Case Study: Abnormal Uterine Bleeding and Multiple Uterine Myoma
This case study presents a 39-year-old Filipino woman with heavy menstrual bleeding and multiple uterine myomas. History of present illness, diagnostic findings, and treatment plan are detailed, highlighting the patient's journey from initial symptoms to medical management recommendations.
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UNIVERSITY OF CEBU MEDICAL CENTER DEPARTMENT OF OBSTETRICS AND GYNECOLOGY PRE-OPERATIVE CONFERENCE August 17, 2024 Ireen S. Pahang Fourth year Resident
Abnormal Uterine Bleeding Multiple Uterine Myoma CASE
GENERAL DATA C.V. 39yo G0 Single Filipino Roman Catholic Consolacion, Cebu HEAVY MENSTRUAL BLEEDING
HISTORY OF PRESENT ILLNESS 6 YEARS PTC 6 YEARS PTC - Noted palpable solid hypogastric mass, fist sized, with onset of intermittent crampy hypogastric pain, PS 5-7/10, lasting for 1 hour, sporadic, resolves spontaneously - Associated with heavy menstrual bleeding using 9 maternity pads/ day on the first 3 days of menses - No other symptoms such as changes in bowl or bladder habits - Tolerated condition
HISTORY OF PRESENT ILLNESS INTER INTERIM IM Intermittent hypogastric pain and heavy menstrual bleeding persisted the following years Tolerated condition
HISTORY OF PRESENT ILLNESS 10 MONTHS PTC 10 MONTHS PTC Sought consultation with private gynecologist for lower back pain Hypogastric mass now at the level of umbilicus CBC revealed severe anemia with hemoglobin of 6
HISTORY OF PRESENT ILLNESS 10 MONTHS PTC 10 MONTHS PTC TVS (10/25/23) Enlarged anteverted uterus (21.4x15x11.5cm) with proliferative endometrium Multiple uterine myoma M1: 11.7x11.2x9.8cm posterofundal (FIGO Grade 6) M2: 5.4x6.4x4.9cm, anterior midcorpus (FIGO Grade 6) M3: 4.3x4.4x3.0cm, left anterior isthmic (FIGO Grade 6) M4: 2.3x2.1x2.4cm, anterior midcorpus (FIGO Grade 4) Non-visulaized both ovaries due to poor acoustic window secondary to huge uterine masses, no cul de sac fluid
HISTORY OF PRESENT ILLNESS 10 MONTHS PTC 10 MONTHS PTC Admitted for 4 days S/P Blood transfusion 4 units PRBC S/P Leuprorelin 11.25mg deep IM Advised myomectomy after medical management with GNRH Agonist
HISTORY OF PRESENT ILLNESS INTERIM INTERIM Good compliance with medical management No symptoms such as hot flushes nor mood swings No menstruation since first dose of Leuprorelin was given Low back pain and pelvic pressure still noted (PS 5-7/10) S/P Leuprorelin 11.25mg (10/23/23) Leuprorelin 3.75mg (2/24/2024) Leuprorelin 3.75mg (3/25/2024)
HISTORY OF PRESENT ILLNESS 5 MONTHS 5 MONTHS Patient was advised Abdominal Myomectomy by her private gynecologist Referred to UCMed OB-OPD for charity enrollment Lost to follow-up due to personal problems
HISTORY OF PRESENT ILLNESS 2 MONTHS PTC 2 MONTHS PTC Heavy menstrual bleeding recurred, used 9 fully soaked pads/ day, lasting for 5 days Tolerated condition
HISTORY OF PRESENT ILLNESS 2 WEEKS PTC 2 WEEKS PTC Follow-up at OB-OPD Repeat TVS for surveillance was done (7/27/24) Enlarged anteverted uterus with proliferative endometrium Multiple uterine myoma M1: 12.98x13.03x9.19cm (11.7x11.2x9.8cm) posterofundal (FIGO Grade 5) M2: 3.98x4.24x4.51cm (5.4x6.4x4.9cm), anterior midcorpus (FIGO Grade 5) M3: 4.8x5.1x4.43cm (4.3x4.4x3.0cm), left anterior isthmic (FIGO Grade 6) Left adnexal mass consider an ovarian new growth with benign sonographic features by IOTA simple rules Unilocular anechoic cyst 6.72x6.18x4.18cm
HISTORY OF PRESENT ILLNESS 2 WEEKS PTC 2 WEEKS PTC CBC: hemoglobin 14.1, hematocrit 43.4 Dilatation and curettage done as outpatient (7/27/2024) Histopathology: secretory endometrium Scheduled for Abdominal Myomectomy
PAST MEDICAL HISTORY No known comorbidities
PERSONAL AND SOCIAL HISTORY No known allergy Non-smoker Non alcoholic beverage drinker Denies use of illicit drugs Graphic designer
OBSTETRIC AND GYNECOLOGIC HISTORY G0 LMP 8/2/2024; PMP 7/10/2024 M: 13yo I: regular D: 6-7 days A: 7-8 pads/ day, moderately soaked S: none C: 30yo P: 1 C: condom P: Normal (3/23/24) S: none
REVIEW OF SYSTEMS GENERAL: GENERAL: (-)weight loss, (-)anorexia, (-)weakness HEENT: HEENT: (-)blurring of vision, (-)ear pain, (-)anosmia, (-)dysphagia PULMONARY: PULMONARY: (-)cough, (-)dyspnea GI: GI: (+)hypogastric pain, (-)hematochezia, (-)melena, (-)constipation GUT: GUT: (-)hematuria, (-)dysuria, (-)frequency, (+)hypogastric mass ENDOCRINE: ENDOCRINE: (-)no heat/cold intolerance, (-)thyroid enlargement MUSCKULOSKELETAL: MUSCKULOSKELETAL: (-)joint pain, (-)muscle weakness HEMATOLOGIC: HEMATOLOGIC: (-)easy bruising, (-)swollen lymph nodes NEUROLOGIC: NEUROLOGIC: (-)seizure, (-)confusion
PHYSICAL EXAMINATION BP: 120/70mmHg HR: 76bpm Height: 158cm RR: 20cpm BMI: 22.25kg/m2 T: 36.2 C Weight: 55.4kg GENERAL: GENERAL: conscious, coherent, not in distress HEENT: HEENT: anicteric sclerae, pinkish lips C/L: C/L: equal chest expansion, clear breath sounds CVS: CVS: distinct heart sounds, no murmurs Abdomen: Abdomen: solid hypogastric mass 20 weeks size, knobby contour, movable, non-tender, NABS Extremities: Extremities: strong pulses
PHYSICAL EXAMINATION SE: SE: non-parous, smooth, closed cervix, deviated to the right BIMANUAL PELVIC EXAMINATION BIMANUAL PELVIC EXAMINATION: : I: non-parous, no lesions C: closed, smooth, firm, no cervical motion tenderness U: 20 weeks size, knobby and smooth contour, movable, nontender A: no palpable adnexal mass, no tenderness D: minimal clear discharge, non-foul smelling RVE: no fullness on posterior cul de sac, non-tender, no mass, no nodularity, intact septum
PRIMARY IMPRESSION G0, Abnormal Uterine Bleeding secondary to Multiple Uterine Myoma S/P Leuprorelin x 3 doses S/P Blood transfusion x4u PRBC (October 2023)
BIOETHICAL ANALYSIS The patient is a 39 y.o, single, G0, diagnosed with AUB- Multiple uterine myoma Goals of treatment: resolution of abnormal uterine bleeding and hypogastric pain, with preservation of fertility MEDICAL INDICATION PATIENT PREFERENCE QUALITY OF LIFE CONTEXTUAL FEATURES
BIOETHICAL ANALYSIS Preferred initial treatment: Medical: GNRH agonist, sex steroid hormones (DMPA, COCs, LNG- IUS), tranexamic acid Laparoscopic and hysteroscopic myomectomy Contemplated procedure: Abdominal Myomectomy with Chromopertubation, left ovarian cystectomy, possible Total abdominal hysterectomy, bilateral salpingectomy Benefit more with abdominal myomectomy (beneficence) than long term GNRH therapy (nonmaleficence) MEDICAL INDICATION PATIENT PREFERENCE QUALITY OF LIFE CONTEXTUAL FEATURES
BIOETHICAL ANALYSIS The patient made an informed decision to have surgery out of her own free will. She understands the possible risks and complications, as well as the management if these will arise. Still desirous of pregnancy, thus myomectomy was chosen despite the risk of recurrence (18-20%) The family has been supportive to whatever management that has to be done MEDICAL INDICATION PATIENT PREFERENCE QUALITY OF LIFE CONTEXTUAL FEATURES
BIOETHICAL ANALYSIS MEDICAL INDICATION Stage PATIENT PREFERENCE Removal of the myomas will alleviate the bulk symptoms The patient may return to her usual activities once fully recovered Pregnancy is advised >18 months post-op for scarred uterus, however, studies showed that pregnancy is allowable after 6 months post-op especially in cases of advanced maternal age and other fertility issues QUALITY OF LIFE CONTEXTUAL FEATURES
BIOETHICAL ANALYSIS MEDICAL INDICATION PATIENT PREFERENCE Cost of the medical and surgical management has been discussed by a private gynecologist lost to follow- up referral to charity access to affordable management The patient and her family were cooperative in the management of the case There are no religious or legal issues that may create conflicts of interest in the clinical decisions QUALITY OF LIFE CONTEXTUAL FEATURES
PROCEDURE Abdominal myomectomy with Chromopertubation, Left ovarian cystectomy, possible Total abdominal hysterectomy, bilateral salpingectomy
PRE-OPERATIVE PLANS Secure consent to the procedure Risk assessment as outpatient c/o IM charity Stratified as low risk to develop cardiopulmonary complications intraoperatively Anesthesiologist charity house on-call To secure 2 units PRBC, screened & crossmatched Chlorhexidine as body wash before bedtime and early morning
PRE-OPERATIVE PLANS Diet: DAT Solids allowed 6 hours prior to induction of anesthesia Clear liquids allowed up to 2 hours prior to induction of anesthesia Antimicrobial prophylaxis within 60mins prior to cutting Cefazolin 2 grams IVTT ANST prior to cutting Application of elastic bandage thigh high once at OR
POST-OPERATIVE PLANS Intermittent pneumatic compression stockings until fully ambulatory To terminate IVF within the first 24 hours postop To resume regular diet within 24 hours postop Postop pain analgesia care of anesthesia service Removal of urinary catheter within 24 hours postop Early ambulation within 24 hours postop
