8/3/2019 Myoma Edited

1/2

Objectives:

To define myoma and its different types

To describe its pathogenesis and correlate it with its clinical findings

To differentiate it from other abdominal masses

To identify ancillary procedures for its definite diagnosis

To identify its various complications

To identify various treatment options

Patient profile: HS, 35 G0, single from Paranaque City.

Chief complaint: abdominal mass

Past Medical History: (-) DM, HPN, TB, asthma, goiter, cancer, allergy, previoushospitalization or surgeries

Family Medical History: (+) thyroid disease - sister (-) HPN, DM, asthma, allergies

Personal/Social/Sexual History: nonsmoker, nonalcoholic beverage drinker, denies illicit

drug use, vocational course graduate currently unemployed, coitarche at 30 years to asingle nonpromiscuous sexual partner, (-) OCP, IUD, DMPA use

Menstrual History: menarche at 15, regular monthly intervals, 4-5 days duration, 2pads/day, (+) dysmenorrheaLMP: Oct 10, 2011 PMP: September 2011

Obstetric History: G0

History of Present Illness2 years and 11 months PTA: During routine PE for employment abroad, an abdominal masswas noted by the attending physician. No visible abdominal enlargement, no abdominalpain, vaginal bleeding, vaginal discharge, menometorrhagia, weight loss/gain. Patient

consulted at PGH where transvaginal UTZ done revealed multiple myoma uteri.

She was advised operation but this was delayed due to insufficient funds. She waseventually lost to follow up.

2 months PTA: patient returned due to enlarging abdominal mass. She was scheduled for ORand eventually admitted at ward14B.

(-) weight loss, anorexia, fever, cough, colds, dysphagia, dyspnea, chest pain, palpitations,profuse vaginal bleeding, pallor, easy fatiguability, weakness, edema, joint pains.

Physical Examination:BP: 120/80 HR: 88. RR: 20. Temp: afebrile

Awake, conscious, coherent, ambulatory, not in cardiorespiratory distressAnicteric sclerae, pink conjunctiva, (-) tonsillopharyngeal congestion, (-)neck veinengorgementEqual chest expansion, clear breath sounds, (-)crackles or wheezesAdynamic precordium, distinct heart sounds, normal rate regular rhythm (-) murmursFlabby abdomen, normoactive bowel sounds (+) abdominal mass: 20x25 firm, nontender,movable with distinct bordersIE: normal external genitalia, nulliparous vagina, cervix smooth firm and closed measuring 3x 2.5cm (Lx W), corpus enlarged to 22-24 weeks size, (-)adnexal masses or tendernessDRE: good sphincteric tone, intact rectal vault, bilateral parametria smooth and pliable

8/3/2019 Myoma Edited

2/2

Full and equal pulses, pink nailbeds, no cyanosis clubbing or edema

Assessment:Multiple Myoma uteri, multipleG0

Diagnostics:Blood Type O+

Hemoglobin (g/dl) 13Hematocrit (%) 39RBCs ( x 106 /ml) 4.0RDW < 14.5MCV 92MCH 30MCHC % 31Platelet count 397

WBC 10.05Neutrophils 0.54Band forms 0.03Basophils 0.75Eosinophils 0.02lymphocytes 0.28Monocytes 0.04

yellow, slightly hazy, Specific Gravity 1.015pH 6.0, (-) Glucose, Ketones, Blood, Protein, Bilirubin, Nitrate, LeukocyteNormal Urobilinogen 0.1-1.0Occasional casts, Rare RBCsRare casts and WBCsFew Epithelial cells and Mucus threads

Transvaginal UTZThe uterus is anteverted with irregular contour and heterogenous echopattern measuring22.5x8.9x20.2cm (cervix measures 3.2x3.2x2.4).

There are 3 well-circumscribed heterogenous masses seen (M1) 9.0x8.2x8.3cm, posterior-midcorpus, intramural with subserous component (M2) 9.8x10.1x10.8cm, posterior isthmic,intramural and (M3) 6.0x7.0x7.3cm, posterofundal intramural with subserous component.

The endometrium is hyperechoic measuring 0.2cm and pushed anteriorly with intactsubendometrial halo anteriorly.

The right ovary measures 2.7x2.9x1.8cmThe left ovary measures 2.3x2.8x2.3cm.No free fluid in the culdesac.

Impression:Multiple myoma uteriPelvic endometriosis with endometrial cystsNormal ovaries

Plan:Explorative laparotomy, myomectomy chromotubationPossible total hysterectomy under regional anesthesia

Guide Questions1. What is myoma? Differentiate its types.2. How does it present, and correlate these with the patient.3. What other pathologies would you consider given the finding of an abdnominal mass?4. How do you establish its diagnosis?5. What are its complications?6. What are the various treatment options (medical and surgical)?7. How will you advise this patient?