INVESTIGATIONS:- The investigations aim at:

 To confirm the diagnosis

 Preoperative assessment
To confirm the diagnosis:-
Although, the majority of uterine fibroids can be diagnosed from the history and
pelvic examination but at times pose problems in diagnosis.
Ultrasound and Color Doppler (TVS) findings are:
(i) Uterine contour is enlarged and distorted.
(ii) Depending on the amount of connective tissue or smooth muscle proliferation,
fibroids are of different echogenecity-hypoechoic or hyperechoic.
(iii) Vascularization is at the periphery of the fibroid.
(iv) Central vascularization indicates degenerative changes; Ultrasound is an useful
diagnostic tool to confirm the diagnosis of fibroid. Transvaginal ultrasound can
accurately assess the myoma location, dimensions volume and also any adnexal
pathology. Hydroureter or hydronephrotic changes can be diagnosed. Three-
dimensional ultrasonography can locate fibroids accurately.
(v) Serial ultrasound examination is needed during medical or conservative
management.
Saline Infusion Sonography (SIS) is helpful to detect any submucous fibroid or polyp.
Magnetic resonance imaging (MRI) – is more accurate compared to ultrasound. It helps to
differentiate adenomyosis from fibroids. MRI is not used routinely for the diagnosis. It is
expensive and not widely available.
Laparoscopy- Laparoscopy is helpful, if the uterine size is less than 12 weeks and associated
with pelvic pain and infertility. Associated pelvic endometriosis and tubal pathology can be
revealed. It can also differentiate a pedunculated fibroid from ovarian tumor, not revealed by
clinical examination and ultrasound.
Hysteroscopy is of help to detect submucous fibroid in unexplained infertility and repeated
pregnancy wastage. The presence and site of sub mucous fibroid can be diagnosed by direct
visualization during hysteroscopy. Submucosal fibroid can be resected at the same time using
a resecting hysteroscope.
HSG when done, a filling defect can be seen.
Uterine curettage-In the presence of irregular bleeding, to detect any co-existing pathology
and to study the endometrial pattern, curettage is helpful. It additionally helps to diagnose a
submucous fibroid by feeling a bump. However, hysteroscopy and biopsy is a better
alternative.
Preoperative assessment: Apart from routine preoperative investigations, intravenous
pyelography to note the anatomic changes of the ureter may be helpful.
Differential diagnosis: The fibroid of varying sizes may be confused with:
(1) Pregnancy (2) Full bladder (3) Adenomyosis (4) Myohyperplasia (5) Ovarian tumor (6)
TO mass.
 MANAGEMENT OF FIBROID UTERUS
Symptomatic
Asymptomatic

Symptomatic fibroids
MEDICAL MANAGEMENT
Drug therapy has established a firm place in the management of symptomatic
fibroids. The drugs are used either as a temporary palliation or may be used in rare cases, as
an alternative to surgery. Prior to drug therapy, one must be certain about the diagnosis.
The objectives of medical treatment are:
 To improve menorrhagia and to correct anemia before surgery.
 To minimize the size and vascularity of the tumor in order to facilitate surgery.
 In selected cases of infertility to facilitate hysteroscopic or laparoscopic surgery.
 As an alternative to surgery in perimenopausal women or women with high-risk
factors for surgery.
 Where postponement of surgery is planned temporarily.
To minimize blood loss
As a temporary palliation, various drugs are used to minimize blood loss and to correct
anemia when a definite surgery cannot be undertaken for certain periods.drugs usedto
minimize blood loss are;
 Antiprogesterones (Mifepristone)
 Danazol
 GnRH analogs:
Agonists, Antagonists
 LNG-IUS
 Prostaglandin synthetase inhibitors
Antiprogesterones- Mifepristone (RU486) is very effective to reduce fibroid size and also
menorrhagia. It may produce amenorrhea. It reduces the size of the fibroid significantly. A
daily dose of 25-30 mg IS recommended for 3 months. 5 mg daily dose is also found
effective. Long-term therapy is avoided as it causes endometrial hyperplasia. Asoprisnil is
used with success. It is a selective progesterone receptor modulator. It does not cause
endometrial hyperplasia.
Danazol -can reduce the volume of fibroid slightly. Because of androgenic side effects,
danazol is used only for a period of 3-6 months. Danazol administered daily in divided doses
ranging from 200-400 mg for 3 months minimizes blood loss or even produce amenorrhea by
its antigonadotropin and androgen agonist actions.
GnRH agonists - Drugs commonly used are goserelin, luporelin, buserelin or nafarelin.
Mechanism of action is sustained pituitary down regulation and suppression of ovarian
function. Optimal duration of therapy is 3 months. Addback therapy may be needed to
combat hypestrogenic symptoms.
GnRH antagonists -Cetrorelix or ganirelix causes immediate suppression of pituitary and
the ovaries. They do not have the initial stimulatory effects. Benefits are same as that of
agonists. Onset of amenorrhea is rapid.
Prostaglandin synthetase inhibitors-These are used to relieve pain due to associated
endometriosis or degeneration of the fibroid. They cannot improve menorrhagia due to
fibroids.
Levonorgestrel-releasing Intrauterine System (LNG-IUS) reduces blood loss 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.
ADVANTAGES OF GnRH ANALOGUE;
 Improvement of menorrhagia and may produce amenorrhea.
 Improvement of anemia.
 Relief of pressure symptoms.
 Reduction in size (50%) when used for a period of 6 months.
 Reduction in vascularity of the tumor.
 Reduction in blood loss during myomectomy.
 May facilitate laparoscopic or hysteroscopic surgery.
Disadvantages

 Hypoestrogenic side effects (Vasomotor symptoms, Trabecular bone loss).

 Cost (high).
 Regrowth of myomas on cessation of therapy.
 Degeneration (some leiomyomas)-causing difficulty in myoma enucleation.
However, with the stoppage of the therapy, the tumor will attain its previous size slowly.
Benefits are achieved when therapy is given for a period of three months.
SURGICAL MANAGEMENT OF FIBROID UTERUS
Myomectomy can done by;
-Laparotomy
- Laparoscopy
-Hysteroscopy
Embolotherapy
Myolysis
Hysterectomy
Myomectomy is the nucleation of myomata from the uterus leaving behind a
potentially functioning organ capable of future reproduction.
As such, the surgeon should be satisfied with the operation designed to serve the
objective. It is indeed useless to perform a hectic surgery to remove such myomata only to
leave behind an uterus which is unlikely to conceive in future.Among the contraindications
few are relative rather than absolute. Restoration of anatomy and function of the uterus, tubes
and ovaries following myomectomy are important, not only for future reproductive function
but also to avoid the future hazards.
Important Considerations Prior To Myomectomy
 lt should be done mainly to preserve the reproductive function.
 The wish to preserve the menstrual function in porous women should be judiciously
complied with.
 Myomectomy is a more risky operation when the fibroid(s) is too big and too many.
 Risk of recurrence and persistence of fibroid is about 30-50 percent.
 Risk of persistence of menorrhagia is about 1-5 percent.
 Risk of relaparotomy is about 20-25 percent.
 Pregnancy rate following myomectomy is about 40-60 percent.
 Pregnancy following myomectomy should have a mandatory hospital delivery,
although the chance of scar rupture is rare (little more when the cavity is open).
Indications Of Myomectomy
 Persistent uterine bleeding despite medical therapy.
 Excessive pain or pressure symptoms.
 Size >2 weeks, woman desirous to have a baby.
 Unexplained infertility with distortion of the uterine cavity.
 Recurrent pregnancy wastage due to fibroid.
 Rapidly growing myoma during follow-up.
 Subserous pedunculated fibroid.
Pre-Requisites to Myomectomy
Hysteroscopy or hysterosaIpingography- to exclude any submucous fibroid or a
polyp or any tubal block.
Hysteroscopy/endometrial biopsy-in cases of irregular cycles, not only to remove a
polyp but also to exclude endometrial carcinoma.
Examination of the husband from fertility point of view (semen analysis).
Contraindications Of Myomectomy
 Infected fibroid.
 Growth of myoma after menopause.
 Suspected malignant change (sarcoma).
 Parous women where hysterectomy is safer and is a definitive treatment.
 Function less fallopian tubes (bilateral hydrosalpinx, tuba-ovarian mass) - decision
must be judicious with the advent of microsurgery and ART.
 Pelvic or endometrial tuberculosis.
During pregnancy or during caesarean section.
However, the final decision as to whether to perform myomectomy or
hysterectomy is to be taken following laparotomy. As such, it is prudent on the part of
surgeon to declare the operative decision as 'myomectomy to be tried' and if the conditions
arise so, it may end in hysterectomy.
Vaginal myomectomy: -

Submucous pedunculated myoma can be removed vaginally . .Morcellation

(removal by piecemeal) is needed if the tumor is large. A moderate size fibroid can be
removed by twisting.In that case, fibroid is grasped with a sponge forceps.
Endoscopic Surgery:-

1.Hysteroscopy: Generally a fibroid of 3-4 cm in diameter or a polyp is resected with a

hysteroscope. Pedicle or the base of the fibroid is coagulated using electrocautery.YAG laser
can also be used .
Complications of hysteroscopic surgery are uterine perforation, fluid overload,
hemorrhage.
2.Laparoscopy: Subserous and intramural fibroids could be removed laparoscopically.
Electrocautery,laser and extra-corporeal sutures are used for hemostasis. Laparoscopic
surgery is not suitable when the fibroid is large, deep intramural, multiple or technically
inaccessible. Leiomyomas can be desiccated (myolysis) using laser or bipolar diathermy.
Embolotherapy: Uterine artery symbolization (UAE) causes avascular necrosis followed
by shrinkage of fibroid. Uterine arteries are occluded by injecting polyvinyl alcohol particles
through percutaneous femoral catheterization. This may be an option to women with
symptomatic fibroid where surgery is not preferred. Result: Improvement ofmenorrhagia is
observed in 80-90 percent with 60 percent reduction in size.

Complication of UAE:
Postembolization syndrome: Fever, sepsis, Myometrial infarction and necrosis,
amenorrhea and ovarian failure.
Complications related to the procedure: femoral artery injury.
Contraindications: Active pelvic infection, desire for future pregnancy, drug allergy.
MRI-guided focused high-energy

Ultrasound: ultrasound waves induce copulative necrosis in myomas. It causes localized

thermal ablation of the fibroid tissue. It may need multiple treatments. It causes less pain
compared to UAE, It has less postoperative complications.

HYSTERECTOMY

It is the operation of choice in symptomatic fibroid when there is no valid reason for
myomectomy.The patient over the age of 40 years and in those not desirous of further child
are the classic indications. Removal of ovary: It is preferable to remove the ovaries in post
menopausal women and to preserve the same in earlier age,if they found healthy.

ADVANTAGES OF HYSTERECTOMY:-

 There is no chance of recurrence.

 adnexal pathology and unhealthy cervix ,if any are also removed.

Indications for emergency surgery in a fibroid

 Torsion of the subserous pedunculated fibroid

 Massive intra peritoneal hemorrhage following rupture of vein over the subserous
fibroid
 Uncontrolled infected fibroid
  Uncontrolled bleeding fibroid

ASYMPTOMATIC FIBROID(75%)

Fibroid s detected accidently on routine examination for complaints other than fibroids
are dealt with as follows;

 observation
 Surgery

Observation :- A certain diagnosis of fibroid should must ,prior to contemplating expectant

management .the risk of sarcomatous changes is so insignificant(.1%) that prophylactic
removal of fibroid is unjustified in asymptomatic cases.
Indications of expectant management:
 Size <12 weeks (of pregnancy size)
 Diagnosis certain
 Follow up possible
Periodic examination at interval of 6 months is needed. If the symptoms of fibroid appear and
or it grows and increases in size, surgery is indicated.
CERVICAL FIBROID
Symptoms
In nonpregnant state, the symptoms are predominantly due to pressure effect on
the surrounding structures.
Anterior cervical: Bladder symptoms like frequency or even retention of urine are
conspicuous. The retention is more due to pressure than elongation of urethra.
Posterior cervical: Rectal symptom is in the form of constipation.
Lateral cervical: Vascular obstruction may lead to hemorrhoids and edema legs (rare).
The ureter is pushed laterally and below the tumor.
Central cervical: Central fibroid produces predominantly bladder symptoms. The cervix is
expanded on all sides. The uterus sits on the top of the expanded cervix (lantern on the dome
of St. Paul's).
In pregnancy, it remains asymptomatic but produces insuperable obstruction during
labor.
Fibroids arising from the vaginal part of the cervix may remain asymptomatic
during non-pregnant state but produces obstruction during labor. lf pedunculated, there may
be a sensation of something coming down or if infected a foul smelling discharge per
vaginum.
Treatment
Supravaginal fibroids:
Myomectomy may be tried if the patient is young and desirous of having a baby.
But, it is not only technically difficult but the anatomic and functional restoration of the
cervix cannot be adequate to achieve the objective of future reproduction.
 As such, mostly it is dealt with by hysterectomy. The principle to be followed is
nucleation followed by hysterectomy to minimize the injury to the ureter. Preoperative GnRH
analogs administration for 3 months facilitates surgery.
Vaginal part fibroids: If the tumor is sessile, myomectomy and if pedunculated,
polypectomy is done.
NURSING MANAGEMENT
Nursing Diagnosis: Acute Pain related to inflammation due to the addition of mass in
the uterus
Objectives: Pain can be reduced or lost.Expected outcomes are:
Pain scale(1-10)= 1-3.Respiration = 16-24 beats / minute.,Pulse  = 60 -100 beats / min and
expression showed no signs of pain and seemed to relax.
Nursing Interventions:-
1. Observation of a pain scale (1-10)
Rational: Observation of a pain scale is necessary for us to know the level of pain
experienced by the client so that we can provide appropriate interventions for clients.
2. Find the area, location, and intensity of pain
Rational: To determine the location of pain, pain in the abdomen may indicate the likelihood
of complications
3. Give a sitting position while hugging a pillow or a position in the sense of comfort by
the client
Rational: It can provide comfort to the client.
4. Give instruction in relaxation techniques and deep breathing techniques
Rational: relaxation and deep breathing techniques to increase comfort and reduce the level
of pain experienced by the client
5. Encourage clients to use a warm compress
Rational: Warm compresses can increase vasodilation of blood vessels at the site of pain so
that pain can be reduced.
6. Collaboration in the delivery of analgesics and antiemetics, as indicated when necessary.
Rational: The provision of analgesia is necessary if the client is a pain scale of 7-10,
this analgesic increase relaxation, decrease attention to pain, and control the adverse action.
7. Provide information about the use of analgesics that are prescribed or not prescribed
Rational: The specific instructions about the use of drugs, increasing awareness of safe use
and side effects.
8. Evaluation of vital signs.
Rational: To determine the condition of clients after the intervention so that it can be done to
determine further action.
 II:Impaired Urinary Elimination: Retention related to the suppression by the
neoplastic tissue mass in the surrounding area, impaired sensory / motor.
Objective: Clients urinate a normal amount and pattern of regular or no interference

Outcome:The amount of urine 1500 ml/24 hours and regular pattern, no bladder distention
and edema

Nursing Interventions:
-Monitor inputs and outputs as well as the characteristics of urine
-Determine the client's normal voiding pattern and note the variations
-Encourage clients to increase fluid intake
-Check all the urine, note the presence of stones and send output to a laboratory for analysis
-Investigate complaints of a full bladder: suprapubic palpation to distention. Note the
decrease in urine output, edema periorbital / dependent
-Observations of changes in mental status, behavior or level of consciousness
-Supervise laboratory tests, samples of electrolytes, BUN creatinine
-Take a urine for culture and sensitivity
-Give the drug as indicated, for example:
-Note the catheter patency was settled, when using
-Irrigation with acidic or alkaline solution as indicated
III: Ineffective individual coping related to emotional excess.
Nursing Interventions:
1. Assess client's understanding of her illness.
Rational: maternal anxiety of the pain will be greatly influenced by knowledge.

2. Determine the additional stress that accompanies it.

Rational: stress can impair the autonomic nervous response, so it is feared to increase the
pain.

3. Provide an opportunity to discuss how the pain.

4. Help clients identify coping skills during the period covered.

Rational: the use of behavior management techniques can help clients adapt to the pain they
experienced.

5. Give the period of sleep or rest.

Rational: the pain and fatigue due to spending a lot of body fluids tends to be a problem that
must mean a lot of the body tends to be significant problems that must
be addressed immediately.

6. Push the skills of stress, such as relaxation techniques, visualization, guidance, imagination
and deep breathing exercises.
Rational: it can reduce pain and distract the client to pain
IV:Anxiety related to situational crisis (hysterectomy or chemotherapy), threats to self-
concept, changes in health status, stress
Outcomes :
Clients are able to use effective coping strategies.
Clients report to the nurse decreased anxiety.
Clients are able to use relaxation techniques to reduce anxiety.
Clients are able to maintain social relationships, and concentration.
Clients report to nurse enough sleep, no physical complaints due to anxiety, and no behavior
indicating anxiety.

Nursing interventions:-
-Reassure the patient and assess the patient's level of anxiety .
-Explain to the patient throughout the procedure actions and feelings that might arise during
the action .
-Trying to understand the patient's condition ( empathy ) .
-Provide information about the diagnosis , prognosis and act with good communication .
-Accompanying patients to reduce anxiety and increase comfort .
-Encourage the patient to express feelings .
-Create a trusting relationship .
-Help the patient to explain the circumstances that can lead to anxiety .
Help the patient to reveal things that provoke anxiety and listen attentively .
-Teach the patient relaxation techniques .
-Instruct the patient to enhance the worship and prayer .
-Collaboration with physicians for the provision of drugs that relieve anxiety.