Department Of Obstetric & Gynecology PELVIC MASS JORDAN UNIVERSITY OF SCIENCE AND TECHNOLOGY Department Of Obstetric & Gynecology PELVIC MASS Supervised by Dr Isam Lataifeh Esra Sami Mohamed Fayez

Introduction

Differential Diagnosis Gynecological causes: 1) uterine masses pregnancy fibroids endometrial carcinoma adenomyosis

Differential Diagnosis 2) Tubal masses inflammatory origin ectopic pregnancy carcinoma 3) Ovarian masses functional cysts endometriomas Ovarian neoplasms

Differential Diagnosis Non - gynecological causes bowel gas or faeces in sigmoid or caecum appendicitis diverticular diseases miscellaneous distended bladder, pelvic kidney abdominal wall hematoma retroperitoneal neoplasm

History age pain (onset and type,site ), menstrual status, menstrual disturbances, interference with sexual activity , look for GIT symp (abd.bloating or fullness ,constipation or change in stool caliber) parity, gravidity (obs hx), previous personal (past surgical & medical) and family history family history breast( BRCA family Risk ), ovarian , GI tumors + ( Fibroids have a familial pr) weight loss

Physical Exams General exam (VS ,weight, hydration, anemia) Lymphadenopathy (supraclavicular) chest + breast exam abdominal exam : masses and tenderness etc bimanual exam (size,shape,irregularity ,mobility , consistency) ( sensitivity and specificity of pelvic exam R both only 50 %) rectovaginal exam (post.uterine surface, uterosacral ligament , POD, rectum )

FIBROIDS tumors or lumps made of muscle cells and other tissue that grow within the wall of the uterus. may grow as a single tumor or in clusters

Where do uterine fibroids grow?

Where do uterine fibroids grow? Submucosal fibroids grow just underneath the uterine lining. Intramural fibroids grow in between the muscles of the uterus. Subserosal fibroids grow on the outside of the uterus. Pedunculated fibroids grow out from the surface of the uterus, or into the cavity of the uterus

Symptoms (patient’s history) GYNECOLOGICAL PROBLEMS 1) Abnormal vaginal bleeding - intermenstrual - menorrhagia - irregular bleeding 2) Pain -acute (degeneration & torsion) -chronic pelvic pain -deep dysparunia pain -throughout menstruation

Symptoms cont’ 3) Pressure symptoms - bladder pressure - bowel compression - nerve compression 4) Infertility -tube obstruction -interfere with implantation

Associative Risk Factors Hereditary? Null parity Black women, low in asian Age : 35-50 (reproductive age) – estrogen & progesterone’s role - Fibroids grow rapidly during pregnancy when hormone levels are elevated. - Fibroids shrink after menopause when hormone levels are decreased. Obesity is associated with the presence of uterine fibroids. *genetic, hormonal, environmental

Investigation & Diagnosis complete blood count (CBC) - anaemia blood tests (bleeding disorder & hormonal level) Most often confirmed by transabdominal ultrasound Transvaginal ultrasound endometrial biopsy – rule out carcinoma

Investigation & Diagnosis Pelvic exams

Hysterosalpingography - uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images.

Hysteroscopy - small, lighted telescope

MRI, CT Scan

Management and Treatment Treated only if : -symptomatic regardless of the size -if the size > 12 W fetal gestational age even if it’s asymptomatic Medical Rx - Uterine Artery Embolization - GRHA & Androgens Analogues Surgical Rx -myomectomy -hysterectomy

Surgical Rx Myomectomy (laparoscopy, hysteroscopy, open laparatomy) -removes only the fibroids and leaves the healthy areas of the uterus in place -preserving ability to have children

Surgical Rx Hysterectomy -removal of the whole uterus -done if fibroids are large + abnormal bleeding + nearly menopause + not wanting children

Types of hysterectomy Abdominal hysterectomy is a procedure that involves a cut into the abdomen to remove the uterus. Vaginal hysterectomy is less invasive because the doctor reaches the uterus through the vagina, instead of making a cut into the abdomen

Medical Rx Uterine Artery Embolization (radiology intervention) - cuts off the blood supply to the fibroids, making them shrink -access to femoral artery -tiny tube into the vessel -guided to the uterus (fluoroscopy) -inject tiny plastic particles into artery supplying the fibroid -fibroid shrinks

Uterine Artery Embolization

Uterine Artery Embolization Advantages - Relief of symptoms in 85 % - non-surgical, safe - no significant blood loss - one-night stay - resume daily activities in short time Disadvantages -moderate to severe cramps -injury to uterus -infection

Focused ultrasound surgery inside of a specially crafted MRI scanner visualize fibroid’s anatomical location, and then locate and destroy (ablate) them focused high-frequency, high-energy sound waves are used to target and destroy the fibroids single treatment session is done in an on- and off-again fashion, sometimes spanning several hours

Focused ultrasound surgery

Medical Rx Gonadotropin Releasing Hormone Agonists -Estrogen and progesterone levels fall, menstruation stops, fibroids shrink and anemia often improves Androgens -Danazol, a synthetic drug similar to testosterone, has been shown to shrink fibroid tumors, reduce uterine size, stop menstruation

Obstetric Complications Abortions (submucous) Abnormal fundal height, lie and presentation Failure of implantations Abnormal labor Preterm labour and prematurity Atonic postpartum haemorrage ~ sarcomatous change?