1. 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

2. Introduction

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

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

5. 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

6. 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

7. 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 )

8. 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

9. Where do uterine fibroids grow?

10. 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

11. 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

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

13. Associative Risk Factors
Hereditary?
Null parity
Black women, low in asian
Age : (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

14. 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

15. Investigation & Diagnosis
Pelvic exams

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

17. Hysteroscopy - small, lighted telescope

18. MRI, CT Scan

19. 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

20. 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

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

22. 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

23. 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

24. Uterine Artery Embolization

25. 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

26. 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

27. Focused ultrasound surgery

28. 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

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