RELEVENT CLINICAL HISTORY
The uterine fibroid was incidentally found 10 years ago in 2000 during further management at University Malaya Medical Centre (UMMC) for miscarriage. But the size of uterine fibroid was still small. She could not see or feel the mass at that time. No treatment was given at that time. She was told to go regular follow up afterwards. However, she defaulted. Until 5 years ago, the mass was gradually increased up to the umbilicus level. She went to general practitioner (GP) because her distended abdomen. She was referred to UMMC but defaulted again because of no pain or per vaginal bleeding. In between she never went to any follow up regarding her problem.2 years later, her abdomen was getting worse which was distended make her uncomfortable. It was associated with menorrhagia especially on day 1 until day 3 with 5-6 fully soaked pad flooding and blood clots. Then, she came to UKMMC as asymptomatic anaemia and distended abdomen.
She was first seen at UKMMC on June last year which is 6 months ago. She still had her menses at that time. On assessment, she was noted mild pallor and her Hb was 9.5 g/dl with uterus size of 34 weeks size of gravid uterus. Based on assessment and scan result, she was counseled for GnRH analogue for 6 cycles and proceeds for TAHBSO. She was informed regarding purpose and side effect of GnRH analogue. She was agreed upon. Pipelle sampling and pap smear was done at UKMMC. Beside that, she was found to have high blood pressure and started Atenolol 50 mg.
She had subfertility for 15 years and the problem had never been investigated. However, there was no compressive symptoms of abdominal distention for instances altered bowel habit and change in urinary frequency. no symptoms suggestive anaemia such as giddiness, headache and palpitation. She has no dyspareunia and abdominal pain. There was no loss of appetite and loss of weight and other symptoms of metastasis such as back pain, bone pain and shortness of breath.
MENSTRUAL HISTORY
She attained menarche at 12 years old. She had regular cycle of 28-30 days with normal flow of 7 days without flooding or blood clots. Her last menstrual period was on 9th July 2009. Previously her menses was normal until 3 years ago she had prolonged menses for 15 days and heavy bleeding especially on day 1 until day 3 with 5-6 pads fully soaked with flooding and blood clots. The bleeding was decreased in amount day by day and stopped on day 15 with minimal spotting. There was no dysmenorrhea, intermenstrual bleeding and post-coital bleeding. No per vaginal discharge noted. Pap smear was done on September last year with normal result. She never practiced any contraceptive methods.
PAST OBSTETRIC HISTORY
In year 2000, she had history of complete miscarriage at 5 weeks which was diagnosed at UMMC. Subsequently, in year 2002 she had history of incomplete miscarriage at 14 weeks. Dilatation and curettage was done at UMMC.
PAST MEDICAL HISTORY
She had been diagnosed as hypertension last year and treated with Atenolol 50 mg OD. No known other medical illness such as diabetes mellitus and cardiovascular disease.
PAST SURGICAL HISTORY
Past surgical history was unremarkable.
DRUG HISTORY
She was on antihypertensive; Atenolol 50 mg OD since last year and completed 6 cycles of GnRH analogue Zoladex. Last cycle was on 25th November 2009.No known drug allergy.
FAMILY HISTORY
Both parents already passed away due to unknown cause. There is no family history of malignancy. All her siblings are alive and currently well and healthy. There was no family member with similar problem.
SOCIAL HISTORY
She is a housewife. Previously she worked as a clerk at private company whereas her husband is a pensioner of supervisor at Car Company. They have been married for 15 years. Both of them are non alcohol consumer. She does not smoking whereas her husband is a smoker. The total income was about RM 2500.
SUMMARY
My patient, Madam Noraini Hashim, a 46 year old Para 0+2 housewife with subfertility for 15 years and a known case of symptomatic uterine fibroid who presented with abdominal distention at suprapubic region that was gradually growing for 10 years and menorrhagia for 3 years was admitted for TAHBSO.
RELEVENT CLINICAL EXAMINATION
General
She was lying comfortably supine on the bed. She was alert, conscious and cooperative. She does look obese. She has no pallor, jaundice and cyanosis. Her hydration status was good. No sign of chronic anaemia such as koilonychia, angular stomatitis and atrophic glossitis. There was no bilateral pedal oedema or calf tenderness. Otherwise her vital signs were within normal limit.
SYSTEMIC
Central nervous system examination
My patient was alert and oriented to person, time and place. Her speech was normal. All her cranial nerves were grossly intact. There was no muscle wasting or fasciculation. Both upper and lower limb showed normal muscle tone, muscle power, reflexes, sensation and propioception.
Cardiovascular system examination
She was appropriately exposed and propped up 45 degrees. There was no collapsing pulse, radio-radial delay or radio femoral delay. The jugular venous pressure was present and not raised. The apex was palpable and not displaced, located at the fifth intercostal space, 1 cm medial to the midclavicular line. No thrill and parasternal heave. First and second heart sounds were audible with absence of extra heart sound or cardiac murmur. All peripheral pulses are present.
Respiratory system examination
She was appropriately positioned at 45 degrees as before. The trachea was centrally located. There were no skeletal abnormalities or previous surgical scar. The chest was moving symmetrical bilaterally with respiration on anterior and posterior view. The chest expansion, vocal fremitus and vocal resonance were equal bilaterally. There was vesicular breath sound without adventitious sounds such as wheezing or crepitations.
Breast and thyroid examination
My patient was appropriately exposed and positioned. Both breasts were about symmetrical bilaterally without skin changes. The nipples were inverted and look normal. The breasts were not tender. There was no mass or no axillary lymphadenopathy palpable. No thyroid enlargement or lymphadenopathy. Otherwise, the neck looks normal.
Abdominal examination
On inspection, there was abdominal distention at the suprapubic region. There was no previous surgical scar, dilated vein or skin pigmentation. The abdomen is soft and non tender. There was suprapubic mass that corresponds to 32 weeks size of gravid uterus and measures about 23x 23 cm. It was non tender and firm. The margin is regular but lobulated with smooth surface. It was unable to get below the mass and the mass is mobile side to side but not vertically. It is well circumscribed and dull on percussion. There was no ascites and no hepatosplenomegaly. The kidneys were not ballotable. There was no bruit over the mass. The bowel sound is normal.
Pelvic examination
There was no abnormality detected on the vulva and vagina. There were no signs of pruritus, erythema, erosion, skin lesion and growth. The cervix looks healthy and cervical os was closed. On bimanual examination, the cervix was tubular. There was no hardness or irregularity. The cervix was moved away when examiner moved the mass towards the xiphisternum. There was fullness of both adnexa and pouch of Douglas. Uterosacral ligament was not thickened.
Per rectal examination
It revealed fullness of pouch of Douglas. No rectal involvement. There was good anal tone and smooth anal mucosa.
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Provisional diagnosis: Uterine fibroid
Points for:
Points against:
Differential diagnosis:
Leiomyosarcoma
Points for:
Points against:
Endometriosis and fibroid
Points for
Points against:
Adenomyosis
Points for:
Points against:
Ovarian benign tumor
Points for:
Points against:
Ovarian carcinoma
Points for:
Points against:
STATE RELEVENT INVESTIGATION WITH REASONS
1. Full blood count:
To assess haemoglobin level pre and post operations for anemia and to look for any sign of infection indicated by total white cell counts and neutrophil level. Platelet level is also counted to look for bleeding tendency.
2. Blood group cross match:
It is important if blood transfusion is necessary.
3. Coagulation profile:
It is to assess the coagulation function.
4. Renal profile:
It is to look for obstructive nephropathy. (Compressive effect of the mass to the urinary system)
5. Liver function test:
It is to assess the liver function before operation.
6. Blood glucose level
It is to screen for hyperglycemia since my patient never check before.
7. Lipid profile
It is to look for hyperlipidemia.
8. Electrocardiogram:
Assessment of cardiovascular function pre operation as screening since my patient is 46 years old
9. Chest X-ray:
It is to assess the condition of the lungs before operation.
10. Pap smear:
To rule out cervical carcinoma
11. Pipelle sampling:
To rule out endometrial carcinoma
12. CA 125:
It is to exclude underlying ovarian epithelial carcinoma.
13. Ultrasonography of the pelvis: transabdominal or transvaginal ultrasound.
IDENTIFY THE PROBLEMS IN TERM OF PRIORITY
IMMEDIATE AND SUBSEQUENT MANGEMENT
Madam Noraini Hashim was electively admitted for further surgical management for uterine fibroid on 19th January 2009. She was hospitalized 2 day prior operation. Her vital signs were monitored and a number of investigations were assessed to identify the problems that may increase the operative risk. She was seen by anaesthetist for the assessment of patient's fitness for operation. She was informed briefly concerning the nature of the operation, benefits, outcome, indications and possible complications that may arise. TAHBSO is indicated for large uterine fibroid instead of hysterectomy. Informed consent was obtained for TAHBSO. She was aware that the she cannot bear children herself after the procedure and may experience climateric symptoms and other menopausal symptoms later. Details of pre-operative preparation were bowel preparation and nil by mouth start on 12 mid night before operation. IV line and CBD were established. Her vital sign was monitored. Thromboembolic dexterent(TED) sock was applied prior operation for prophylaxis deep venous thrombosis.
She underwent surgery on 19th January 2009. TAHBSO was done as planned. Intra-operative finding were there was huge and multiple uterine fibroid which is highly vascularized. The fibroid were right broad ligament fibroid 6 x 6 cm, 3 anterior fibroid measured 8x8, 2x2 and 2x2cm and posterior fibroid 12 x 15 cm. Both ovaries looked normal. The biopsy of uterus and cervix was taken and sent to the histopathological laboratory.
After operation, she was kept nil by mouth. Her vital signs were monitored half and hourly until stable and change to 4 hourly. She was infused 2 pints of normal saline and 2 pints of Hartman. Epidural analgesia was continued for 1 day. Subcutaneous heparin 5000IU BD was given for thromboembolic prophylaxis. Once she tolerated orally, change to tablet arcoxia 120mg OD. Cloxacillin 500 mg QID was given for 1 week. Pad chart and input & output chart were established in the ward.
FINAL CONCLUSION/ PLAN FOR FURHER MANAGEMENT/ PATIENT'S PROGRESS
At 20th January 2010, day 1 post TAHBSO, she was well, alert and conscious. Epidural analgesia and CBD were off while oral analgesia was continued. She did not feel nausea and did not vomit. There was minimal pain at the operation site. She was encouraged to tolerate orally and ambulate. On inspection of her wound, it was clean, the dressing not soaked. Abdomen is soft and mild tenderness at the operation site. Her vital sign were monitored. Her blood pressure was ranging 120-160/65-90 which is not stable. She was afebrile throughout hospitalization. She used 2 pads which were half soaked.
On day 2 post operative, she was getting better. She already ambulated and tolerate orally. She was comfortable and could pass urine and bowel open. However, there was slight pain at the operation site. The medications were continued which are
Her vital signs were monitored as well as inspection of operation site. She was asked regarding menopausal symptoms for instances hot flushes and night sweat. She denied any of them. She was planned to discharge tomorrow.
After discharged, she was asked to come back after 10 days for suture removal and 6 weeks later to review histopathological result. She was informed regarding wound care and advised to come to hospital earlier if she develops fever.
PREVENTIVE AND COMMUNITY HEALTH ASPECT
A fibroid is a benign tumor of uterine smooth muscle known as leiomyoma being the most common tumor found in the women about 20 percent especially after 30 years of age. The etiology of uterine fibroid is not known yet. A range of hypothesis accounting for the pathogenesis of fibroids has been explored regarding hormones interaction, cytogenetic features and environmental factors. However, there are risk factors for clinically significant fibroids which can be divided into modifiable and non modifiable. Thus, reduction of modifiable risk factors can help to prevent uterine fibroid to occur.
The non modifiable factors are genetic, age and race. Those have family history of fibroids especially first degree relatives are increased risk of developing the disease. Average age for fibroids to become symptomatic is 35-50 years. Women who are of childbearing age are at increased risk of developing fibroids. African American women are 2-3 times more likely to have uterine fibroids and increased risk for developing the condition at a younger age than the rest of the population of women with uterine fibroids. Asian women have a lower incidence of symptomatic uterine fibroids.
The modifiable risk factors are obesity, dietary intake, cigarettes smoking, oral contraceptives and pregnancy and child birth. There has been some research on these risk factors. Some studies have suggested that obese women are higher risk of fibroids. Thus, leading a healthy life style can prevent of overweight. Promotion of healthy life style includes balanced diet and regular exercise. In addition, consumption of beef, red meat and ham has been associated with the presence of uterine fibroid. However, there are recent research has shown some protective value to uterine fibroids which are green vegetables, fruit and fish. Cigarette smoking was associated with decreased risk of fibroids; smokers of 20 cigarettes a day had a risk roughly two thirds that of non-smokers.
Risk of fibroids decreased consistently with increasing number of term pregnancies; women with five term pregnancies had only a quarter of the risk of women who had had none. So far, pregnancy and childbirth seem to have a protective effect. Risk also decreased consistently with increasing duration of oral contraception use; the risk of fibroids was reduced by some 31% in women who had used oral contraceptives for 10 years. Changes in a woman's hormone levels may impact fibroid growth. Therefore, pregnant or OCP can reduce estrogen level and subsequently reduced the growth of fibroid. Foremost, uterine fibroid will shrink after menopause when hormonal levels are decreased.
COMMUNICATION ISSUES
A good communication skill is important to develop rapport with my patient. Luckily, Madam Noraini Hashim is a friendly person; she is very approachable and cooperative. Thus, effective history taking can be gained easily. Because of her problems started 10 years ago, she had difficulty to remember the detail. However, she managed to tell me the chronology of the problem after I encourage her. She admitted that she had defaulted from follow up twice for her fibroid. At that time, she did not realize the risk and consequence of uterine fibroid. In addition, she did not find her abdominal distention as a problem until its growing to the 34 weeks size of gravid uterus which makes her uncomfortable. When she presented to PPUKM, she has been investigated thoroughly and informed regarding her problem and further management. She looks very keen about her disease. Thus, well understanding communication between doctor and patients is important in delivering the message. She will be more compliant to the management plan if she well understands about her disease.
SPRIRITUAL ISSUES/COMPLIMENTARY MEDICINE
Madam Noraini Hashim is a very spiritual and open minded person. She accepted her illness and agreed for further management that will make her sterilize. She realized that she did not have chance to get children anymore. Hence, she always prays to God to strengthen her inner spirit. Fortunately, she has very supportive husband. They share the problem together and believe that the illness is a test for human being. Therefore, family support plays a role in emotional and spiritual development.
MEDICAL ETHICS
Medical ethics is the study of moral values and judgment as they apply to medicine. Consent must be taken from the patient. I was there when the doctor discuss with her and take the informed consent. She was told everything regarding TAHBSO for instances benefit, indications, the procedure, risk and the complications that may be raised later. She was informed about this management in the clinic earlier, thus she has no difficulty in understanding the information given. It is medico legal to inform patients what are going to be decided and given. Hence, I politely introduced myself and asked her permission to take her case as my case write up. I take her consent verbally for history taking and physical examination.
PROFESSIONAL JUDGEMENT
Based on my judgment, the management plan for my patient was appropriate. Even though, she has no children and desire to have one, she has very huge uterine fibroid that may cause pressure such as abdominal pain and abdominal distention. The criteria fulfill to continue TAHBSO instead of myomectomy. Myomectomy is not chosen because it has the chance to the fibroid recur. GnRH analogue was given 6 cycles to shrink the fibroid before the surgery. Her medical condition was maintained prior the operation while a thorough investigations were done prior to the operation to assess her fit to undergo the operation. All the procedures were done properly with good indication.
CRITICAL APPRAISAL AND LIFELONG LEARNING
I realized that my clerking skills and physical examination in gynecology cases was not effective as I was practiced more on obstetric cases. Knowing lack of knowledge, I read the topic before and focus during round and teaching. I have to compliment what I have learnt in the ward with my prior knowledge. I found that I was lack of practice and skills in handling the case. Instead of asking doctors, I read some journal regarding the disease. From this case, I have learnt how to take history in gynecology cases and generate differential diagnosis based on patient's symptoms. The idea will lead to further investigation that necessarily done to the patient for instances blood investigations and imaging procedures. After the diagnosis is established and confirmed, only then the definitive surgical treatment started to my patient.
REFERENCES
