CASE

PRESENTATION
C

Residents-in-charge: Dr. Gonzalez/Dr. Yusingbo/Dr. Bunyi

Presented by: Intern Maria Cristina S. Amat
OBJECTIVES:
• To present a case of a patient with hypogastric pain
• To discuss myoma uteri and its clinical features, diagnosis and
treatment
• To present a journal regarding the treatment of myoma uteri
CLINICAL HISTORY
C
GENERAL DATA
• R.O.
• 39-year old
• G4P3 (3013)
• Filipino, married, Roman Catholic
• Born in Capiz and currently lives in Las Pinas City
CHIEF COMPLAINT

HYPOGASTRIC PAIN
HISTORY OF PRESENT ILLNESS
• Hypogastric pain
• Crampy, 5/10, intermittent, lasts for 1 week
• No palpable mass, no dysuria, no frequency, no
dribbling, no vaginal bleeding, no flank pain, no
constipation, no menstrual irregularities
3
• Self medicated with Mefenamic acid which
MONTHS
provided temporary relief
• No consult was done
HISTORY OF PRESENT ILLNESS
• Persistence of hypogastric pain
• Crampy, 7/10, intermittent, lasting for 1 week
• No palpable mass, no dysuria, no
1 frequency, no dribbling, no vaginal
MONTH
bleeding, no flank pain, no constipation,
no menstrual irregularities
HISTORY OF PRESENT ILLNESS
• SJDH OPD consult:
• Abdomen: flat, soft, non-tender, no palpable mass
• External genitalia: grossly normal
• SE: cervix pinkish, smooth with minimal whitish discharge
• IE:
1 • cervix firm, long and closed;
MONTH • uterus asymmetrically enlarged to 16 weeks size
• no adnexal mass or tenderness
• RVE: tight sphincteric tone, smooth rectal mucosa, cervix firm
and long, uterus asymmetrically enlarged to 16 weeks; no
adnexal mass or tenderness
HISTORY OF PRESENT ILLNESS
• SJDH OPD consult:
• Assessment: G4P3 (3013) Myoma uteri
• Plan: TVS, urinalysis, CBC, pap smear

1
MONTH
TRANSVAGINAL ULTRASOUND
UTERUS Anteverted
7.5 x 5.8 x 6.2cm
Intramural myoma measuring 8.06x7.79x10.48cm,
anterior uterine wall
ENDOMETRIUM 4.1 x 3.1 x 0.2cm
CERVIX 3.3 x 3.0 x 2.8cm
OVARY Right 2.6 x 2.3cm
Left 2.7 x 1.4cm
 CBC Urinalysis
Hgb 11.9 Yellow Sugar negative
Hct 35.8 6.0 Albumin trace
WBC 10.47 Clear WBC 1-2/HPF
Plt 298 1.020 RBC 1-2/HPF
Seg 71.5
Pap smear
Lymph 22.2
Negative for intraepithelial lesion or
malignancy
HISTORY OF PRESENT ILLNESS
• OPD consult:
• Assessment: G4P3 (3013) Myoma uteri
• Plan: CP clearance – Low Risk
Schedule for Total Abdominal Hysterectomy
1
MONTH
PAST MEDICAL HISTORY
• Bronchial Asthma
• Since childhood
• Salbutamol (Ventolin) as needed for exacerbations
• No recent asthmatic attacks
• No allergies
• No surgeries
FAMILY HISTORY
• Diabetes mellitus – maternal
PERSONAL AND SOCIAL HISTORY
• SPED teacher
• Non-smoker, non-alcoholic
MARITAL AND SEXUAL HISTORY
• Single
• Living in for 20 years
• 42-year old insurance company employee
• First sexual contact: 20 years old
• # of lifetime sexual partners: 1
• Denies dyspareunia or post-coital bleeding
MENSTRUAL HISTORY
• Menarche: 16 years old
• Interval: regular
• Duration: 4 days
• Amount: 3 fully soaked regular pads per day
• Denies dysmenorrhea
OBSTETRIC HISTORY

• LNMP: September 15-17, 2018 (2 days prior to admission)

• PMP: August 17-20, 2018
GYNECOLOGIC/CONTRACEPTIVE
HISTORY
• No vulvar rashes, no pruritus, no foul-smelling discharge
• Last pap smear: September 2018 – negative for intraepithelial
lesion or malignancy

• Natural family planning: withdrawal

• Denies use of artificial family planning methods such as oral
contraceptive pills, injectables and condoms
REVIEW OF SYSTEMS
• GENERAL: No weakness, no loss of appetite, no easy fatigability, no weight
loss
• INTEGUMENT: No pallor, no jaundice, no rashes
• HEENT: No headache, no eye pain, redness or swelling, no otalgia, no
otorrhea, no vertigo, no tinnitus, no difficulty hearing, no epistaxis, no nasal
discharge, no hoarseness, no dysphagia, no sore throat
• RESPIRATORY: No cough, no dyspnea
• CARDIOVASCULAR: No chest pain, no palpitation, no paroxysmal nocturnal
dyspnea, no orthopnea
REVIEW OF SYSTEMS
• GASTROINTESTINAL: No anorexia, no nausea, no vomiting, no
hematemesis, no melena, no hematochezia, no diarrhea, no constipation
• URINARY: No dysuria, no flank pains, no hematuria
• ENDOCRINE: No polydipsia, no polyuria, no heat or cold intolerance
• EXTREMITIES: No edema, no myalgia, no arthralgia
• NERVOUS: No seizures, no tremors, no one-sided weakness
 PHYSICAL
EXAMINATION
C
GENERAL SURVEY
• Awake, conscious, coherent
• Oriented to time, place, person
• Ambulatory
• Not in cardiorespiratory distress
VITAL SIGNS
• Blood pressure: 90/60 mmHg
• Heart rate: 72 beats/min
• Respiratory rate: 19 cycles/min
• Temperature: 36.4 C

ANTHROPOMETRICS
• Height: 168 cm
• Weight: 60 kg
• BMI: 21.26 kg/m2
PHYSICAL EXAMINATION
• INTEGUMENT
• No note of pallor, no jaundice, no cyanosis, no rashes, no erythema;
No masses or lesions noted; good skin turgor
• HEENT
• pink palpebral conjunctivae, anicteric sclerae, moist pinkish oral
mucosa, uvula is midline, tongue is pink, non-hyperemic, non-
hypertrophic tonsils; no cervical lymphadenopathies
PHYSICAL EXAMINATION
• CHEST AND LUNGS
• No chest wall deformities; no use of accessory muscles noted;
symmetrical chest expansion; clear breath sounds; Breast examination:
symmetrical, no discolorations or retractions; non-tender, no palpable
masses bilaterally
• CARDIOVASCULAR
• No precordial bulge; Point of maximal impulse 5th ICS LMCL; no
heaves, no thrills; normal rate, regular rhythm, no S3 or S4; no
murmurs
ABDOMEN
• Flat, no visible masses, pulsations or peristalsis
• Normoactive bowel sounds
• Soft, non-tender abdomen, no palpable mass
• Tympanitic on all quadrants
GENITOURINARY
• No CVA tenderness
PELVIC EXAMINATION
• External Examination: grossly normal
• Speculum Examination: cervix pink, smooth with minimal white
discharge
• Internal examination: cervix firm, long and closed; uterus
asymmetrically enlarged to 16 weeks; no adnexal mass or tenderness
• Rectovaginal examination: tight sphincteric tone, smooth rectal
mucosa, cervix firm and long, uterus asymmetrically enlarged to 16
weeks; no adnexal mass or tenderness
EXTREMITIES
• No deformities, no edema
• No joint tenderness, no joint swelling, full and equal peripheral
pulses
ADMITTING DIAGNOSIS
• G4P3 (3013)
• Myoma uteri, intramural
• Bronchial asthma not in acute exacerbation
PLAN
• Total abdominal hysterectomy
COURSE IN THE
WARDS
C
UPON ADMISSION
• NPO post midnight
• IVF: D5LR 1L to run for 8 hours to be hooked 2 hours prior to OR
• Diagnostics: CBC, blood typing
• Schedule for total abdominal hysterectomy
• Give Cefoxitin 2g IV ANST 1 hour prior to OR
• Reserve 2 units FWB
• Dulcolax 2 tabs at bedtime
SRNU OR
OPERATING ROOM
• PELVIC EXAMINATION UNDER SPINAL EPIDURAL
ANESTHESIA
• Internal examination: cervix firm, long and closed; uterus
asymmetrically enlarged to 16 weeks; no adnexal mass or
tenderness
INTRAOPERATIVE FINDINGS
cephalad

right left

caudad
INTRAOPERATIVE FINDINGS
• 7x7cm

Intramural
myoma
INTRAOPERATIVE FINDINGS
• VITAL SIGNS
• 110/80mmHg
• 82 beats/min
• 20 cycles/min
• 36.1C
• Urine Output: 500 cc, clear
• ESTIMATED BLOOD LOSS: 400cc
OR RR
RECOVERY ROOM
RR SRNU
DAY 1 POST-OP
DAY 2 POST-OP
DAY 3 POST-OP
HISTOPATHOLOGIC FINDINGS
• Intramural leiomyoma
• Chronic cervicitis with squamous metaplasia
FINAL DIAGNOSIS
• G4P3 (3013)
• Myoma uteri, intramural;
• Bronchial asthma not in acute exacerbation
• Total abdominal hysterectomy under spinal epidural anesthesia
CASE DISCUSSION
C
SALIENT FEATURES
SUBJECTIVE OBJECTIVE
39 G4P3 (3013) Internal exam: cervix long and closed;
Hypogastric pain uterus asymmetrically enlarged to 16
weeks; no adnexal mass or tenderness
No vaginal bleeding, no bowel or
urinary changes TVS:
Intramural myoma measuring
8.06x7.79x10.48cm, anterior uterine
wall
LEIOMYOMA
• Most common benign neoplasm of the uterus
• Muscle cell origin
• 1/3 of myomas will be symptomatic
• Less than 1% malignant potential
EPIDEMIOLOGY
• Affects 20-40% of women during their reproductive years and 69%
in the peri- and post-menopausal period
• In the Philippines (2008), myomas accounted for 8,358 of 32, 679
benign gynecological conditions (25.6%)

Fernandez, M.A. 2008. Myoma uteri: Minimally invasive approaches.

RISK FACTORS
✔
 Increasing age Patient:
 Early menarche 39 year old
 Low parity G4P3 (3013)
 Tamoxifen use Menarche: 16 years old
No tamoxifen use
 Obesity BMI: 21.26 kg/m2
 African-American race Filipino
 Family history No family history
LOCATION
Patient
✔
 Corpus of the uterus- majority
 Fallopian tube
 Round ligament PIC OF CUT SECTION
 Cervix
 Retroperitoneum
 CLASSIFICATION
 Submucous - bleeding
✔
 Intramural - hypogastric pain
 Subserous – pressure symptoms
Patient

Intramural myoma
measuring 7x7cm, anterior
uterine wall
CLINICAL FEATURES
 Abnormal uterine bleeding
✔
 Pelvic pain Patient:
 Pelvic pressure Hypogastric pain
 Bowel or bladder dysfunction -intermittent
 Infertility -crampy
 Recurrent miscarriage
 Abdominal protrusion
PHYSICAL EXAMINATION
✔
 IE: irregularly enlarged uterus Patient:
 Abdomen: palpable mass No palpable mass
IE: uterus
asymmetrically
enlarged to 16 weeks
size
IMAGING STUDIES
✔
 Ultrasound
 Sonohysterography
 Hysteroscopy
 Hysteroslapingography
 CT scan
 MRI
 HISTOPATHOLOGIC FINDINGS
• GROSS EXAMINATION:
glistening, pearly-white, whorled configuration

Patient
Example
TREATMENT
 TREATMENT
NON-SURGICAL SURGICAL

Medical Uterine Artery Myomectomy Hysterectomy

Embolization

-GnRH agonists Ablation Wish to preserve the uterus* Definitive treatment

-Androgens (Danazol) Persistent abnormal bleeding, Persistent abnormal bleeding, pelvic
pelvic pain or pressure pain or pressure
-Aromatase inhibitors Asymptomatic myoma >8cm Asymptomatic myoma >8cm
(Letrozole)
-Selective Progesterone
Receptor Modulators
(Mifepristone, Ulipristal)

*Society of Obstetricians and Gynecologists of Canada CPG

Vilos GA, Allaire C, Laberge PY, et al. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015;37(2):163.
 JOURNAL
PRESENTATION
C
OBJECTIVE
• To study technique, complications, and outcomes of transvaginal
ultrasound-guided radiofrequency myolysis (TRFAM) of uterine
myomas.
INTRODUCTION
• Ablation therapy using thermal energy sources has been
the focus of interest as a minimally invasive strategy for
patients with abnormal bleeding due to myomas.
ADVANTAGES
• Reduced morbidity (operating time, blood loss, and length
of hospital stay)
• Preservation of the endometrial cavity
• Real-time imaging guidance
• Outpatient procedure
METHODS
INCLUSION CRITERIA: EXCLUSION CRITERIA:
- Symptomatic patients - Four or more myomas
- No more than 3 fibroids >5cm
of any size - Malignancy or
- Unresponsive to medical precancerous conditions
therapy - Coagulopathy
- Not easily removed by - Pregnancy
hysteroscopy or - PID
laparoscopy - Comorbidities
PROCEDURE

TVS Loading of
IV sedation
Hgb antibiotics
PROCEDURE

Radiofrequency
Post op
needle under TVS Myolysis
care
guidance
OUTCOME MEASURES
Monitoring 1, 3, 6, and 12 months post op

- Volume reduction
- Hemoglobin level
- Symptom control
- Patient satisfaction
VOLUME REDUCTION
 RESULTS
• SYMPTOM CONTROL
• All patients had normal menstruation at a mean follow up of 3 months
• HEMOGLOBIN LEVEL
• Preoperative Hgb ranging from 7.2-10.5g/dL to 10.7-12.1g/dL at 3 months (P< .0001)
• PATIENT SATISFACTION
• 98.04% (200/205) of patients expressed satisfaction with the procedure
CONCLUSION
• Transvaginal radiofrequency myolysis for submucosal and
intramural cavity-distorting myomas is a safe, fast,
minimally invasive, and effective technique to treat
metrorrhagia and reduce myoma volume.
• Optimal patients are those with a myoma volume < 39
cm3.
RECOMMENDATIONS
• Larger study group
• Longer follow up
REFERENCE:
• Lobo, R.A., Gershenson, D.M., Lentz, G.M., Valea, F.A., Comprehensive Gynecology.
• Victoria E. Rey, Rocío Labrador, María Falcon, and José Luis Garcia-Benitez. (September 2018).
Transvaginal radiofrequency ablation of myomas: technique, outcomes, and complications. Journal
of Laparoendoscopic & Advanced Surgical Techniques. http://doi.org/10.1089/lap.2018.0293
• Fernandez, M.A. (2013 June 17). Myoma uteri: Minimally invasive approaches. The Philippine
star. Retrieved from
http://www.pressreader.com/philippines/the-philippine-star/20130617/281745561949811
• Society of Obstetricians and Gynecologists of Canada. Clinical Practice Guidelines: Myoma uteri.
• Vilos GA, Allaire C, Laberge PY, et al. The management of uterine leiomyomas. J Obstet Gynaecol Can.
2015;37(2):163.
THANK YOU!
C