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MRCOG - Part 2 > Fibroids > Flashcards

Fibroids Flashcards

1
Q

What are fibroids

A

Benign tumours arising from the myometrium of the uterus.

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2
Q

Types of fibroids

A
  1. Subserosal
  2. Intramural
  3. Submucosal
  4. Pedunculated
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3
Q

What is submucosal fibroid

A

develop near the outer serosal surface of the uterus and extend into the peritoneal cavity.

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4
Q

symptoms of Subserosal fibroids

A

Asymptomatic; may cause pressure symptoms.

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5
Q

What is Intramural fibroids

A

fibroids develop within the myometrium

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6
Q

symptoms of intramural fibroids

A

May cause HMB, dysmenorrhoea

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7
Q

Symptoms of submucosal fibroids

A

May cause HMB, pain, and subfertility.

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8
Q

What are submucosal fibroid

A

develop near the endometrial surface of the uterus and extend into the uterine cavity

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9
Q

What are pedunculate fibroids

A

attached to the myometrium by a pedicle. May cause torsion

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10
Q

History (symptoms and signs) of Fibroids

A
  • Symptoms depend on the size, number, and location of the fibroids
  • Heavy & prolonged bleeding (most common)
  • Abdominal swelling, pelvic or abdominal pain or discomfort.
  • Dyspareunia.
  • Pressure symptoms – constipation or urinary symptoms such as
    frequency or difficulty in voiding.
  • Acute, severe abdominal or pelvic pain following torsion of a pedunculated fibroid or ‘red degeneration’.
  • Subfertility, miscarriage.
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11
Q

Abdominal examination in case of fibroids

A

mass arising from the pelvis, smooth/multi-nodular, firm, mobile from side-to-side.

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12
Q

Pelvic examination in case of fibroids

A
  • mass arising out of the pelvis, with an irregular knobbly shape, a firm or hard consistency, and can be moved slightly from side-to- side.
  • Any movement of the abdominal mass moves the cervix
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13
Q

Prevalence of fibroids

A

Prevalence increases progressively from puberty until the menopause.
- 40–60% of women have fibroids by 35 years of age.
- which is increased to 70–80% by 49 years of age.

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14
Q

Do fibroids resolve with age

A

Usually shrink after menopause as they are promoted and maintained by oestrogen and progestogen.

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15
Q

Prevalence of fibroids is higher in which groups?

A
  • Black women
  • Women with early onset of puberty.
  • Obese women – probably due to higher oestrogen levels.
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16
Q

Gynecological risks due to fibroids

A
  • HBM – anaemia, affects QOL.
  • Compression of ureters by large fibroids - hydronephrosis.
  • Torsion of pedunculated fibroid – acute pain.
  • Leiomyosarcoma – minimal risk.
  • Fertility issues
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17
Q

Pregnancy complications due to fibroids

A
  • 1st and 2nd trimester miscarriage.
  • Higher rates of CS
  • Preterm delivery.
  • Malpresentation, mechanical complications in labour.
  • PPH.
  • Acute pain requiring hospital admission (5–6%) – red degeneration of
    fibroid owing to avascular necrosis (when rapid growth of a fibroid, promoted by high levels of sex hormones, outgrows its blood supply).
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18
Q

DD of fibroids

A
  • Adenomyosis: difficult to distinguish from fibroids may be associated with it
  • Pregnancy
  • Benign causes of a pelvic mass: benign ovarian mass –
    hemorrhagic cyst, dermoid cyst, or endometrioma.
  • Malignant causes of a pelvic mass: ovarian cancer,
    endometrial cancer, leiomyosarcoma
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19
Q

Investigations for diagnosis of Fibroids

A
  1. USS
  2. Saline or contrast sonographyL improves assessment of SM fibroids
  3. 3D USS
  4. MRI: superior to conventional US
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20
Q

when to refer asymptomatic fibroids to 2ry care

A
  • Fibroids are palpable abdominally.
  • Intra-cavity fibroids.
  • Uterine length on USS>12 cm.
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21
Q

Do we advise hysterectomy for asymptomatic fibroids

A

Do not advise hysterectomy for asymptomatic fibroids solely to improve detection of adnexal masses, to prevent impairment of renal function, or to rule out malignancy

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22
Q

Medical management of symptomatic fibroids

A
  1. NSAIDs
  2. Contraceptive steroids (COCs)
  3. LNG-IUS
  4. Anti-Progesterone agents (mifepristone)
  5. Aromatase Inhibitors
  6. GNRH agonists
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23
Q

How do fibroids cause HMB ?

A
  • Mass effect causing increased surface area
  • Interferes with uterine contractility
  • Increased vascularity
  • Altered prostaglandin production
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24
Q

FIGO classification for fibroids ?

A

submucosal
0 submucosal
1- <50% intramural
2 ->50% intra mural

OTHERs
3- contacts endometrium but is intramural
4-intramural
5-subserosal but> 50% intra mural
6- subserosal <50% intramural
7-oendunculated

STEPW

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25
Q

Routes for myomectomy ?

A
  • Hysteroscopic
  • Abdominal - Open, Lap, Robotic
  • Hysteroscopic for submucosal - 0,1
  • Rest - Abdominal route
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26
Q

(fibroids) When is the risk of malignancy higher ? and how to minimize risk of malignancy spreading

A

Postmenopausal
Premenopausal - if solitary large lesion not responding to GnrH or ulipristal

1 in 2000

Avoid morcellation. If done - use bags for removal

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27
Q

Disadvantage of using Gnrh prior to myomectomy?

A

Loss of surgical planes

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28
Q

Which is better in ttt of fibroids Total or subtotal hysterectomy?

A

Total obviates the need for further surgery as it removes the cervix

Subtotal associated with lesser morbidity and faster recovery

So let the patient decide

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29
Q

How do we decide the route of hysterectomy in ttt of fibroids

A

Abdominal preferred if no prolapse or associated pelvic pathology - adnexal mass, adhesions, endometriosis

Vaginal - preferred in presence of prolapse

In Abdominal - Lap preferred

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30
Q

Overall complication rate of hysterectomy?

A

4%

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31
Q

Hysterectomy accounts for what portion of genitourinary tract injury ?

A

75%

1-2% is the rate for all gynaecological procedures combined
Of these, 75% due to hysterectomy

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32
Q

Injury to GI tract during hysterectomy?

A

0.1-1%

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33
Q

Vaginal cuff dehiscence most common after which procedure?

A

TLH

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34
Q

Urinary tract injury more common after which procedure?

A

TLH

35
Q

Out of ablation and hysterectomy
More likely to undergo future gynecological surgery in terms of repeat procedure?

More likely to have surgery for incontinence, prolapse ?

A

Ablation - more common on the 1st 2 years

Hysterectomy- more likely to undergo surgery for prolapse, Incontinence

36
Q

Mode of action of anti progesterone

A

Mifepristone acts at the level of the progesterone receptors,

found in high concentration in fibroids.

37
Q

effect of anti-progesterone on fibroids

A

-Reduction in fibroid volume of 26–74% (comparable to GnRHa, slower rate of recurrent growth after cessation of mifepristone treatment).
- amenorrhoea rates up to 90%
- stable bone mineral density.

38
Q

SE of Anti-progesterone

A
  • endometrial hyperplasia without atypia (14–28%)
  • transient elevations in transaminase levels (4%) requiring LFT monitoring.
39
Q

Mode of action of Aromatase inhibitors in ttt of fibroids

A

Aromatase inhibitors block ovarian and peripheral oestrogen production and decrease oestradiol levels.
Small studies showed reduction in leiomyoma size and symptoms.

40
Q

efficacy of GNRHa in ttt fibroids

A

35–65% reduction in fibroid volume within 3 months.

41
Q

Preoperative use of GNRHa in ttt of fibroids

A

Preoperative in women with anaemia and to reduce the size of fibroids and blood loss during surgery.

no significant difference in blood loss with preop. GnRHa has shown

42
Q

Sequential regimen of GNRHa in ttt of fibroids

A
  • GnRHa is first used to achieve downregulation
  • to which steroids are added after 1–3 months of therapy, gives maximal results.
  • However, the addition of progestin add-back therapy results in an increase in mean uterine volume to 95% of baseline within 24 months.
43
Q

Disadvantages of use of preoperative GNRHa

A

it may make the fibroids softer and the surgical planes less distinct, leading to difficulty in dissection.

44
Q

GNRH antagonist effect in ttt of fibroids

A
  • advantage of not inducing an initial steroidal flare as seen with GnRH agonists.
  • Rapid effect of the GnRH antagonist
    allows a shorter duration of side effects with pre-surgical treatment.
  • Reduce fibroid volume by 25–40% in 19 days, thereby allowing surgery to be scheduled sooner
45
Q

interventions to reduce blood loss during myomectomy

A

evidence from a few RCTs is limited: misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, tourniquet, and mesna may reduce bleeding during myomectomy.

46
Q

Surgical management of fibroids

A
  • hysterectomy
  • myomectomy (abd., laparoscopic, hysteroscopic)
  • UAE
47
Q

Advantages of hysterectomy in ttt of fibroids

A
  • Relieves symptoms
  • prevents recurrence
  • provides permanent contraception
  • allows treatment with oestrogen-only HRT.
48
Q

Risks of Abdominal myomectomy

A

hysterectomy
blood loss
risk of transfusion
adhesions.

49
Q

Rate pf recurrence of fibroids after abd myomectomy

A

depends on the number of fibroids;
single leiomyoma – 27% risk
multiple leiomyomas – 59% risk.

** preoperative use of GnRH agonists affects recurrence risk.**

50
Q

Advantages of laparoscopic myomectomy over abdominal

A
  • less haemoglobin drop
  • reduced operative blood loss
  • quicker recovery, diminished postoperative pain
  • fewer overall complications but longer operation time.
51
Q

Cautions during Patient selection to laparoscopic myomectomy

A

be cautious if:
- fibroids > 5–8 cm
- multiple fibroids
- or presence of deep IM leiomyomas

as it may be associated with increased operative time and blood loss.

52
Q

Recurrence rate pf fibroids after laparoscopic myomectomy

A
  • 12% at 1 year
  • up to 84% at 8 years.
53
Q

Conversion rate of laparoscopic to abdominal myomectomy

A

11%

54
Q

Rate of complication of laparoscopic myomectomy

A

8-11%

55
Q

Indications for hysteroscopic myomectomy

A

abnormal uterine bleeding caused by SM fibroids.

56
Q

Classification for hysteroscopic myomectomy

A

Classified based on the amount of leiomyoma within the uterine cavity:
* Type 0 – completely intra-cavitary.
* Type I – < 50% intramural.
* Type II – > 50% intramural.

57
Q

Rate of Successful removal at the initial hysteroscopy myomectomy

A

85–95%

58
Q

Rate of subsequent surgery after hysteroscopic myomectomy

A

Subsequent surgery is needed in ≈ 5–15% of cases,
and most of these cases involve a second hysteroscopic procedure.

59
Q

Complications of hysteroscopic myomectomy

A

Complication rate of 1–5%
* fluid overload with secondary hyponatraemia
* pulmonary oedema
* cerebral oedema
* intraoperative and postoperative bleeding
* uterine perforation
* gas embolism
*infection.

60
Q

How is UAE is done?

A

Femoral artery is cannulated and an embolic agent is injected into the uterine arteries to impair the blood supply to the uterus and fibroids.

This has a differential effect on f ibroids (that have a higher blood supply than the surrounding myometrium).

61
Q

Effect of UAE on fibroids

A

Fibroid shrinkage – 60% by the end of 6 months with further shrinkage up to one year.

62
Q

Indications for UAE

A
  • surgery is CI.
  • unwilling to have a blood transfusion.
  • previous unsuccessful surgery for fibroids.
63
Q

Absolute CI for UAE in case of fibroids

A
  • Current or recent infection of genital tract.
  • Patient refusing hysterectomy under any circumstances.
  • Doubtful diagnosis due to the clinical factors or inadequate imaging.
64
Q

UAE has more benefits in ttt of large or small fibroids

A

the outcome for smaller fibroids is better than for larger fibroids with similar complication rates.
Large fibroid is not a contraindication.
However, volume reduction might not be sufficient to satisfy patient’s expectations.

65
Q

Pre-requisites begore UAE

A

Do not give GnRHa within 2 months prior to the procedure

66
Q

Which is better in diagnosing fibroids and adnemyosis MRI or USS

A

MRI is superior

67
Q

Action of UAE on Fibroids in presence of adenomyosis

A

Less effective

68
Q

Immediate complications of UAE

A
  1. Groin Hematoma
  2. Arterial thrombosis
  3. Pseudo-aneurysm
  4. Non-target embolization (presence of ovarian–uterine anastomoses can compromise the ovary.)
69
Q

Early complications of UAE

A
  • post-embolization syndrome: pain, nausea, fever, flu-like symptoms with raised inflammatory markers and white cell count.

frequent and self-limiting

70
Q

Management of post-embolization syndrome

A
  • Frequent and self-limiting.
  • Manage with analgesics and anti-inflammatory drugs.
  • Re-admission may be required in 3–5% of cases.
71
Q

Late complications of UAE

A
  • Vaginal discharge (self-limiting) – 20–30%.
  • Fibroid expulsion – 10%, more w/ SM
  • Sexual dysfunction – 12%
  • Infection (endometritis) – 0.5%.
  • Amenorrhoea (POI) – 1.5–7%, but the majority of these patients are > 45 years old (25% risk in this age group)
72
Q

Precentage of further treatment of fibroids after UAE

A
  1. repeat UAE
  2. exploration of uterine cavity
  3. myomectomy
  4. hysterectomy
    * 25% if < 40 years
    * 10% if 40–50 years of ag
73
Q

What kind of contraception to be used in case of fibroids

A
  • W/o no uterine distortion: all methods can be used
  • W/ distortion: not IUD or IUS if can’t be fitted easily

not clear if hormonal methods has any effect on size of fibroids

74
Q

Clinical sign to Leiomyosarcoma

A

rapid growth in uterine size

75
Q

Incidence of leiomysarcoma

A

rare 2-3/1000

76
Q

Risk factors for sacrcomas

A
  • Increasing age
  • a history of prior pelvic radiation
  • tamoxifen use
  • a rare genetic predisposition.
77
Q

How to differentiate between sarcomas and other intrauterine lesions

A

MRI and Endometrial Biopsy

78
Q

Do Fibroids do absolute subfertility?

A

no, many women can concieve w/o interventions

79
Q

How can fbroids cause subfertility

A
  1. mechanical effect due to cavity distortion with IM and SM fibroids
  2. possible effect on uterine blood flow
  3. impaired implantation with IM fibroids.
80
Q

rate of fibroids presence in women w/ infertility

A

5–10% of women with infertility

fibroids are the sole factor in 1–2.4% of women with infertility.

81
Q

IVF outcome in women with fibroids

A
  • SM/IM fibroids distorting the uterine cavity cause a 70% reduction in pregnancy
  • Removal of these fibroids
    restores the pregnancy rate to that of the control group.
82
Q

Management of subfertility due to fiborids

A
  • Try naturally for 2 years, unless the woman is ≥ 34 years
  • SM fibroids: hysteroscopic resection.
  • Myomectomy: consider for a woman with fibroids who has undergone unsuccessful IVF cycles despite appropriate ovarian response and
    good quality embryos.
  • UAE: has not effect on pregnancy outcome after IVF
83
Q

SBA

What proportion of women using ulipristal acetate will develop Progesterone receptor modulator associated endometral changes PAEC?

A
  • 60%
  • up to 2/3 of women using it
  • resolve after 6 months of discontinuation
84
Q

SBA

Most common benign tumor in females

A

Uterine Leiomyoma
prevelance= 30%

MRCOG - Part 2 (43 decks)

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