Professional Documents
Culture Documents
MYOMA UTERI
Supervised by:
dr. M. Arief Solehudin, Sp.OG, MKes
Presented by:
Muhammad Anka Pradana Putra
(2012730064)
CHAPTER I
INTRODUCTION
Uterine of myoma are the most common benign tumors in female, affecting the half of
women and mostly in reproductive age. Histologically, the tumor is composed of smooth
muscle and fibrous connective tissue, so named as uterine leiomyoma, myoma, or
fibromyoma. It has been estimated that at least 20 percent of women at the age of 30 have
got fibroid in their wombs. Fortunately, most of them (50%) remain asymptomatic. The
incidence of symptomatic fibroid in hospital outpatient is about 3 percent . These are more
common in nulliparous or in those having one child . The prevalence is highest between 35
45 years.
The etiology still remains unclear but chromosomal abnormality, estrogen effect,
progestin effect, and growth factor (EGF, IGF-I, TGF) were playing role inits pathogenesis. It
is predominantly an estrogen effect-dependent tumor for its growth. The risk factor that
increased the incidence ofmyoma uterine are nulliparity, obesity, hyperestrogenic state, and
black women. The clinical symptomps of myoma uterine are mostly asymptomatic (75%) but
25 % were symptomatic. The symptomps are menstrual abnormality : mennorhagia (30%) or
metrorrhagia/ irreguler bleeding, dysmenorrhea, dyspareunia, infertility, pressure symptomps,
recurrent pregnacy loss (misscariage, pre-term labor) lower abdominal / pelvic pain, and
abdominal enlargement. On abdominal examination the tumor may not be sufficiently. On
bimanual examination eveals the uterus irregulary enlarged by the swelling felt per abdomen.
Although the majority of myoma uterine can be diagnosed from the history and pelvic
examination but at times pose problem in diagnosis and ultrasound is an useful diagnostic
tool to confrm the diagnosis of myoma uterine. Life threatening complication include severe
anemia, intraperitoneal hemorrhage from rupture veins over the subserous fibroid, severe
infection, and sarcomatous change. The management of myoma uterus include medication
and surgical
CHAPTER II
CASE
I.
II.
IDENTITY
Name
Age
Religion
Education
Occupation
Date of Admission
: Mrs.R
: 52 years old
: Moeslem
: Junior High School
: Farmer
: May 31st 2016
HISTORY
a. Chief Complaint
:
Patient complaint about lower abdomnal pain
b. History of present ilness :
Patient complaint about lower abdomnal pain. And the patient also
complaint of pain when urinate for 1 weeks. She doesn't have any
complaint before.
Patient had 4 child, the first pregnancy was 36 years ago, the second
pregnancy was 33 years ago, the third pregancy was 29 years ago, and the
fourth pregnancy was 19 years ago. She hadnt complaint mentruation
abnormality any mass or when her pregnancy and after pregnancy. 1 month
before her admission patient had the ultrasonography examination and it was
said that her myom bigger.
Patient using implant contraception for 5 years, and pil contraception for
10 years.
c. Family History
Patient didnt have family history of tumor and malignancy
d. History of past ilness :
History of hypertension
History of diabetes mellitus
History of allergy
History of epilepsy
History of urinary tract/ kidney disease
History of trauma
History of surgery
e. History of mentrual cycle :
Menarche
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: 15 years old
Menstrual
cycle
28
days,
.......................................................................duration
regulary,with
of
days,
Years
Gestationa
1980
l
Age
9 month
1983
9 month
1987
9 month
1997
9 month
Labor
History
Spontaneous
Per Vaginam
Spontaneous
Per Vaginam
Spontaneous
Per Vaginam
Spontaneous
Per Vaginam
Birth
Weight
Breast
Feeding
Male
3300 gram
2 years
Male
3200 gram
1 years
Male
3300 gram
1 years
Male
3100 gram
2 years
Sex
PHYSICAL EXAMINATION
General condition
: Appeared moderately
Level of consciouness : Compos Mentis
Vital Sign
- Blood pressure
: 120/80 mmHg
-
Heart Rate
: 82 beats per minutes
Respiratory rate
: 20 breaths per minutes
Blood temperature : 36,0oC
Weight
Height
BMI
: 52 kg
: 156 cm
: 22,6 kg/m2 (Normal)
General examination
a. Eyes
: Anemi conjungtiva -/-; icteric sclera -/-
b. Mouth
c. Thorax
- Heart
- Lung
..............
Crackles -/Mammae : Aerola hyperpigmentation, nipple retraction -/-,
..............
Abdomen :
Myoma Uteri
Extrimitas :
Gynecologic Examination
Inspection
Gravida 18-20
week
Vulva : Within normal limits Mass (-), ulcer (-), hyperemia (-)
Vagina : within normal limits Mass (-), ulcer (-), hyperemia (-)
Inspeculo
Vagina: Erotion (-), bleeding (-), mass (-), inflammation (-)
Portio: Erotion (-), fluxes (-), livide (-), fluor albus (-), bleeding (-), mass
IV.
V.
IMAGING EXAMINATION
Uterine contour is enlarged and distorted
LABORATORY EXAMINATION
Type
Result
Units
Normal Value
HEMATOLOGY
Hemoglobin
Hematocrit
Eritrocytes
Leucocytes
Platelets
Erytrocytes Index
MCV
MCH
MCHC
16,6
45
5.0
15.900
392.000
90
34
37
g/dl
%
Million/ L
Thousand/L
Thousand/L
fl
pg
g/ dL
12-14
37-47
3,8-5,2
4000-10.000
150.000-450.000
80-100
26-34
32-36
BLOOD CHEMISTRY
Liver function
AST (SGOT)
22
U/I
< 31
....ALT (SGPT)
13
U/I
<32
4.3
g/dL
6,3-8,2
23
mg/dL
15-36
0,60
mg/dL
Natrium
143
mmol/L
137-150
Kalium
4,1
mmol/L
3,5-5.5
Calsium
9,3
mg/dL
8-10,4
Chloride
104
mmol/L
94-108
120
mg/dL
<140
Albumin
...
Kidney Function
Ureum
Creatinin
0,52-1,04
Electrolytes
Blood Glucose
Random blood glucose
VI. RESUME
P4A0 52 years old,that was diagnosed having myoma 1 month ago, came with
chief complaint of pain lower abdomen and patient complaint pain when she urinate
since 1 week ago. The patient has 4 children. She gave birth to her last child 19 years
ago. The patient used implant contraception for 5 years and contraception pil for 10
years.
On physical examination blood pressure 120/80 mmHg heart rate 82 bpm,
respiratory rate 20 times per minutes, temperature 36,0 oC, On laboratory within normal
limits.
VII. WORKING DIAGNOSIS
P4A0, 52 years old with myoma uteri
VIII. PLANNING
Pro Total Hysterectomy Salpingo-oophorectomy bilateral ( Juny 1st 2016)
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
Total
Hysterectomy
operation + salpingo
oophorectomy
bilateral
Total Hysterectomy +
salpingo
oophorectomy
bilateral
POST OP:
Diet
fasting
until
bowel
sound +, the
diet gradually
Claneksin 3x1
indicated
by
myoma uteri
gr IV
Metronidazol
e Infus 2x1
Alinamin 3x1
IV
Ranitidin 2x1
IV
Catheter (UO
observation)
Hb
examination
after 6 hours
post operation
Hb 6 hours post op :
14,7 g/dL
I
Continued
therapy
Maintained
catheter (UO =
0,86cc/24h) >
continue observe
bilateral
indicated
by
myoma uteri
Bowel
Sound
(+)
4x/minutes
Flatus (-)
Juny
th
2016
06.00 a.m
P4A0, 52 years
Old Post Total
Hysterectomi +
UO
Active
mobilization
(gradually)
Metronidazole
Infus 2x1
Claneksi 2x1 IV
Alinamin 3x1
IV
Ranitidin
IV
Paracetamol
3x1 PO
Cefadroxil
2x1
2x500 mg P.O
(POD-2)
Temp : 36,3 C
Flatus (+)
Juny
2016
06.00 a.m
(POD-3)
Traknesamat
bilateral
3x500mg P.O
by
myoma uteri
P4A0, 52 years
Old Post Total
Patient discharge
Hysterectomi +
2x500 mg P.O
Asam
salpingo
Urinating (+)
Flatus (+)
Defecation (-)
Asam
oophorectomy
indicated
th
salpingo
oophorectomy
Traknesamat
bilateral
indicated
by
3x500mg P.O
myoma uteri
XII. PROGNOSIS
Quo ad vitam
: Bonam
Surgical steps
1. Patient in supine position and general anesthesi was done
2. Aseptic and Antiseptic was done
3. After peritoneum was opened, Size of uterus 14 x 14 cm with surface was uniform
enlarged in a single fibroid. Conclusion: Myoma uteri
4. Left and Right ovarium within normal limits
5. Total Hysterectomy and salpingo oophorectomy bilateral done
6. Uterus was sutured
7. Abdomen was flushed with NACL
8. Fascia was suture
9. Skin was surtured subcuticular
10. Operation was done with total bleeding 500 cc,and weight of myoma uteri was 1,7
kg
11. Uterus was sent to pathology anatomy
CHAPTER III
CASE ANALYSIS
I.
PROBLEMS
1. How do you diagnosed the patient ?
2. How the teori of myoma uteri ?
3. How is myoma uterine treated by medication ?
4. What are the type of hysterectomy procedures and indication ?
5. What is the indication total hysterectomy with salpingektomy ?
II.
DISCUSSION
1. How to diagnosed this patient ?
THEORY
ANAMNESIS
Asymptomatic
Menstrual abnormality
CASE
ANAMNESIS
mennorhagia (30%) or
metrorrhagia/ irreguler
Infertility
bleeding
Dysmenorrhea
Dyspareunia
Infertility
Pressure symptomps
Recurrent oregnancy loss
(misscariage, pre-term labor)
Lower abdomnal/ pelvic pain
Abdominal enlargement
PHYSICAL EXAMINATION
Tumor may not be sufficiently enlarge
to be felt per abdomen if < 14 week
PHYSICAL EXAMINATION
The uterus feel is hard, and enlarge (1
fingers below umbilical, 18 -20 week)
Palpation
Palpation
Tenderness (+) on suprapic, the
uterus with tender and solid
degeneration
Margin are well defined except
origin
Surface is nodular; may be
single fibroid
fibroid
Mobility is restricted from above
downwards but can be moved
from side to side
Percussion
uterus irregulary
Enlarge by the swelling felt per
Percussion
abdomen
uterus
Enlarge by the swelling felt per
abdomen
IMAGING :
Ultrasound
distorted
Depending on the amount of
connective tissue or smooth
muscle proliferation, fibroids are
of different echogenecityhypoechoic or hyperechoic
IMAGING :
Ultrasound
Cytogenetics
Each leiomyoma is derived from a single progenitor myocyte. Thus, multiple tumors
within the same uterus each show inde-pendent cytogenetic origins . The primary
mutation initiating tumorigenesis is unknown, but identifiable karyotypic defects are
found in approximately 40 percent of leiomyomas. A number of unique defects
involving chromosomes 6, 7, 12, and 14 and less commonly X, 1, 3, 10, 13 have been
identifi ed to corre-late with rates and direction of tumor growth. It is anticipated that
further characterization of the specific functions of these karyotypic changes will help
to define the important steps in leiomyoma development.
Estrogen Effects
Uterine leiomyomas are estrogen- and progesterone-sensitive tumors .Consequently,
they develop during the reproductive years. After menopause, leiomyomas generally
shrink, and new tumor development is infrequent. Thus, it seems that many risk or
protective factors depend on circum-stances that chronically alter estrogen or
progesterone levels or both. Th is concept is integral in understanding many of the
risk factors associated with leiomyoma development and growth and in formulating
treatment plans. Sex steroid hormones likely mediate their effect by stimulating or
inhibiting transcription and production of cellular growth factors. Leiomyomas
themselves create a hyperestrogenic environment, which appears requisite for their
growth and mainte-nance. First, compared with normal myometrium, leiomyoma cells
contain a greater density of estrogen receptors, which results in greater estradiol
binding. Second, these tumors convert less estradiol to the weaker estrone . A third
mechanism described by Bulun and colleagues involves higher levels of cytochrome
P450 aromatase in leiomyomas compared with normal myocytes. This specific
cytochrome isoform catalyzes the conversion of andro-gens to estrogen in a number
of tissues. There are a number of conditions associated with sustained estrogen
exposure that encourage leiomyoma formation.
Progestin Effects
The role of progesterone in leiomyomas is less clear, and indeed both stimulatory and
inhibitory effects have been reported. For example, exogenous progestins have been
hormone
To minimize the size and vascularity of the tumor in order to facilitate surgery.
Symptoms.
GnRH antagonists-Cetrorelix or ganirelix causes immediate suppression of
pituitary and the ovaries. They do not have the initial stimulatory effect.
Benefits
are
same
as
that
of
agonists.
Onset
of
amenorrhea
is
and uterine size. However, this is not recommended when the uterine size is >12
weeks or there is distortion of uterine cavity.
Preoperative therapy:It is indeed advantageous to reduce the size and vascularity
of fibroid prior to either myomectomy or hysterectomy. While operation will be
technically easier in broad ligament or cervical fibroid, in myomectomy, there
may be little difficulty in enucleation of the tumor from its pseudocapsule
Uterine fibroid
TO mass
Endometriosi
Supracervical (also called subtotal or partial) hysterectomyThe upper part of
the uterus is removed, but the cervix is left in place. This type of hysterectomy
Difficul TO mass
Obstetric causes
Endometriosis (rectovaginal septum
Radical hysterectomyThis is a total hysterectomy that also includes removal of
structures around the uterus. It may be recommended if cancer is diagnosed or
suspected.Indication:
Carcinoma endometrium
Carcinoma
cervix-stage
Age and parity :An ideal condition is that the patient preferably be in the
perimenopausal age group with family completed. However, the operation may
have to be done under forced circumstances even in comparatively young age
group
or
unmarried
or
nulliparous
women
(Examplecontemplating
pouches.
Pelvic endometriosis particularly involving the rectovaginal septum.
Emergency hysterectomy (cesarean hystere-ctomy).
The surgeon and patient should discuss the potential benefits of the removal of the
fallopian tubes during a hysterectomy in women at population risk of ovarian
cancer who are not having an oophorectomy.
Randomized controlled trials are needed to support the validity of this approach to
reduce the incidence of ovarian cancer.