CASE REPORT

MYOMA UTERI

Supervised by:
dr. M. Arief Solehudin, Sp.OG, MKes
Presented by:
Muhammad Anka Pradana Putra
(2012730064)

Department of Obstetrics and Gynecology

Medical Faculty of Muhammadiyah Jakarta University
RSUD R. Syamsudin, S.H., Sukabumi
2016

CHAPTER I
INTRODUCTION
Uterine of myoma are the most common benign tumors in female, affecting the half of
women and mostly in reproductive age. Histologically, the tumor is composed of smooth
muscle and fibrous connective tissue, so named as uterine leiomyoma, myoma, or
fibromyoma. It has been estimated that at least 20 percent of women at the age of 30 have
got fibroid in their wombs. Fortunately, most of them (50%) remain asymptomatic. The
incidence of symptomatic fibroid in hospital outpatient is about 3 percent . These are more
common in nulliparous or in those having one child . The prevalence is highest between 35
45 years.
The etiology still remains unclear but chromosomal abnormality, estrogen effect,
progestin effect, and growth factor (EGF, IGF-I, TGF) were playing role inits pathogenesis. It
is predominantly an estrogen effect-dependent tumor for its growth. The risk factor that
increased the incidence ofmyoma uterine are nulliparity, obesity, hyperestrogenic state, and
black women. The clinical symptomps of myoma uterine are mostly asymptomatic (75%) but
25 % were symptomatic. The symptomps are menstrual abnormality : mennorhagia (30%) or
metrorrhagia/ irreguler bleeding, dysmenorrhea, dyspareunia, infertility, pressure symptomps,
recurrent pregnacy loss (misscariage, pre-term labor) lower abdominal / pelvic pain, and
abdominal enlargement. On abdominal examination the tumor may not be sufficiently. On
bimanual examination eveals the uterus irregulary enlarged by the swelling felt per abdomen.
Although the majority of myoma uterine can be diagnosed from the history and pelvic
examination but at times pose problem in diagnosis and ultrasound is an useful diagnostic
tool to confrm the diagnosis of myoma uterine. Life threatening complication include severe
anemia, intraperitoneal hemorrhage from rupture veins over the subserous fibroid, severe
infection, and sarcomatous change. The management of myoma uterus include medication
and surgical

CHAPTER II
CASE
I.

II.

IDENTITY
Name
Age
Religion
Education
Occupation
Date of Admission

: Mrs.R
: 52 years old
: Moeslem
: Junior High School
: Farmer
: May 31st 2016

HISTORY
a. Chief Complaint
:
Patient complaint about lower abdomnal pain
b. History of present ilness :
Patient complaint about lower abdomnal pain. And the patient also
complaint of pain when urinate for 1 weeks. She doesn't have any
complaint before.

Patient had 4 child, the first pregnancy was 36 years ago, the second
pregnancy was 33 years ago, the third pregancy was 29 years ago, and the
fourth pregnancy was 19 years ago. She hadnt complaint mentruation
abnormality any mass or when her pregnancy and after pregnancy. 1 month
before her admission patient had the ultrasonography examination and it was
said that her myom bigger.
Patient using implant contraception for 5 years, and pil contraception for
10 years.
c. Family History
Patient didnt have family history of tumor and malignancy
d. History of past ilness :
History of hypertension
History of diabetes mellitus
History of allergy
History of epilepsy
History of urinary tract/ kidney disease
History of trauma
History of surgery
e. History of mentrual cycle :
Menarche

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: 15 years old

Menstrual

cycle

28

days,

.......................................................................duration

regulary,with
of

days,

.......................................................................changed 2 pads a day

.......................................................................( 60cc), dysmenorrhea (-)

Last Menstrual
: 3 month ago, with

duration ........................................................................of 11 days

f. Martial history :
Married twice, the first husband for 7 years, and second husband for 27
years
g. Contraception history : (+)
Patient using contraception implant for 5 years, and pil contraception for
10 years.
h. Obstetric history :
No

Years

Gestationa

1980

l
Age
9 month

1983

9 month

1987

9 month

1997

9 month

Labor
History
Spontaneous
Per Vaginam
Spontaneous
Per Vaginam
Spontaneous
Per Vaginam
Spontaneous
Per Vaginam

Birth
Weight

Breast
Feeding

Male

3300 gram

2 years

Male

3200 gram

1 years

Male

3300 gram

1 years

Male

3100 gram

2 years

Sex

PHYSICAL EXAMINATION

General condition
: Appeared moderately
Level of consciouness : Compos Mentis
Vital Sign
- Blood pressure
: 120/80 mmHg
-

Heart Rate
: 82 beats per minutes
Respiratory rate
: 20 breaths per minutes
Blood temperature : 36,0oC

Weight
Height
BMI

: 52 kg
: 156 cm
: 22,6 kg/m2 (Normal)

General examination
a. Eyes
: Anemi conjungtiva -/-; icteric sclera -/-

b. Mouth
c. Thorax
- Heart
- Lung

: Wet oral mucosal membrane

:
: Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/-,

..............
Crackles -/Mammae : Aerola hyperpigmentation, nipple retraction -/-,

..............
Abdomen :

breast milk -/-

Inspectio : Convex on suprapubic

Palpation :
Tenderness (+) on suprapic, the uterus with tender
and solid consistencyis, and enlarge (2 fingers
below umbilicalis), Surface is uniform enlarged in a
single fibroid

Myoma Uteri

Percussion : Dull on suprapubic

Auscultation : Bowel sounds (+)

Extrimitas :

Gynecologic Examination
Inspection

Gravida 18-20
week

Edema (-/-/-/-), CRT < 2 seconds

Vulva : Within normal limits Mass (-), ulcer (-), hyperemia (-)
Vagina : within normal limits Mass (-), ulcer (-), hyperemia (-)

Inspeculo
Vagina: Erotion (-), bleeding (-), mass (-), inflammation (-)

Portio: Erotion (-), fluxes (-), livide (-), fluor albus (-), bleeding (-), mass

(-), inflammation (-)

VT Bimanual :
Vagina
Portio
Uteri corpus
Adnexal

: Pain (-), mass (-)

: Pain (-), mass (-)
: Pain (-), mass following uterus movement
: Ovarian and tuba are not palpable.

IV.
V.

IMAGING EXAMINATION
Uterine contour is enlarged and distorted
LABORATORY EXAMINATION

Type

Result

Units

Normal Value

HEMATOLOGY
Hemoglobin
Hematocrit
Eritrocytes
Leucocytes
Platelets
Erytrocytes Index
MCV
MCH
MCHC

16,6
45
5.0
15.900
392.000
90
34
37

g/dl
%
Million/ L
Thousand/L
Thousand/L
fl
pg
g/ dL

12-14
37-47
3,8-5,2
4000-10.000
150.000-450.000
80-100
26-34
32-36

BLOOD CHEMISTRY
Liver function
AST (SGOT)

22

U/I

< 31

....ALT (SGPT)

13

U/I

<32

4.3

g/dL

6,3-8,2

23

mg/dL

15-36

0,60

mg/dL

Natrium

143

mmol/L

137-150

Kalium

4,1

mmol/L

3,5-5.5

Calsium

9,3

mg/dL

8-10,4

Chloride

104

mmol/L

94-108

120

mg/dL

<140

Albumin

...

Kidney Function
Ureum
Creatinin

0,52-1,04

Electrolytes

Blood Glucose
Random blood glucose

VI. RESUME
P4A0 52 years old,that was diagnosed having myoma 1 month ago, came with
chief complaint of pain lower abdomen and patient complaint pain when she urinate
since 1 week ago. The patient has 4 children. She gave birth to her last child 19 years

ago. The patient used implant contraception for 5 years and contraception pil for 10
years.
On physical examination blood pressure 120/80 mmHg heart rate 82 bpm,
respiratory rate 20 times per minutes, temperature 36,0 oC, On laboratory within normal
limits.
VII. WORKING DIAGNOSIS
P4A0, 52 years old with myoma uteri
VIII. PLANNING
Pro Total Hysterectomy Salpingo-oophorectomy bilateral ( Juny 1st 2016)

IX. DIAGNOSIS AFTER PROCEDURE

P4A0 52 years old post total hysterectomy + salpingo-oophorectomy bilateral
indicated by myoma uteri.
X TREATMENT AFTER PROCEDURE
Metronidazole 2x1
Claneksi 3x1
Alinamin 3x1
Ranitidin 2x1
XI. FOLLOW UP
DATE

SUBJECTIVE

OBJECTIVE

ASSESSMENT

May 31st Pain when she BP : 120/80 P4A0, 52 years

Old
with
2016
urinate
mmHg
15.00 pm
HR :80 x/mnt
myoma uteri
RR :20 x/mnt
Temp : 36oC
Juny 1st Complaint (-)
BP : 120/80 P4A0, 52 years
Old
with
2016
mmHg
05.00 a.m
HR :80x/mnt
myoma uteri
RR :16 x/mnt
Temp : 36,3o C
Juny 1st After surgery
BP : 140/80 P4A0, 52 years
Patient was in
Old Post Total
2016
mmHg
16.00 p.m pain at post HR :63 x/mnt
Hysterectomi +
RR :18 x/mnt
operation site
salpingo
Temp : 35,3o C
injury (VAS 6)
oophorectomy
bilateral

PLANNING
Total

Hysterectomy

operation + salpingo
oophorectomy
bilateral
Total Hysterectomy +
salpingo
oophorectomy
bilateral
POST OP:
Diet

fasting

until

bowel

sound +, the

diet gradually
Claneksin 3x1

indicated

by

myoma uteri

gr IV
Metronidazol

e Infus 2x1
Alinamin 3x1

IV
Ranitidin 2x1

IV
Catheter (UO

observation)
Hb
examination
after 6 hours
post operation

Hb 6 hours post op :
14,7 g/dL
I

Post Op pain BP : 120/80 P4A0, 52 years

Old Post Total
(+) : VAS 4
mmHg
HR :80 x/mnt
Hysterectomi +
RR :18 x/mnt
salpingo
Temp: 37,0oC
oophorectomy

Continued

therapy
Maintained
catheter (UO =
0,86cc/24h) >
continue observe

bilateral
indicated

by

myoma uteri
Bowel

Sound

(+)
4x/minutes
Flatus (-)

Juny

th

2016
06.00 a.m

Post Op pain BP : 110/80

HR :80 x/mnt
(+) : VAS 2
RR :16 x/mnt

P4A0, 52 years
Old Post Total
Hysterectomi +

UO
Active
mobilization

(gradually)
Metronidazole

Infus 2x1
Claneksi 2x1 IV
Alinamin 3x1

IV
Ranitidin

IV
Paracetamol

3x1 PO
Cefadroxil

2x1

2x500 mg P.O

(POD-2)

Temp : 36,3 C
Flatus (+)

Juny

2016
06.00 a.m
(POD-3)

Post Op pain BP : 110/80

HR :80 x/mnt
(+) : VAS 2
RR :20 x/mnt
Temp : 36,6 C

Traknesamat

bilateral

3x500mg P.O
by

myoma uteri
P4A0, 52 years
Old Post Total

Patient discharge

Hysterectomi +

with take home

Cefadroxil

2x500 mg P.O
Asam

salpingo
Urinating (+)
Flatus (+)
Defecation (-)

Asam

oophorectomy
indicated

th

salpingo

oophorectomy

Traknesamat

bilateral
indicated

by

3x500mg P.O

myoma uteri
XII. PROGNOSIS

Quo ad vitam

: Bonam

Quo ad functionam : Malam

Quo ad sanationam : Bonam

XIII. OPERATION REPORT

Date : Juny 1st 2016

Pre-operative diagnosis : P4A0, 52 years old with myoma uteri
Planning : Pro total hysterectomy salpingo-oophorectomy bilateral
Post operative diagnosis P4A0, 52 years old, post total hysterectomy+ salpingo
oophorectomy bilateral indicated by myoma uteri

Surgical steps
1. Patient in supine position and general anesthesi was done
2. Aseptic and Antiseptic was done

3. After peritoneum was opened, Size of uterus 14 x 14 cm with surface was uniform
enlarged in a single fibroid. Conclusion: Myoma uteri
4. Left and Right ovarium within normal limits
5. Total Hysterectomy and salpingo oophorectomy bilateral done
6. Uterus was sutured
7. Abdomen was flushed with NACL
8. Fascia was suture
9. Skin was surtured subcuticular
10. Operation was done with total bleeding 500 cc,and weight of myoma uteri was 1,7
kg
11. Uterus was sent to pathology anatomy

CHAPTER III
CASE ANALYSIS

I.

PROBLEMS
1. How do you diagnosed the patient ?
2. How the teori of myoma uteri ?
3. How is myoma uterine treated by medication ?
4. What are the type of hysterectomy procedures and indication ?
5. What is the indication total hysterectomy with salpingektomy ?

II.

DISCUSSION
1. How to diagnosed this patient ?
THEORY
ANAMNESIS
Asymptomatic
Menstrual abnormality

CASE
ANAMNESIS

mennorhagia (30%) or

Lower abdominal pain

Abdominal enlargement

metrorrhagia/ irreguler

Infertility

bleeding
Dysmenorrhea
Dyspareunia
Infertility
Pressure symptomps
Recurrent oregnancy loss
(misscariage, pre-term labor)
Lower abdomnal/ pelvic pain
Abdominal enlargement

PHYSICAL EXAMINATION
Tumor may not be sufficiently enlarge
to be felt per abdomen if < 14 week

PHYSICAL EXAMINATION
The uterus feel is hard, and enlarge (1
fingers below umbilical, 18 -20 week)

Palpation

Feel is firm, more toward hard;

maybe cystic in cystic

Palpation
Tenderness (+) on suprapic, the
uterus with tender and solid

degeneration
Margin are well defined except

consistencyis, and enlarge (2

the lower pole which cannot be

fingers below umbilicalis),

reached suggestive of pelvic in

Surface is uniform enlarged in a

origin
Surface is nodular; may be

single fibroid

uniform enlarged in a single

fibroid
Mobility is restricted from above
downwards but can be moved
from side to side
Percussion

The swelling is dull on percussion

Pelvic examination

Bimanual examination reveals the

uterus irregulary
Enlarge by the swelling felt per

Percussion

The swelling is dull on percussion

Pelvic examination

Bimanual examination: Mass

movement was palpable following

abdomen

uterus
Enlarge by the swelling felt per

abdomen
IMAGING :
Ultrasound

Uterine cotntour is enlarged and

distorted
Depending on the amount of
connective tissue or smooth
muscle proliferation, fibroids are
of different echogenecityhypoechoic or hyperechoic

IMAGING :
Ultrasound

Uterine contour is enlarged

2. How the teori of myoma ?

Cytogenetics
Each leiomyoma is derived from a single progenitor myocyte. Thus, multiple tumors
within the same uterus each show inde-pendent cytogenetic origins . The primary
mutation initiating tumorigenesis is unknown, but identifiable karyotypic defects are
found in approximately 40 percent of leiomyomas. A number of unique defects
involving chromosomes 6, 7, 12, and 14 and less commonly X, 1, 3, 10, 13 have been
identifi ed to corre-late with rates and direction of tumor growth. It is anticipated that
further characterization of the specific functions of these karyotypic changes will help
to define the important steps in leiomyoma development.

Estrogen Effects
Uterine leiomyomas are estrogen- and progesterone-sensitive tumors .Consequently,
they develop during the reproductive years. After menopause, leiomyomas generally
shrink, and new tumor development is infrequent. Thus, it seems that many risk or
protective factors depend on circum-stances that chronically alter estrogen or
progesterone levels or both. Th is concept is integral in understanding many of the
risk factors associated with leiomyoma development and growth and in formulating
treatment plans. Sex steroid hormones likely mediate their effect by stimulating or
inhibiting transcription and production of cellular growth factors. Leiomyomas
themselves create a hyperestrogenic environment, which appears requisite for their
growth and mainte-nance. First, compared with normal myometrium, leiomyoma cells
contain a greater density of estrogen receptors, which results in greater estradiol
binding. Second, these tumors convert less estradiol to the weaker estrone . A third
mechanism described by Bulun and colleagues involves higher levels of cytochrome
P450 aromatase in leiomyomas compared with normal myocytes. This specific
cytochrome isoform catalyzes the conversion of andro-gens to estrogen in a number
of tissues. There are a number of conditions associated with sustained estrogen
exposure that encourage leiomyoma formation.

Progestin Effects
The role of progesterone in leiomyomas is less clear, and indeed both stimulatory and
inhibitory effects have been reported. For example, exogenous progestins have been

shown to limit leio-myoma growth in clinical trials. Similarly, epidemiologic studies

link depot medroxy-progesterone use with a lower incidence of leiomyoma development . In contrast, other studies report a stimulatory influence of progestins on
leiomyoma growth. For example, the antiprogestin RU486 induces atrophy in most
leiomyomas. Moreover, in women treated with gonadotropin-releasing

hormone

(GnRH) agonists, leiomyomas typically decrease in size. However, if progestins are

given simultaneously, there may be increasedleiomyoma growth. More recent
research suggests that progesterone is the primary mitogen for tumor growth and that
estrogens role is to upregu-late progesterone receptors .
3. How is myoma uterine treated by medication ?
Drug therapy has established a firm place in the management of symptomatic fibroids.
The drugs are used either as a temporary palliation or may be used in rare cases, as an
alternative to surgery. Prior to drug therapy, one must be certain about the diagnosis.
The objectives of medical treatment are:

To improve menorrhagia and to correct anemia before surgery.

To minimize the size and vascularity of the tumor in order to facilitate surgery.

In selected cases of infertility to facilitate hysteroscopic or laparoscopic

.............surgery
a definite surgery cannot be undertaken for certain periods.
Antiprogesterones Mifepristone (RU 486) is very effective to reduce fibroid
size and also menorrhagia. It may produce amenorrhea. It reduces the size of the
fibroid significantly. A daily dose of 2530 mg is recommended for 3 months. 5
mg daily dose is also found effective. Long-term therapy is avoided as it causes
endometrial hyperplasia. Asoprisnil is used with success. It is a selective

progesterone receptor modulator. It does not cause endometrial hyperplasia.

Danazol -can reduce the volume of a fibroid slightly. Because of androgenic
side effects, danazol is used only for a period of 36 months. Danazol
administered daily in divided doses ranging from 200-400 mg for 3 months
minimizes blood loss or even produce amenorrhea by its antigonadotropin and

androgen agonist actions.

GnRH agonistsDrugs commonly used are goserelin, luporelin, buserelin or
nafarelin . Mechanism of action is sustained pituitary down regulation and
suppression of ovarian function. Optimal duration of therapy is 3 months.
Addback therapy may be needed to combat hypestrogenic

Symptoms.
GnRH antagonists-Cetrorelix or ganirelix causes immediate suppression of

pituitary and the ovaries. They do not have the initial stimulatory effect.
Benefits

are

same

as

that

of

agonists.

Onset

of

amenorrhea

is

rapid.Prostaglandin synthetase inhibitorsThese are used to relieve pain due to

associated endometriosis or degeneration of the fibroid. They cannot improve
menorrhagia due to fibroids.
Levonorgestrel-releasing Intrauterine System (LNG-IUS) reduces blood loss

and uterine size. However, this is not recommended when the uterine size is >12
weeks or there is distortion of uterine cavity.
Preoperative therapy:It is indeed advantageous to reduce the size and vascularity
of fibroid prior to either myomectomy or hysterectomy. While operation will be
technically easier in broad ligament or cervical fibroid, in myomectomy, there
may be little difficulty in enucleation of the tumor from its pseudocapsule

4. What are type of hysterectomy procedure ?

Total hysterectomyThe entire uterus, including the cervix, is removed. Indication

: DUB

Uterine fibroid

TO mass
Endometriosi
Supracervical (also called subtotal or partial) hysterectomyThe upper part of
the uterus is removed, but the cervix is left in place. This type of hysterectomy

can only be performed laparoscopically or abdominally. Indication :

Difficul TO mass
Obstetric causes
Endometriosis (rectovaginal septum
Radical hysterectomyThis is a total hysterectomy that also includes removal of
structures around the uterus. It may be recommended if cancer is diagnosed or
suspected.Indication:

Carcinoma endometrium

Carcinoma

cervix-stage

5. What indication total hysterectomy and salpingektomy bilateral ?

Some considerations of hysterectomy total (Benign Lesions)

Age and parity :An ideal condition is that the patient preferably be in the
perimenopausal age group with family completed. However, the operation may
have to be done under forced circumstances even in comparatively young age
group

or

unmarried

or

nulliparous

women

(Examplecontemplating

myomectomy).Total or subtotal: The preferred surgery is always a total

hysterectomy unless there is sufficient reason to leave behind the cervix. The
indications of subtotal (supracervical) hysterectomy are:
Difficult tubo-ovarian mass with obliteration of the anterior and posterior

pouches.
Pelvic endometriosis particularly involving the rectovaginal septum.
Emergency hysterectomy (cesarean hystere-ctomy).

Risks of developing ovarian neoplasms (benign or malignant). relative risk (rr) of

ovarian cancer is 0.6 even 10 years after hysterectomy.
Based on the current understanding of ovarian carcinogenesis and the safety of
salpingectomy, the American College of Obstetricians and Gynecologists supports
the following recommendations and conclusions:

The surgeon and patient should discuss the potential benefits of the removal of the
fallopian tubes during a hysterectomy in women at population risk of ovarian
cancer who are not having an oophorectomy.

When counseling women about laparoscopic sterilization methods, clinicians can

communicate that bilateral salpingectomy can be considered a method that
provides effective contraception.

Prophylactic salpingectomy may offer clinicians the opportunity to prevent ovarian

cancer in their patients.

Randomized controlled trials are needed to support the validity of this approach to
reduce the incidence of ovarian cancer.