normal and abnormal puerperium
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Normal and Abnormal Puerperium
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Synonyms
leiomyoma of uterus
leiomyomas
fibromyomas
myofibromas
fibroids
fibromas
myomas
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Incidence
Most common solid pelvic tumors
Develop in 20 ~ 25% of women during reproductive years
30 ~ 50 years old
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Correlative Factors
An estrogenic milieu may be necessary
Progesterone function
Growth factor and their receptor : epithelial growth factor ( EGF ) Insulin-like growth factor ( IGF ) platelet-derived growth factor
Puberty
Menopause
Estrogen Progesterone
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Pathology
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Gross AppearanceRare only a single , usually many existWell-circumscribed , nonencapsulatedA pseudocapsule is present.The consistency is usually firm or even hard except when degeneration or hemorrhage has occurred.color : light gray or pinkish whitecut section : an intertwining pattern or
a whorl-like arrangement ; bulgy
Pseudocapsule
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Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the uterus.
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Microscopic Appearance
Composition : smooth muscle
connective tissue
The nonstriated muscle fibers are arranged in bundles of various sizes that run in multiple directions.
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Classification ( 1 )
According to growth location :
• Myomas on the body of uterus ( 90% )• Myomas on the cervix of uterus ( 10% )
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Classification ( 2 )According to the relation to uterine muscle :• Submucous ( 10 ~ 15% )• Intramural ( 60 ~ 70% )• Subserosal ( 20% )
Few leiomyomas are actually of a single “pure” type.
— hybrids
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Clinical Manifestation
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Symptoms
menorrhagia and prolonged menstrual period :commonPelvic pain :
occurs in pregnancy if undergoing degeneration or torsion of a pedunculated myomaPelvic pressure : urinary frequency
bowel difficulty ( constipation )Spontaneous abortionInfertility
Menorrhagia
Pedunculated
spontaneous abortion
Infertility
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Signs
A palpable abdominal tumour
Pelvic examination : uterus — enlarged and irregular ; hard
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Degeneration
Hyaline degeneration
Cystic degeneration
Red degeneration
Sarcomatous change
The others : fat degeneration
calcification
the secondary infection
Result from the diminished vascularity of the
connective-tissue element
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Red DegenerationOccasionally seen as a complication of pregnancy( during pregnancy or immediate postpartum period )
The pathogenesis is unknown , may be the result of the accumulation of blood in the tumour because of venous obstruction.
The cut surface resembles raw meat.
Clinical features : a cause of pain ( acute ) fever rapid growth , tender
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Here is a very large leiomyoma of the uterus that has undergone degenerative change and is red (so-called "red degeneration"). Such an appearance might make you think that it could be malignant. Remember that malignant tumors do not generally arise from benign tumors.
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Sarcomatous Change
Rare : 0.4% ~ 0.8%
More common at 40 ~ 50 years old
Usually occur in intramural fiboids
grow quickly
vaginal bleeding
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Diagnosis
History
Bimanual examination
Ultrasonography ( B–ultrasound examination )
Hysteroscopy
Laparoscopy
Hysterography
Hysteroscopy
Laparoscopy
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Differential Diagnosis
Pregnancy
Ovarian tumour
Adenomyosis
Malignant tumors of uterus
• sarcoma of uterus
• endometrial carcinoma
• cervical cancerwww.freelivedoctor.com
Treatment
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Observation and Follow Up
Small , asymptomatic fibroids need not be treated , especially near menopause.
Interval : 3 ~ 6 months
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Medical Treatment
Androgenic agents : testosterone propionate
GnRH-a :• induce a hypoestrogenic pseudomenopausal
state
• not recommended for longer than 6 months
• “add-back” regimens
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Surgery Treatment( 1 )Indications :
greater than 10 weeks’ gestational size
menorrhagia , lead to anemia
have pressure symptoms
grows rapidly
failure of medical treatment
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Surgery Treatment( 2 )Method :
Myomectomy—conservative therapy preserve fertility
significant risk of recurrence
Hysterectomy— radical therapy
Subtotal hysterectomy
hysterectomy
myomectomy
Only true “cure” for leiomyomas
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Surgery Treatment( 3 )Approach :
• trans-abdominal
• trans-vaginal
• laparoscopic or hysteroscopic
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It is important to individualize the choice of therapy.
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Uterine Leiomyomas Complicating Pregnancy
impact on pregnancy : abortion
impact on delivery : premature labour fetal malpresentation retained placenta placenta previa need for operative delivery ( birth canal obstruction ) postpartum hemorrhage
Conservative treatment
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Critical PointsMay be related to superabundant estrogen.Well-circumscribed , nonencapsulated.
Have a pseudocapsule.Can be classified into submucosal 、 intramural and subserosal types.Different types have different features.Menorrhagia is common.Four degeneration typesIndividualized treatment , include observation 、 medical treatment and surgical treatment.
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