area of subperitoneal surfaces,seen during pregnancy and while on ocp. Often associated with adenomyosis,pelvic endometriosis and pid
Why degeneration starts centrally
Vessels that supply the fibroid lie in the capsule and send radial branches into the tumour. So central receives least blood supply
Varieties of fibroid
. Intramural
. Submucous
. Subserous
. Cervical
. Pedunculated
. Parasitic
Extra uterine myoma locations
Round ligament
Utero ovarian ligament
Utero sacral ligament
Vagina
Vulva
Parasitic, omentum
Pseudo meigs syndrome
Pedunculated fibroid can cause right sided hydrothorax and ascites mimicking malignant ovarian tumor.
Secondary changes and complications oin fibromyomas
. Hyaline change,cystic degen and atrophy
. Calcareous degen,osseus degen
. Red degen
. Sarcomatous change
. Torsion,hemorrhage
. Infection/ulceration,in dependant part of submucous polyp
. Inversion of uterus
. Endometrial ca associated with fibromyoma
. Endometrial and myohyperplasia
. Accompanying adenomyosis
. Parasitic fibroid
DD of red degen(patient febrile,moderate leucocytosis and raised esr,aseptic condition)
Appendicitis
Twisted ovarian cyst
Pyelitis
Accidental hemorrhage
Clinical symptoms of fibroids
. Menstrual disturbances- menorrhagia,polymenorrhagia,intermenstrual bleeding,continuous bleeding,post menopausal bleeding
. Infertility
. Pain- spasmodic,dysmenorrhea,backache,abdominal
. Lump in abdomen or mass protruding at introitus
. Pressure symptoms on adjacent viscera-bladder,ureters,rectum
. Pregnancy losses,pph uterine inversion
. Vaginal discharge
DD of fibroids
. Hematometra/ pyometra
. Pregnancy
. Adenomyosis
. Bicornuate uterus
. Endometriosis
. Ectopic pregnancy
. Chronic pid
. Ovarian tumour
. Chronic inversion
. Full bladder
. Bilateral tubo ovarian masses
. Pelvic endometriosis
. Endometrial ca
. Uterine sarcoma
. Ovarian neoplasms
. Paraovarin cysts
. Pelvic kidney
Round ligament corresponds developmentally to
Ubernaculum testis
Round ligaments are morphologically continuos with
Ovarian ligaments
Inv for fibroids
. HB and blood grp
. USG shows well defined hypoechooc with cystic spaces, check number location and size,useful in follow up,does not recognise sarcomatous change.
. Doppler helps diff between fibroids and adenomyosis
. Hsg for patency
. Hysteroscopy for submucous fibroid
. D and c to rule out endometrial ca
. Radiography for calicified
. MRI accurate in identifying adenomyosis and sarcoma
. 3d sonography for exact location
Indication for trmrnt of asymptomatic fibroid
. Infertilty caused by cornual fibroid,habitual abortions due to submucous fibroid
. More than 12 weeks size
. Pedunculated cuz it could cause torsion
. Pressure on ureter bladder,causing uti
. In menopausal women cuz malignancy
. When nature of tumour cannot be ascertained clinically
. All synptomatic
Medical therapy
. Iron therapy for anemia
. Mirena for menorrhagia,in uterus less than 12 weeks size
. RU486 , mifepristone 10-25 mg daily for 3 months,shrinkage by 50%
. Danazol 400-800 mg daily for 3-6 months,shrinkage by 60%
. Low dose ocp,gestrinone 2.5 mg thrice a week
. Asoprisnil,SERM, better than mifepristone
Gnrh therapy
. In premenopausal and young women
. 3 monthly leuprolide acetate 11.23 mg
. Pure antioestrogen faslodex
Surgical methods for fibroid removal
Myomectomy
. Vaginal myomectomy
. Laparoscopic myomectomy
Uterine artery embolization
MRI guided percutaneous laser ablation using high frequency intensity focused ultrasound
Hysterectomy
. Abdominal
. Vaginal
. Laparoscopic
When should myomectomy be performed
In pre ovulatory menstrual cycle to reduce blood during surgery
Disadvantage of laparoscopic myomectomy
More bleeding due to non applicability of hemostatic clamp
What is intercede
Oxidized regenerated cellulose to prevent or reduce adhesions
Contra indications of UAE
. Subserous and pedunculated,cuz necrosis and fall into peritoneal cavity
. Submucous fibroid not cured
. Infertility rate increased due to adhesions
. Calcified fibroid cannot shrink
. Associated inflammatory disease may preclude the employment of dis technique
Technique of UAE
Femoral catheterization,using polyvinyl alcohol,gel foam particles or metal coils
Other indications for UAE
. Av aneurysm or increased uterine vascularity causing menorrhagia
. Pph
. Placenta accreta to reduce bleeding before placental removal or cs delivery
Abdominal hysterectomy includes
. Total hysterectomy
. Subtotal,when cervix is retained
. Panhysterectomy(TAH,with b/l salphingo oopherectomy
. Extended and wertheim hysterectomy in cancer of cervix and uterine cancer
Advantages of subtotal hysterectomy
. Sexual function,for normal cervical discharge
. Vault prolapse is less common.less bleeding and less risk of bladder and ureter trauma
. Less morbidity, due to trauma of bladder and denervation,causing difficulty in micturition and incontinence
.
Disadvantages of conserving ovaries
. Benign or malignant ovarian tumour
. Residual ovarian syndrome,and cause dyspareunia
. Atrophy due to linking of vessels,causing early menopause
Complications of hysterectomy
. Primary reactionary and secondary hemorrhage
. Trauma to bladder,ureter and bowel
. Sepsis
. Anaesthetic complications
. Paralytic ileus,intestinal obstruction due to adhesions
. Thrombosis,pulm embolism,chest infection
. Burst abdomen,hernia
. Post op infection
Adhesions
