Case study of a patient with Recurrent uterine myoma

Certification

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This is to certify that this work was conducted by Gabriel Anita Amarachi

Mr Nicholas

( Supervisor)

DEDICATION

All glory to God the Father, son and the holy spirit who I dedicate this work to.

Acknowledgement
My profound gratitude goes to God almighty with whom the success of this nursing case study was
made possible.

Abstract

Chapter 2

Literature review

A uterine myoma is a non-cancerous (benign) tumour that grows in and around the uterus (womb). It is
also known as fibroid or leiomyomas

Uterine myoma develop from the muscle tissue of the uterus. They may also grow in the fallopian tubes,
cervix, or tissues near the uterus.

Leiomyomas are the most common solid pelvic tumor in women, causing symptoms in approximately
25% of reproductive age women. However, with careful pathologic inspection of the uterus, the overall
prevalence of leiomyomas increases to over 70%, because leiomyomas can be present but not
symptomatic in many women. The average affected uterus has six to seven fibroids.
They can vary in size, from being so tiny you cannot see them with the naked eye to being the size of a
melon. It is possible to have one or many fibroids.

Most women with fibroids have no symptoms while others may have painful or heavy periods.If large
enough, they may push on the bladder, causing a frequent need to urinate. A woman can have one
uterine fibroid or many. Occasionally, fibroids may make it difficult to become pregnant, although this is
uncommon.

It is believed that estrogen and progesterone have a mitogenic effect on leiomyoma cells and also act by
influencing (directly and indirectly) a large number of growth factors, cytokines and apoptotic factors as
well as other hormones.

Leiomyomas are usually detected in women in their 30's and 40's and will shrink after menopause in the
absence of post-menopausal estrogen replacement therapy. They are two to five times more prevalent
in black women than white women. Risk for developing leiomyomas is also higher in women who are
heavy for their height and is lower in women who are smokers and in women who have given birth.
Although the high estrogen levels in oral contraceptive pills has led some clinicians to advise women
with leiomyomas to avoid using them, there is good epidemiologic evidence to suggest that oral
contraceptive use decreases the risk of leiomyomas.

★Classification of uterine myoma

Leiomyomas are classified by their location in the uterus.

1.)Subserosal leiomyomas are located just under the uterine serosa and may be pedunculated (attached
to the corpus by a narrow stalk) or sessile (broad-based).

2.)Intramural leiomyomas are found predominantly within the thick myometrium but may distort the
uterine cavity or cause an irregular external uterine contour.

3.)Submucous leiomyomas are located just under the uterine mucosa (endometrium) and, like
subserosal leiomyomas, may be either pedunculated or sessile. Tumors in subserosal and intramural
locations comprise the majority (95%) of all leiomyomas; submucous leiomyomas make up the
remaining 5%.

What is an adnexal mass?

An adnexal mass is a growth that develops around the uterus, usually in your ovaries, fallopian tubes
and neighboring connective tissues. Some adnexal tumors are fluid-filled, while others are solid. They
can appear at any age, and most of them go away on their own within a few months. They’re called
adnexal tumors because they appear in the adnexa of the uterus. The term “adnexa” refers to the
ovaries, fallopian tubes and ligaments that secure the female reproductive organs.
Adnexal tumors affect women of all ages, but they most commonly occur during the childbearing years.

What’s the difference between uterine polyps and adnexal tumors?

Uterine polyps form inside the uterine lining, while adnexal tumors usually form in the ovaries, fallopian
tubes or connective tissues surrounding the uterus. Both conditions can cause similar symptoms, such as
irregular menstrual periods.

Who do adnexal tumors affect?

Adnexal tumors affect women of all ages, but they most commonly occur during the childbearing years.

Causes/ predisposing factors of adnexal tumors

Adnexal masses can be caused by numerous gynecologic and non-gynecologic factors. Most commonly,
the tumors originate from the female reproductive system. But they can also originate in the urinary or
digestive systems.

•Gynecologic adnexal tumors

Most adnexal masses are caused by problems with the female reproductive system. The most common
causes include:

★Ovarian cysts. These fluid-filled cysts form on your ovaries. They’re generally painless — most people
never develop symptoms. Ovarian cysts are extremely common.

★Noncancerous ovarian tumors. When abnormal cells grow and multiply in the ovaries, they become
solid masses, with occasional cystic components. Benign (noncancerous) tumors typically don’t spread
to nearby tissues or other parts of your body.

★Ovarian cancer. When an ovarian tumor is malignant (cancerous), it can grow and spread to other
areas of the body. Ovarian cancer is one of the most common types of cancer in women.

★Ectopic pregnancy. If a fertilized egg doesn’t make it all the way to the uterus, it can implant
somewhere else instead, such as the fallopian tube. When this happens, it’s called an ectopic pregnancy,
and it cannot be carried all the way to term. If the egg keeps growing outside of your uterus, it can cause
internal bleeding and severe pain. Left untreated, ectopic pregnancies can be fatal for the pregnant
person.

★Broad ligament leiomyoma. A leiomyoma may be located adjacent to the ovary and fallopian tube and
be mistaken for an adnexal mass.
★Hydrosalpinx. When the fallopian tube fills with fluid, it's called a hydrosalpinx. These typically don't
cause symptoms but can result in pelvic pain or infertility.

★Tubo ovarian abscess. The genital tract can be infected by an infection, which can lead to
inflammation of the fallopian tube, ovary, and sometimes surrounding structures, including the bowel or
bladder.

•Non-gynecologic adnexal tumors

These masses usually originate in the urinary or gastrointestinal systems. Common types include adnexal
tumors of the colon and appendix. It’s also possible for breast cancer and colon cancer to metastasize
(spread) to the pelvis, resulting in adnexal tumors.

Clinical manifestations of adnexal mass

Adnexal mass symptoms may include:

Pelvic pain.

Difficulty urinating.

Bleeding near the mass.

Frequent urination.

Bloating.

Irregular periods, especially in premenopausal people.

Constipation.

Gastrointestinal disorders.

Pain during sex.

In many cases, people with adnexal tumors don’t experience any symptoms.

Investigations/ Diagnostic tests

Adnexal tumors are most often detected during routine examinations. They may also be discovered
during pelvic examinations or ultrasounds. Once you receive a diagnosis, your healthcare provider can
run additional lab and imaging tests to determine what caused the adnexal mass. In some cases, you
may be asked to take a pregnancy test to rule out ectopic pregnancy.

Causes and predisposing factors of uterine myoma

Uterine fibroids are common. As many as one in five women may have fibroids during their childbearing
years. Half of all women have fibroids by age 50.
Fibroids are rare in women under age 20. They are more common in African Americans than White,
Hispanic, or Asian women.

No one knows exactly what causes fibroids. They are thought to be caused by:

Hormones in the body

Genes (may run in families)

Fibroids can grow:

In the muscle wall of the uterus (myometrial)

Just under the surface of the uterine lining (submucosal)

Just under the outside lining of the uterus (subserosal)

On a long stalk on the outside the uterus or inside the uterus (pedunculated)

Anatomy and physiology of the uterus

The human uterus is a pear-shaped organ which is made up of two distinct anatomic regions: the cervix
and the corpus.

The corpus is further divided into the lower uterine segment and the fundus. The cervix is a narrow
cylindrical passage which connects at its lower end with the vagina. The cervix widens at it's upper end
to form the lower uterine segment (isthmus); the lower uterine segment in turn widens into the uterine
fundus.

The corpus is the body of the uterus which grows during pregnancy to carry a fetus.

Extending from the top of the uterus on either side are the fallopian tubes (oviducts); these tubes are
continuous with the uterine cavity and allow the passage of an ova (egg) from the ovaries to the uterus
where the egg may implant if fertilized.

The thick wall of the uterus is formed of three layers: endometrium, myometrium, and serosa. The
endometrium (uterine mucosa) is the innermost layer that lines the cavity of the uterus.
Throughout the menstrual cycle, the endometrium grows progressively thicker with a rich blood supply
to prepare the uterus for potential implantation of an embryo. In the absence of implantation, a portion
of this layer is shed during menstruation.

The myometrium is the middle and thickest layer of the uterus and is composed of smooth (involuntary)
muscle. The myometrium contracts during menstruation to help expel the sloughed endometrial lining
and during childbirth to propel the fetus out of the uterus. The outermost layer, or serosa, is a thin
fibrous layer contiguous with extrauterine connective tissue structures such as ligaments that give
mechanical support to the uterus within the pelvic cavity.

★ Pathophysiology of Uterine Fibroids

The cause of uterine leiomyomata is idiopathic till date. However, several

hypotheses have been made, namely:

1.) Glucose-6-phosphate dehydrogenase studies suggest that each individual leiomyoma is unicellular in
origin that is monoclonal. Hence, this implies

a genetic probability for the growth of uterine.

ii. In increment in the exposure of circulating oestrogens is another hypothesis for the growth of uterine
fibroids. Effectively, leiomyomas contain oestrogen receptors in higher concentrations than the
surrounding myometrium. But at lower concentrations than the endometrium, this oestrogen may
contribute to tumour enlargement by increasing the production of extracellular matrix. On the other
hand, progesterone increases the mitotic activity of myomas in young women. It may allow for tumour
enlargement by down-regulating apoptosis in

the fibroids . They usually decrease in size after menopause, so whenever myomas grow after
menopause, malignancy must be seriously considered.

Clinical manifestations of uterine myoma

Common symptoms of uterine fibroids are:

1.)Abnormal uterine bleeding:

The most common bleeding abnormality is menorrhagia (prolonged uterine bleeding, also called
hypermenorrhea). Normal menstrual periods typically last four to five days, whereas women with
fibroids often have periods lasting longer than seven days. Women with fibroids also can have such
heavy bleeding that they need to change sanitary protection frequently (perhaps every hour) or hesitate
to participate in their normal activities for fear of socially embarrassing bleeding. Abnormal bleeding can
occur with any of the three classes of fibroids, women with submucous fibroids seem particularly prone
to this complication.
2.)Pelvic pressure: results from an increase in size of the uterus or from a particular fibroid. Most
women with leiomyomas have an enlarged uterus; in fact, doctors describe the size of a uterus with
fibroids as they would a pregnant uterus, for example, as a 12 week-size fibroid uterus. It is not unusual
for a uterus with leiomyomas to reach the size of a four to five month pregnancy. In addition to vague
feelings of pressure because a fibroid uterus is usually irregularly shaped (having many lumps and
bumps), women can experience pressure on specific adjacent pelvic structures including the bowel
and/or bladder. Pressure on these structures can result in difficulty with bowel movements and
constipation or urinary frequency and incontinence. Rarely, fibroids can press on the ureters (which
carry urine from the kidneys to the bladder) which can lead to kidney dysfunction. A sensation of pelvic
heaviness or fullness or a feeling of a mass in the pelvis is particularly characteristic of large tumours.

3.)Leiomyomas are also associated with a range of reproductive dysfunction including recurrent
miscarriage, infertility, premature labor, fetal malpresentations, and complications of labor.

4.)Pain: Pain may either be due to red degeneration, infarction or torsion of a uterine fibroid, or mat
stem from attempts to expel a pedunculated submucousal fibroid. The pressure and heaviness on the
pelvis may press on nerves within the pelvis thereby creating pain that radiates to the back or lower
extremities.

Investigations/diagnostic tests

The diagnosis of uterine fibroids is made from the clinical manifestations; pelvic

examination, laboratory investigations and imaging.

• A Pelvic ultrasound scan is the test of first choice. Here, three-dimensional

scan is preferred to a two-dimensional scan due its higher resolution which

helps to rule out a pregnancy, other pelvic masses, a congenital uterine

malformation.

• A magnetic resonance imaging is the gold standard test which is highly accurate in depicting the size,
number and location of myomas to choose the therapeutical modalities.

•Saline sonohysterography can identify and characterise the location of submucosal myomas missed on
classical abdominal or transvaginal ultrasound.

• Plain X-Rays of the lower abdomen and pelvis usually identify only calcified fibroids and sometimes
large fibroids may be seen as soft tissue or calcified masses displacing bowel gas

• Hysterosalpingography may be useful in the infertile patient. It evaluates the

contour of the uterine cavity and the patency of fallopian tubes but does not

evaluate the exact location of fibroids.

• CT scan is not the investigation of choice, fibroids may be detected inciden-

tally while investigating for another condition.

Laboratory investigations may reveal anaemia as a consequence of the

menometrorrhagia of fibroids and depletion of iron stores or leucocytosis and

raised C-reactive proteins in case of acute degeneration or infection.

Differential diagnoses of leiomyomas include pregnancy, adenomyosis,

leiomyosarcoma, or solid ovarian neoplasms.

Chapter 3

GENERAL MANAGEMENT OF RECURRENT UTERINE MYOMA WITH RIGHT COMPLEX ADNEXA CYST

This management includes both medical and nursing depending on the case that is being managed.

MEDICAL MANAGEMENT

The prescriptions of her drugs were detailed under the chemotherapy chart. The drugs were served as
ordered by the doctor and the side effects watched for.

NURSING MANAGEMENT

The management of uterine myoma with right complex adnexa cyst in nursing care is managed using the
nursing process approach which are as follows;

1.) Assessment

2.) Diagnosis

3.) Planning

4.) Implementing

5.) Evaluation

Care study of the patient

Case Report:
A 46-year-old woman with well-controlled diabetes mellitus and hypertension was admitted through the
General Surgery Clinic for investigation of abdominal pain and a 4-year history of progressive abdominal
distension. Her medical history revealed 3 myomectomies, the first done at age 30 years and the other 2
successively for uterine leiomyomas.

On physical examination, the patient’s vital signs were slightly elevated. Her abdominal examination
revealed a distended abdomen with mild tenderness in the lower portion. After being examined, the
patient underwent an exploratory laparotomy, during which a pelvic cyst was found that measured
39×30.2 cm, was filled with serous fluid (10.5 L), and occupied most of the abdominal space. The surgery
went smoothly and there were no complications during or after the procedure. The patient was
discharged home 7 days later in stable condition. Postoperative pathology using hematoxylin and eosin
staining and immunohistochemistry with desmin and alpha-smooth muscle actin resulted in a diagnosis
of leiomyoma with right complex adnexa cyst. When the patient was seen in the outpatient clinic 2
weeks and 3 and 6 months after surgery, her tumor markers were within normal limits. Abdominal and
pelvic computed tomography scans performed at the 6-month visit showed resolution of the loculated
intraperitoneal fluid and no gross local recurrence of the tumor.

Demographic data of patient

Name: Mrs. N.C

Age: 46years

Sex: Female

Occupation: Trader

Religion: Christianity

Marital status: Married

Parity: 5

Nationality: Nigeria

Address: 24b Amakohia Owerri, Imo State

Next of kin: Mr. N.B

Relationship of next of kin: Husband

Address of next of kin: 24b Amakohia Owerri, Imo State

Date of admission: 9th October 2023

Informant: Mrs N.C

Interviewer: G.A
Diagnosis: Recurrent uterine myoma with right complex adnexa cyst

PATIENT'S GENERAL APPEARANCE ON ADMISSION

General inspection: On examination Mrs. N.C was experiencing discomfort and distress due to pain in
the abdomen, eyes were suncken

Hair: Few gray hairs. No alopecia

Head: Suncken eyes, no abnormality on the ear, mouth

Thorax: Slightly elevated respiration

Abdomen: Distended abdomen like that of a pregnant woman

Upper Limbs: No hypotonia noticed at left and right upper limb, both left and right lowers actively.

Skin: Pale skin

Palpation: tender and painful to touch.

Percussion: Dull sound heard on percussion.

Auscultation: No heart murmur.

Systematic review

Central nervous system: She is conscious and speaks well.

Respiratory system: No respiratory distress.

Gastro–intestinal system: No diarrhea, no constipation, there's abdominal distention.

Cardiovascular system: Murmur was notice but with blood pressure of 165/110mmHg.

Musculoskeletal system: There's no stiffness of any part of the body.

Intergumentart system: There's scar in the abdomen due to previous surgeries, no skin rash and no
discoloration observed.

PATIENT'S FAMILY, MEDICAL AND SOCIAL HISTORY

Mrs N.C is a middle aged woman of 46years . She was born into the family of Mr & Mrs. O. in About
Mbaise local government area of Imo state. She is the fourth child of her family.She is married to Mr.N.B
and they have 5 children including males and females. She has a history of diabetes mellitus in the
family and is also suffering the disease. She is a trader; her hobbies are singing and cleaning. She has a
medical history of diabetes, high blood pressure and recurrent fibroids and has undergone 3
myomectomies.
 DIAGNOSIS ON ADMISSION

Mrs. N.C was seen at the outpatient department by the doctor who made a diagnosis of recurrent
uterine myoma with right complex adnexa cyst.

The doctor after a proper and good history taking and thorough physical examination, decided that Mrs.
N.C should be admitted into Ward 4 gynae for proper management.

INVESTIGATIONS ORDERED FOR MRS.N.C.

Mrs. N.C. was placed on the following investigations: Hematoxylin and eosin staining

INVESTIGATION

Hematoxylin and eosin staining

PATIENT'S RESULT

Shows spindle–shaped tumor cells with no mitosis (100X and 200X respectively)