Fibroid uterus in detail ..... odstetrics and gynecolgy

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