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MRCOG PART 2 SBAs and EMQs

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ESSAY 164 - FIBROIDS

Posted by Nitin P.
This is a medical emergency and the airway, breathing and circulation should be assessed immediately. In case the breathing and circulation are absent, a call for help is given and the cardiac team is contacted. In the mean time, the patient is placed in the recovery position and resuscitation with chest compression and artificial breathing is started at the ratio of 15:2.
IV access is obtained as she may be in hypovolaemic shock due to blood loss. Isotonic fluids are started immediately and blood transfused later on. Blood is collected for Full blood count to check for anaemia, coagulation profile to rule out coagulation abnormalities as cause of heavy bleeding, urea and electrolytes and liver function to monitor the patient. A group and cross match is also done.
Once the cardiac collapse team arrives, she may need DC shocks.
At recovery she should be cared for in an HDU.
The measures taken should be documented and signed.
In case the breathing and circulation are normal, she still needs investigations in the form of haemoglobin estimation. The fact that she collapsed means she is quite low on haemoglobin and it would be advisable to admit her for intravenous fluids initially and if need be blood transfusion.
Non-gynae causes for a collapse are considered once the immediate resuscitation is over. Blood loss not compatible with likelihood of collapse is an indicator of a non-gynae cause. History of heart disease, family history of unexplained adult deaths, thrombosis in self or family, cerebrovascular accidents indicate a coexistent pathology. Appropriate referrals are then made.
Ectopic pregnancy should always be considered as a differential and a urine pregnancy test checked.
The heavy bleeding if persistent needs to be controlled. A tranexamic acid drip is started. Progesterone will help to control the acute blood loss. Although estrogen is better to institute immediate control, it carries a risk of thrombosis.
She may need to be taken to theatre under presence of a consultant anaesthetist to do a hysteroscopy to check for a polyp and if necessary remove it.
As a last resort options such as uterine artery embolisation, and emergency myomectomy need to be considered.
b) It should be determined what is the cause of the heavy blood loss. A submucous fibroid may cause it but a subserous or intramural fibroid will not cause heavy bleeding. This should be explained to her. Also the effect of fibroid on fertility, that in most cases it has no effect should be explained.
She may then want to try to control the menorrhagia with anti fibrinolytics and anti inflammatory. The other options to control the menorrhagia are combined oral pill and levonorgestrel intrauterine system. The disadvantage of unwanted contraception is important in this case.
In case of a submucous fibroid or submucous extension, hysteroscopic resection is an option. Highly skilled operator, expensive equipment, fluid overload and risk of perforation are disadvantages.
Where facilities are available, interventional radiological technique of embolisation of artery to fibroid is considered. Disadvantage of severe pain, infection and occasionally need for laparotomy.
Myomectomy either laparotomy or laparoscopic is an option. Risk of hysterectomy, adhesions, future infertility are disadvantages. In addition, laparoscopy carries risks of bowel and blood vessel damage.
She is explained that a large fibroid would increase the complications in pregnancy such as red degeneration and placenta accrete if implanted over the fibroid.
The information is supported with the help of leaflets and she should be given enough time for her decision.
Posted by manjula C.
Resuscitation of the woman is the first priority. ABC of resuscitation needs to be taken care of. Circulation management is important in this case as hypovolemic shock is the likely diagnosis. Other possible causes for collapse could be torsion of pedunculated subserous fibroid, torsion of the ovarian cyst, early pregnancy complication like ectopic pregnancy. Rare causes in this agegroup is myocardial infarction, Cerebrovasuclar accidents, Pulmonary embolism.
Patient is positioned supine with foot end elevated. Two large bore I.V. canulae inserted and initial infusion with crystalloids started. Volume expanders like Haemaccel and Blood transfusion give as per the need. Oxygen is given by mask.
Monitoring of the patient is done by ECG in all 12 leads, O2 saturation by pulse oximeter, ABG analysis, CVP line, input and out put chart.

Condition explained to patient partner and relatives, community midwife can play an important role in this situation. Consultant obstetrician, Consultant anesthetist and Haematologist in informed. Bed in HDU / ITU is to be arranged. History is taken through relatives, midwife, GP, case notes to know the duration and severity of the symptoms, parity and mode of deliveries. Menstural history regarding regularity of cycles, contraception, LMP to rule out pregnancy related bleeding. Any previous ultrasound scan reports, IVP to rule out renal tract pathology secondary to compression by fibroid. Treatment history of medical and surgical are also asked.

Examination for B.P, Pulse, pallor( for anaemia), reflexes ( for CVA), CVS (MI), Respiratory system (for pulmonary emobolism), Per abdomen examination to assess the size of uterus, associated ovarian cyst. Per speculum examination: to note down blood loss, submucosal fibroid prolapse . Bimanual examination is done to assess the uterine size and adnexa.
Investigations: FBC, Blood group and Cross match, Arrange 4 units of blood, coagulation screen, Urea , Electrolyte, LFT. Ultrasound: both transabdomial and transvaginal to confirm number , size , types of fibroids, IVP in a large fibroids to rule out hydronephrosis and hydroureter.

Mangement: Emergency treatment for hypovolemic shock.
Stop / reduced bleeding: Injection of Depomedroxyprogesterone acetate, gives temporary reduction in blood loss, but it has no effect on size or vascularity of the fibroid. GnRH analogues injection provides reduction in blood loss along with the benefits of reducing the size and vascularity of the fibroid .

Long term treatment options for this woman are
1.Treating anaemia with iron supplements.
2. Expectant management, if no further episodes of bleeding till patient completes her family
3.Myometctomy is the definitive treatment option for her.
- Hysteroscopic myomectomy for submucous fibroids – it is a day care procedure, uterine perforation is the risk
- Laproscopic myomectomy for subserous and pedunculated fibroid- associated with minimal blood loss, short hospital stay, quick return to work, cost effective. Risks associated with laparoscopic surgery are injury to bowel and blood vessels, anesthetic risks
- Myomectomy by open laparotomy for any type of fibroid

Myomectomy offers the advantage of retaining uterus, but it is associated with complications of surgery like bleeding which can be torrential and at times needs hysterectomy. Infections, thromboembolism, adhesions, iotrogenic tubal block and infertility are other complications.

Alternatives:
1. Uterine artery embolisation :- is a relatively recent conservative therapeutic approach for the fibroid uterus. hort term results have shown 80% patient satisfaction rate and uneventful pregnancies following treatment in few cases. But its widespread use is limited by the lack of long term data regarding its safety and effects on fertility.
Recent modalities like
2. Laproscopic myolysis:
3. Magnetic resonance guided thermal ablation
4. Magnetic resonance guided focused ultrasound surgery

Are rarely undertaken in a woman who is planning for future pregnancy due to the lack of data on the safety on the pregnancy following the procedures.

Follow up is important after any type of conservative treatment to assess the efficacy of treatment and to detect any regrowths of fibroids.
Posted by Shakira B.
A) a) This is a medical emergency, airway, breathing, circulation should be assessed. The management should be multidisciplinary involving anesthetist, senior obstetrician and hematologist. Resuscitation should begin with placing the patients head down, chest compression and artificial breathing started. Check patients BP, PR, SPO2, ECG and Heart and Lungs. IV access started with 2 large bore needles with crystalloid initially and depending upon patient?s clinical condition O-ve blood started as a life saving measure, until the Xmatch blood of her group is available.
Patient?s history is taken from her relatives or if she recovers history can be taken from her, regarding her duration of symptoms, severity, LMP, any medication before and medical disorders like DM, high BP. Ectopic pregnancy could be a possibility, which can be ruled out by BetaHCG. Non-gynic causes of bleeding should be ascertained like: - heart disease, CVA, VTE.
Depending upon her FBC result, if HB is 8 GM or less, blood transfusion should be started. Other medical treatment like IV estrogen can be used in acute bleeding cases, but not used due to its risk of VTE. COC, danazol, NSAID, anti fibrinolytic not very affective in fibroid compared to its affect in DUB.
GNRH a can reduce the size of fibroid by 40-60% but it has side-effects like menopausal symptoms, osteoporosis limit its use for up to 6 months. But it can be used to built up HB concentration, reduce the size of fibroid, this effect is temporary as once treatment stops fibroid regrows.
b) Heamatinics given to improve her iron stores. If a submucous polyp found can be removed as a day case surgery with Hystrescope. Myomectomy is a treatment of choice as it retains her fertility. In view of the size of fibroid this cannot be done Laproscopicaly. A laporatomy will be necessary. It removes only visible, palpable, fibroids. There is a risk of life threatening hemorrhage and may need blood transfusion or hysterectomy. Prior consent have to be taken with the patient.
Procedure may be complicated by adhesion which may compromise fertility. Use of Danazol or GNRH a prior to Myomectomy will minimize blood loss, but this may be associated with difficulties in shelving fibroid and may progress to hysterectomy. There is a risk that small fibroids left behind could grow to significant size and cause more symptoms. If uterine cavity has been opened up then it has implications for vaginal child birth in future, and patient may need elective CS.
UAE is done in high risk patient. But RCOG recommend this only in tertiary centers. It is not for female who want to retain their fertility as rupture uterus in pregnancy can occur after this treatment due to avascular necrosis.
Other treatment :- 1) NY yag laser ablation of fibroid, causes less pain and done under GA. They are still a part of research treatment.
2) High intensity focused US, it efficacy is controversial.
Patient should be given leaflet and all discussion of long term treatment documented. Treatment options for this patient will be determined a variety of factors and best option for her will be decided after careful assessment and according to her wishes. She is explained that a large fibroid would increase the complications in pregnancy such as red degeneration and placenta accrete if implanted over the fibroid.
The information is supported with the help of leaflets and she should be given enough time for her decision.
Posted by uma M.
This will be recognized as an emergency situation. Immediate attention will be made towards resuscitation of the women. Rapid assessment of the patient’s condition is made initially. Check her BP, PR, RR, SPo2. Note degree of palor. CPR done if needed. Wide bore IV canula insert and fluids (Crystalloids-RL) started,start oxygen by mask. Call for further help,inform senior consultant and seek anaesthetist help if needed. Draw blood for urgent lab investigations – FBC, Blood group and Rh typing, RFT, LFT, X-matching,coagulation screen. Contact blood bank and haematologist for urgent need of blood if needed. Arrangements will be made for continuous monitoring of PR, BP, RR, SPo2 and urine output. If needs she should be managed in ICU .Blood transfusion given as per the need.

After initial resuscitation search for possible causeed. Possible causes include severe anaemia from persistant menorrhagia, torsion of subserous pedanculated fibroid intraperitoneal bleeding from vessel rupture over fibroid(rare cause), pregnancy related causes like ectopic, abortion need to be excluded or non-gynaecological causes like VTE / PE, TIA, cerebral haemarrhage, cardiac diseases should be excluded..

History should include duration of bleeding ,nature of her symptoms prior to this episode, menstrual cycle history – patern, regularity any excessive flow ,LMP. Contraceptive usage any treatment she received, or is on for fibroid. Enquire about the obstetric history and asses risk factors for ectopic.

Examine general condition, per abdomen for any guarding ,, rebound tenderness and any mass size ofmass, .

VE for size of the uterus, any adnexal mass, any cervical movement tenderness or for any fibroid polyps visualize through cervix on P/Sexamination . Investigations should include urine pregnancy test to exclude pregnancy related conditions and USG to note size and site of fibroids, number of fibroids and any free fluid in peritoneal cavity any gestational sac in uterine cavity.

Any identified condition is treated appropriately. Appropriate referral is made if any non-gynaecological cause is noted. Heavy bleeding needs to be control by drugs such as tranexamic acid or high dose progestogens. Any sub mucus polyps can be resected hysteroscopically .Correct anaemia by blood transfusion if severly anaemic or with haematenics(iron supplements )

In long term if she wished to retain her fertility options available depend on size , location of fibroid. Explain her that there is no increase in miscarriages or decreased fertility with all fibroids except sub-mucus fibroids or a fibroid which cause distortion of uterine cavity. If there is no such fibroid patient can be for expectant management and can advise conception. But pregnancy with fibroids are associated with increased PPH, C.S obstructed labour, red degeneration associated with pain.

Medical treatment with GnRH a is useful as a reduses size of fibroid prior to pregnancy. Can be used for 6 months without adverse effects like boneloss but it is a non-oral route and is associated with rapid regrowth after treatment is stopped. Side effects due to estrogen deficiency occur like hotfluses,vaginal dryness. For OCPs can be used. But these postpone conception.Tranexamic acid has not been shown to reduce blood loss significantly if associated with fibroids. Inj .DMPA reduces MBL,but delays conception.
Surgical management options include:
Any submucus fibroid polyps can be removed by hysteroscopic surgery ,this needs expertise and facility should be available . A large sub serous fibroid with extension through the cervix can be removed by vaginal myomectomy.
Myomectomy is standard surgery for removal of a large fibroid. Can be done by laparoscopy or open approach. It carries risk of rupture in later pregnancy also increased chance of placenta being adherent. Post operative adhesions will decrease fertility. But 60% pregnancy rate after one year. There is a small risk of hysterectomy during this procedure.Lap approach results in more weaker scar than open method and so increased rupture.
Laser myolysis is contra indicated if women is contemplating pregnancy as it weakens the myometrium
Uterine Artery Embolization is relatively new procedure, expertis and facilities of interventional radiology is needed.Occasional complications include infection haemorrhage and need for laparotomy. It does not compromise reproductive function and so safe to be used before pregnancy. Long term data or however, sparse.
Give her written information to supplement oral advise .Allow her to make informed choice after counseling .Give information of support groups.






Posted by Rani M.
This is an acute emergency condition and resucitation is taken promptly. ABC of resucitation are followed.senior gynecologist on duty, anesthetist and senior staff nurse are called. Venous access is established and crystalloids or colloids are started till cross matched blood arrives. Samples are taken for F.B.C to look for anemia which is likely, coagulation profile to rule out coagulation disorder which can be a cause of exccesive bleeding or may result from it , for urea and electrolyte , grouping and cross matching 4 units of blood.Pulse, B.P, temperature and oxygen saturaton is checked and monitored.Head end is lowered and oxygen is given by mask

History is taken regarding duration of bleeding (prolonged bleeding reults in anemia), regarding her LMP and use of contraceptives to rule out pregnanacy and its complications. History regarding her recent cervical smear and its result is taken.Speculum examination is done to look for local lesions and fibroid polyp.Vaginal examination is done to look for uterine size, irregularity and adnexal masses.

She is admitted in H.D.U till bleeding reduces and her condition improves. Tranexamic acid is started as I.V. infusion.It has been shown to reduce blood loss associated with fibroid in non randomized studies. High dose progesterone are added to reduce the blood loss ( has been shown to reduce blood loss associated with fibroid but no reduction in fibroid size in comparative studies).

Most of the bleeding settles with in 48 hours by above measures. But if patient\'s condition deteriorates or bleeding does not settle urgent surgical intervention is considered. Examination under anesthesia iis undertaken. Most of the bleeding are due to fibroid polyp in which case polyp can be removed by hysteroscopic resection. Fibroid should be sent for histopathology.

In the abscence of polyp bleeding can still occur in submucous fibroids due to increase in the surface area of endometrial cavity and intramural fibroids due to congestion and dilatation of endometrial venous plexuses. Bleeding in these can be reduced or stopped by Balloon tamponade from Foley\'s catheter in small cavity or Sangestaken Backmoore tube in large cavity.

Treatment to maintain response in instituted. GnRh analogues or Danazol or Gestrinone can be started for short term use prior to myomectomy. these are limited by their side effects. Barrier contraceptives are essential with gestrinone and danazol as risk of virilisation in female fetus.All has been shown to reduce blood loss and shrinkage in size of fibroids. Other alternatives are high dose progesterones for 21 days in 28 days cycle, or combined oral contraceptives if their are no contraindication ( family of personal history of VTE or thrombophilia etc. )

(b) Transvaginal and abdominal ultrasound should be done to look for number, size and location of fibroids prior to undertaking long term treatment .
Myomectomy is the most common and traditional method in women desiring to retain fertility.side effects such as infection, hemorrhage and adhesion formation can be minimised by prophylactic antibiotics, blood transfusion facility , good surgical technique and use of anti adhesion products respectively.In good hands morbidity is not higher than hysterectomy..Risk of scar rupture in future pregnancy if cavity gets opened is low. Laproscopic myomectomy is associated with less post operative pain and faster post op. recovery but is associated with higher recurrence rate , increaased operative time and may need to convert to open procedure.Risk of uterine rupture are higher if diathermy is used, henceforth, ultrasonic blades should be used. laproscopic method has a greater learning curve.

submucous fibroids can be effectively treated by hysteroscopic resection. It is done as day case procedure , under local anesthesia, is associated with high patient satisfaction rates and has low complication rate.But done only for fibroid smaller than 4 - 5 cm,risk of fluid overload and perforation.

LNG-IUS. has been shown to reduce blood loss associated with fibroids and also has been seen to reduce the size of fibroids. Return of fertility is prompt after removal.But it should not be used in uterus larger than 12 weeks size and if there is significant distortion of cavity by fibroids.

There are new techniques which seems to be promising but need further validation from trials .these are MRI guided percutaneous laser ablation,interstial photo
coagulation of fibroid, and High intensity focussed ultrasound .Results so far are from small studies and are encouraging.

Uterine artery embolisation is not recommended in women who desire to retan their fertility by RCOG and ACOG due to concerns regarding uterine rupture in future pregnanacy . though there have been reports about successful pregnancies after uterine artery embolisation further studies are required& shuld not be undertaken without proper counselling of woman regarding complications such as post op cramps, nausea, vomiting,, vaginal discharge, spotting , and in some hot flushes and reduced libido as well as about future pregnancy.
Posted by Mangala sundari R.
Priority is to resuscitate the patient and to stabilise her hemodynamic status.
Call for assistance and start facial oxygen mask, start 2 large Iv cannulas(14/16) and initiate colloid or crystalloid infusions. Blood for FBC, urea, electrolytes, Grouping, rhtyping, antibodies, crossmatching, coagulation studies and bhcg should be sent. Connect pulse oxymeter, ECG leads,keep the head end low, and do arterial blood gas analysis. If patient has shallow breathing with So2 low may need intubation and resuscitation by anesthetist or ICU care. Send for senior gynecologist on call.O negative blood to be started till xmatching takes time in acute emergencies. Any objections to blood transfusion or blood products to be elicited from the medical records or relatives.Intake output to be maintained by continuous bladder drainage by inserting a catheter to avoid overloading of fluids.CVP may need to be inserted to vital signs and hydration. Urine to be checked for pregnancy test to rule out miscarriage or ectopic pregnancy. Adequate hydration and blood transfusion and oxygen usually stabilizes the patient. Incidental non gynaecological cuases need to be ruled out. She can be given Tranexemic acid IV 1 gm to control the bleeding and continue every 4 to 6 hrly till bleeding stops and then orally.

Once the patient is stabilized go through the history and her medical records.Number, size, position of fibroids, the treatment taken so far ( medical and surgical) obstetric history and the out come of previous pregnanacies, previous blood transfusions, LMP,pressure symptoms on urinary and bowel , any recent increase in the size of fibroids to rule out malignant changes. (malignant change less than .5%)
Examination of the abdomen for the mass, tenderness, softness change in consistency, any other abdominal masses. Per vaginal examination to rule out miscarriage, polyps at the os or any other masses or pathology undiagnosed so far like cervical or vaginal malignancy. Ultrasound will usually confirm the findings of fibroid or associated cysts .CTscan or MRI or doppler may be needed if any need to rule out malignancy or any discrepancy in the clinical or USG findings.
Gn Rh analogues need to given to this patient to reduce the size of the fibroids, vascularity and to improve her anemia. She is advised to take adequate nutrition and hematinics to improve her anemia and general condition.. Gn Rh analogues given as injections once in 4 weeks for 3 months maximum upto 6 months. The side effects of Gnrh like hot flushes, amenorrhea,loss of bone mineral density will be explained. The loss of 6% bone mineral density is reversible after 2 years of stopping. She can be given add back therapy during the treatment if the symptoms are severe.
Injection medroxy progesterone 150 mg im every 6 weeks has also been tried to control bleeding but it does not reduce the size or vascularity of the fibroids ..
Since she has a large fibroid with severe menorrhagia, surgery is the definitive option available to her.uterine artery embolisation has been tried in few centers with interventional radiologists, and many untoward incidents have been reported, like, sepsis, pain, hemorrhage and mortality.Successful uncomplicated preganacies have been reported after UAE.The safety of the procedure is yet to be proved .
In the presence of small submucosal fobroids , hysteroscopic removal is possible.
She will be explained about the laparotomy and myomectomy,and the need for hysterectomy as a life saving procedure (less than 1 % ) may have to be performed. If the procedure is extensive with many fibroids or involving the cornua or the tubal orifices, may leave behind a scarred uterus .This again will reduce her reproductive potential, and pregnancy complications like miscarriage, placenta accreta or c saction. If the fibroids reduce in size considerably after the gnrh therapy, she can go for laparoscopic myomectomy,if the expertise is available.The advantages and dis advantages of laparotomy , laparoscopy and the anesthetic risks will be explained to her .before taking a written informed consent. Surrogacy is another option in the event of her unavoidable hysterectomy.
she will be given time to go through the options and make a choice and give furthur appointments in the clinic. l
Posted by Shakira B.
Please give us the correct answers for all these new essays, good points. thanks