OBSTETRIC AND

GYNAECOLOGY POSTING
CLINICAL CASE REPORT
(GYNAECOLOGY)

NAME :
YEAR :
GROUP :
MATRIK NO :
SUPERVISOR :
HISTORY

IDENTIFICATION DATA

Name : Ros Anita binti Mohd Zin

R/N : B 194413

Age : 45 years old

Sex : Female

Race : Malay

Religion : Islam

Occupation : Staff Nurse

Address : Kg Bukit Peraksi Cherang Ruku, 16700 Pasir Puteh, Kelantan

Para :4

Last Menstrual Period (LMP): 28.11.2017

Date of Admission: 04.12.2017

Date of Clerking : 06.12.2017

CHIEF COMPLAINT

Madam Ros Anita was electively admitted three days ago for laparotomy and total abdominal
hysterectomy for uterine fibroid.
HISTORY OF PRESENTING ILLNESS (HOPI):

Patient is known to have hypertension for 2 years, currently on oral Amilodipine 10

mg once daily. Patient was initially presented with heavy and prolonged menses since 2015.
Before that, her menses were regular and it usually lasts for about 7 -8 days with 1-3 days of
heavy flow. She uses 3 or 4 pads per day. She attained menarche at the age of 11. Since 2015,
patient had prolonged menses, approximately 15 days and she uses around 10 pads per day
especially on the first five days of menses. Her prolonged menses was also associated with
blood clots. There was intermenstrual bleeding, mild dysmenorrhea, no dyspareunia and no
dysuria

During end of 2015, patient went to Klinik Kesihatan Rahmat, Terengganu and did an
abdominal ultrasound scan but there was no any abnormal findings. After three months
patient started to feel some mass but she thought it was nothing since she was obese. Patient
went back to the same Klinik Kesihatan on November 2016 with the complain of mass felt at
the left lower abdomen when there was obvious increase in mass size and can be felt like a
ball. Upon abdominal ultrasound scan, a mass of a fist size was noted and she was referred to
HUSM O&G clinic in February. On May 2017, her abdominal ultrasound scan in gynae
clinic of HUSM revealed that the mass was clinical size of 18 weeks uterus, lobulated, moved
with uterus and non-tender.

Initially, they planned for high intensity fibroid focused ultrasound ablation of uterine
fibroid. She was give IM Depo-Provera once in August 2017. However, it was not advisable
to continue it because patient experienced bleeding continuously for one and a half months
(September until October). During this time, she used 5 – 8 pads per day. Patient then came
back for follow up on October 2017 and the mass was clinical size of 22 weeks uterus on
ultrasound scan and they planned for laparotomy and total abdominal hysterectomy on the 6th
of December.

Patient also had anaemic symptoms such as lethargy and palpitations. Her lowest
haemoglobin count during on of the check up was 8.9 g/dL and on the day of clerking her
haemoglobin count was 9.3 g/dL. She was given Tranexamic acid from February till date.
Currently, she is on her 8th day of menses, claimed menses has decreased in amount after IM
Depo-Provera but still having prolonged menses. She uses only 2 – 3 pads per day and having
no abdominal pain. No symptoms of UTI and URTI.
PAST OBSTETRIC HISTORY

She was married at 2000 at the age of 28 years old and this is her first marriage and it was
non-consanguineous marriage. She has 3 children.

Year Sex Place Term/Method of Birth Complication Breastfeeding

delivery weight
2002 Boy HTA Full term/ Lower 3.7 kg No complication Until 1 month
segment caesarean
section

2004 Girl HTA Full term/ 2.9 kg No complication Nil

Spontaneous vaginal
delivery

2008 Girl HTA Full term/ Lower 2.8 kg No complication Until 6 months
segment caesarean
section

2009 Girl HTA Full term/ Lower 3.8 kg No complication Until 2 year-
segment caesarean old
section

PAST GYNAECOLOGICAL AND MENSTRUAL HISTORY

She attained her menarche at the age of 11 years old. The menses was regular, and it was 28-
30 days cycle, with 7 to 8 days menses. The maximum flow is usually at first and second day of
menses. She will use about 3-4 pads during that day. Since 2015 she experienced excessive bleeding
where her menses will usually lasts for 15 days and she uses more than 10 pads per day during this
time. She has mild dysmenorrhea, intermenstrual bleeding but no pain during intercourse and no post-
coital bleeding. Pap smear has been done twice before. The latest one was done in August and the
result was negative for malignancy.
PAST MEDICAL AND SURGICAL HISTORY

She has hypertension since 2015 but no history of other chronic illness such as diabetes mellitus
and asthma. She has previous history of 4 C-section surgeries and no other surgeries have been done.

FAMILY HISTORY

My patient is the sixth child out of 9 siblings. Her father has passed away at the age of 64 with
no known medical illness. Her mother is having hypertension which was diagnosed recently in late
2016 at the age of 62. Otherwise everyone else in the family is healthy. There was no history of
congenital anomalies or twin pregnancy in her family. There was no family history of cancer.

PERSONAL AND SOCIAL HISTORY

My patient lives with her husband and her three children in a modern village house with
adequate water and electrical supply. She has completed her education at SPM level. Her husband is 50
years old, who is a smoker who smokes in and out of the house and he works as a labourer in Sabah.
Their monthly income is in the range of RM 2500 to RM 3000 per month. Her extended family supports
her logistically and looks after her children when she was admitted.

DIET HISTORY

My patient takes normal adult diet and did not practice any food taboo. On average, she eats three times
per day. She has no known food allergy.

DRUG HISTORY

She is taking Tranexemic acid for her anaemia symptoms since February and Amilodipine since
2015 for hypertension. She took IM Depo-Provera once before. She never practices any traditional
medicine and also claimed that had no allergy to any kind of drug.
SYSTEMIC REVIEW

General

 Fatigue
 No loss of appetite
 No excessive thirst
 No lumps, no itches
 No disturbance in sleeping pattern.
Cardiovascular

 Shortness of breath
 Palpitations
 No Paroxysmal Nocturnal Dyspnoea (PND)
 No headache
Gastrointestinal

Upper gastrointestinal tract:

 Mild abdominal pain

 No Vomitus
 No hematemesis
 No belching/flatulence
 No water brash
 No heart burn
 No indigestion
 No dysphagia.
Lower gastrointestinal tract:

 No loose stool
 No constipation
 No pain
 Normal bowel habit
 No tenesmus
Liver and gallbladder:

 No yellowish discolouration
 Tea coloured urine and faeces normal
 No itching skin
Genitourinary

 Increase frequency
 No haematuria
 No dysuria
 No reduced urine output
Musculoskeletal

 No arthralgia
 No myalgia
Haematological

 No bleeding tendencies
 No rashes
 No impetigo
PHYSICAL EXAMINATION

GENERAL EXAMINATION

General Inspection

Patient was medium built woman, alert, conscious, comfortable, not tachypnic but look
lethargic. She was lying supine, flat and supported with a pillow and there was branula
attachment at her left hand on blood transfusion. Hydrational status was clinically adequate.
There was no gross deformity and no abnormal movement.

Vital Signs

Respiratory rate : 20 breaths per minutes

Pulse rate : 86 beats per minute, regular rhythm and adequate volume

Blood pressure : 139/72 mmHg

Temperature : 37.0 ˚ C

General Examination

Hand

Palms were moist, warm and pink in color, no palmar erythema, no muscle wasting of thenar
and hypothenar. Capillary refilling time <2s, no peripheral cyanosis and no clubbing

Face

No yellow discoloration of sclera but conjunctiva was pale. Oral hygiene was adequate, the
tongue was not coated and no central cyanosis

Leg

No pitting oedema and no varicose vein

SPECIFIC EXAMINATION

Abdominal Examination

Inspection:

Abdomen was symmetrically distended at lower quadrant until just above umbilicus.
Umbilicus was centrally located and inverted. There were presence of striae albican,
otherwise no dilated vein, no scar and no visible pulsation.

Palpation and Percussion:

Superficially abdomen was soft and non-tender. On deep palpation, noted mass at both
lower quadrant, the mass is firm, smooth surface, strictly mobile side by side, able to
palpate upper border but unable to palpate lower border of the mass which most likely
a pelvic mass. Clinical size of 22 weeks uterus. Liver span 8 cm. Otherwise no palpable
spleen, Traub space resonance, kidneys not ballotable, no ascites, no hernia noted
during cough impulse.

Auscultation:
Normal bowel sound heard.

Lymph Node Examination

No supraclavicular lymph node and inguinal lymph nodes palpable.
Respiratory System

Inspection:

On inspection, the chest was in normal shaped, no gross deformity and it moves with
respiration. There was no scar, there was no subcostal recession or Harrison sulcus seen
on the chest.

Palpation:

Normal and symmetrical chest expansion in each inspiration at all zones. Resonance
and equal tactile fremitus at all upper zones.

Percussion:

Resonance at all zones with liver and cardiac dullness presence.

Auscultation:

Equal air entry at both sides. All zones are vesicular breath sound with no crepitation
and no rhonchi.

Cardiovascular system

Inspection:

The chest moved symmetrical bilaterally. No chest deformity. There is no intercostal

recession noted. No visible vein and scar noted. No visible apex beat.

Palpation:

The apex beat is located at 5th intercostals space at mid clavicular line. No thrills and
parasternal heave.

Auscultation:

Soft 1st & 2nd heart sound were heard, no additional heart sound and no murmur heard
at all auscultation area.
Central nervous system

Higher Mental Function:

Conscious Level : Patient is alert to surrounding

Orientation : Orientated well to time place and person

Memory : Good short term and long term memory

Attention Span : Good attention span

Speech : Able to speak

Calculation : Able to calculate

Logical Thinking : Normal

Abstract Analysis : Normal

Fund of Knowledge : Normal

Motor System

Test Performed Upper Limb Lower Limb

Observation

No No muscle wasting. No muscle wasting.

Abnormal Movements No abnormal movement. No abnormal movement.

No fasciculation. No fasciculation.

Tone Normal. Normal.

Power

Left Limb 4+/5 5/5

Right Limb 5/5 5/5

Reflex

Deep Tendon Reflex Supinator Jerk Normal Knee Jerk Normal

 Biceps Jerk Normal Ankle Jerk Normal

Triceps Jerk Normal

Superficial Reflex Babinski’s Reflex is down going

for Left and Right Lower Limb.

Coordination

Finger Nose Test Normal Normal

Heel Shin Test Normal Normal

Gait Normal Normal

Cerebellar Signs

(1) No titubation

(2) No nystagmus

(3) No intentional tremor

Bimanual Examination (4/12/2017)

Cervix normal 2 cm x 2 cm
No adnexal mass
Mass moves along with uterus
Smooth surface
Uterus mobile

Speculum Examination (4/12/2017)

Vulva & vagina: No any defect

Cervix: Healthy and no growth
INVESTIGATIONS

1) Full Blood Count:

Rationale: ● To look for the presence of anemia due to per vaginal bleeding.

● To look for evidence of any infection.

● To check the platelet count to rule out any platelet disorders

PARAMETERS RESULT NORMAL RANGE

White Blood Cell (WBC) 7.29 x 109/L 4 – 11 x 109/L

Haemoglobin (Hb) 9.3 g/dL >11.0 g/dL

Platelet 283 x 109/L 150 – 400 x 109/L

Red blood cell 5.27 g/dL

Mean cell volume 65.6

MCH 18.5

MCHC 28.2

HCT 34.4

Interpretation: Patient was anemic. All the other parameters were normal.

2) Renal Function Test

Rationale: To assess the kidney function.

Parameters Result Normal range

Urea 3.1 mmol/L 2.5-7.5 mmol/L

Creatinine 74 umol/L 70-130 umol/L

Sodium 144 mmol/L 135-145 mmol/L

Pottasium 4.0 mmol/L 3.5-5.0 mmol/L

Interpretation: All parameters were normal

3)Coagulation Profile

Rationale : To check for any coagulopathy

Parameters Result Normal range

INR 1.07 0.85-1.2

APTT 35.80 seconds 30-40 seconds

PT 13.0 seconds 11 – 13.5 seconds

Interpretation: All parameter were within normal range.

4)Urine FEME

Rationale : To rule out urinary tract infection

Results : Pus cells, red blood cells and epithelial cells count were less than 10 cells/uL

Interpretation : No urinary tract infection

5)Transabdominal ultrasound

Uterus was anteverted. Posterior uterine wall fibroid measuring 11 x 10cm. Uterus was 20 x 11cm.
There was no free fluid or adnexal mass seen. Endometrial thickness was regular, homogenous and 4.4
mm

SUMMARY
Ros Anita, 45 years old Malay lady, Para 4, with underlying controlled hypertension, last child
birth 2009 years ago, last menstrual period 28/11/2017, electively admitted for laparotomy and
total abdominal hysterectomy due to uterine fibroid diagnosed on November 2016. She is also
suffering from anemia from February 2017 and was on Traxenamic acid once daily since then.
Upon examination, she appeared lethargic, vital signs were stable, and abdomen was
symmetrically distended, noted pelvic mass which was firm, smooth surface and strictly mobile
side by side with clinical size of 22-weeks uterus. Upon bimanual examination, the cervix was
normal, no adnexal mass, the mass moved along with the uterus and was firm and smooth in
surface. Other examinations were unremarkable. She had no family history of malignancy and
being financially and logistically supported by her extended family members.
PROBLEM LIST
 Woman of reproductive age up to the point of menopause
 Obesity
 Abnormal uterine bleeding
 Underlying hypertension

PROVISIONAL DIAGNOSIS
 Uterine fibroid

DIFFENTIAL DIAGNOSIS
 Endometriosis
 Endometrial hyperplasia
 Endometrial carcinoma
 Pelvic inflammatory disease
 Coagulative disorder
 Uterine fibroid
 Adenomyosis

DIAGNOSIS POSITIVE FINDINGS NEGATIVE FINDINGS

Endometriosis Heavy uterine bleeding No dyspareunia

Intermenstrual bleeding No cyclical bleeding

Mild dysmenorrhea No pain with bowel movement

Endometrial Heavy uterine bleeding Endometrial thickness was less than 5 mm

hyperplasia on total abdominal sonography
Intermenstrual bleeding

Mild abdominal pain

Endometrial Heavy uterine bleeding Endometrial thickness was less than 5 mm

carcinoma on total abdominal sonography
Intermenstrual bleeding
No loss of weight or no loss of appetite
Mild abdominal pain
Pelvic inflammatory Mild abdominal pain No foul-smelling vaginal discharge
disease No dyspareunia
No post-coital bleeding
No abdominal pain
No adnexal mass
Coagulative disorder Heavy uterine bleeding APTT and PT was normal
Intermenstrual bleeding No bruising or bleeding
tendencies
Uterine fibroid Heavy uterine bleeding
Intermenstrual bleeding
Mild abdominal pain
Uterine mass
Frequency
Adenomyosis Heavy uterine bleeding No diffuse thickening of uterine wall on
Mild abdominal pain sonography
MANAGEMENT
Medical management

1st line management for AUB due to fibroids options available are:
 Tranexamic acid (anti-fibrinolytics)
 Mefanamic acid aka Ponstan (NSAID)
 Hormonal (combined oral contraceptive pill, progestin-only therapies like POPs or
Mirena)
 GnRH agonists ( helps halt endometrial proliferation and can sometimes even reduce
fibroid size. Not routinely used due to high costs and deleterious effects on bone
mineral density and vasomotor symptoms)

Non surgical management

Drug therapy is an option for some women with fibroids. Medications may reduce the heavy
bleeding and painful periods that fibroids sometimes cause. They may not prevent the growth
of fibroids. Surgery often is needed later. Drug treatment for fibroids includes the following
options:

 Birth control pills and other types of hormonal birth control methods—These
drugs often are used to control heavy bleeding and painful periods.
 Gonadotropin-releasing hormone (GnRH) agonists—These drugs stop the
menstrual cycle and can shrink fibroids. They sometimes are used before
surgery to reduce the risk of bleeding. Because GnRH agonists have many
side effects, they are used only for short periods (less than 6 months). After a
woman stops taking a GnRH agonist, her fibroids usually return to their
previous size.
 Progestin–releasing intrauterine device—This option is for women with
fibroids that do not distort the inside of the uterus. It reduces heavy and
painful bleeding but does not treat the fibroids themselves.
Surgical management
1) Myomectomy
 Surgical excision of fibroid
 Can be done via laparoscopy, laparotomy or even hysterectomy (for
submucosal fibroids)
 Pros : good option for patients desiring uterine preservation or desiring future
fertility ( but if endometrial cavity is entered during the time of myomectomy,
future deliveries need to be via elective caesarean due to significant risk of
uterine rupture)
 Cons : fibroids can recur in myometrium

2) Uterine artery embolization

 Interventional radiology procedure where uterine artery is accessed and
embolized via a transcutaneous femoral approach
 Occludes blood supply of fibroids, causing them to shrink by 40 – 60% in size
(uterus still receives sufficient blood supply from collaterals)
 Pros : good option for patients desiring uterine preservation or desiring future
fertility
 Cons : future pregnancies may be at higher risk

3) Endometrial ablation
 Hysteroscopic procedure where endometrial lining is destroyed, thereby
treating abnormal uterine bleeding (70% effective)
 Option for patients desiring uterine preservation but not fertility

4) Hysterectomy
 Provides definitive treatment for fibroids (no more abnormal uterine bleeding,
no risk of recurrence of fibroids)
 Transvaginal or transabdominal can be done (but latter needed if subtotal
hysterectomy desired)
 Concomitant bilateral salpingo-oopherectomy can be offered for post-
menopausal women (negates risk for future development of ovarian cancer)
DISCUSSION

UTERINE FIBROID

Fibroids may be attached to the outside of the uterus or be located inside the uterus or uterine wall.

Uterine leiomyomas also referred to as fibroids are the most common pelvic tumor in
women. They are benign monoclonal tumors arising from the smooth muscle cells of the
myometrium. They arise in reproductive-age women and typically present with symptoms of
abnormal uterine bleeding and/or pelvic pain/pressure. Uterine fibroids may also have
reproductive effects such as infertility or adverse pregnancy outcomes. Fibroids are most
common in women aged 30–40 years, but they can occur at any age. Fibroids occur more
often in African American women than in white women. They also seem to occur at a
younger age and grow more quickly in African American women.

Uterine fibroid typically brought to medical attention due to symptoms in the

abdomen, like this case patient initially just had abdominal discomfort. In fact, the majority
of fibroid are small and asymptomatic, but some women with fibroids have significant
problems that interfere with some aspect of their lives. These symptoms are related to the
number, size, and location of the tumors. Symptoms are classified into three categories:

1. Heavy or prolonged menstrual bleeding

Submucosal myomas that protrude into the uterine cavity are most frequently related
to significant heavy menstrual bleeding. Intramural myomas are also commonly
 associated with heavy or prolonged menstrual bleeding, but subserosal fibroids are not
considered a major risk for heavy menstrual bleeding

2. Bulk-related symptoms (compressive symptoms)

a) Pelvic pressure or pain, it is likely to be chronic, intermittent, dull pressure or

pain. Fibroids also can cause acute pain from fibroid degeneration or torsion of a
pedunculated tumor.

b) Urinary symptoms including frequency, difficulty emptying the bladder, or,

rarely, complete urinary obstruction. Bladder symptoms occur when anterior
fibroid presses directly on the bladder or a posterior fibroid pushes the entire
uterus forward.

c) Bowel symptoms, fibroids that place pressure on the rectum can result in
constipation or if pressure in intestine can result other symptoms of intestinal
obstruction.

d) Venous compression, in which very large uterus may compress the vena cava and
lead to an increase in thromboembolic risk.

3. Reproductive dysfunction.

Fibroid that distort the uterine cavity such as submucosal or intramural with an
intracavitary component can result in difficulty conceiving a pregnancy and an
increased risk of miscarriage. Besides, fibroid also have been associated with adverse
pregnancy outcomes such as placental abruption, fetal growth restriction,
malpresentation, and preterm labor and birth.

Fibroids can be detected during a routine pelvic examination. A number of tests may
show more information about fibroids. Ultrasonography uses sound waves to create a picture
of the uterus and other pelvic organs. Hysteroscopy uses a slender device to see the inside of
the uterus. It is inserted through the vagina and cervix (opening of the uterus). This permits
the doctor to see fibroids inside the uterine cavity. Hysterosalpingography is a special X-ray
test. It may detect abnormal changes in the size and shape of the uterus and fallopian tubes.
Sonohysterography is a test in which fluid is put into the uterus through the cervix.
Ultrasonography is then used to show the inside of the uterus. The fluid provides a clear
picture of the uterine lining. Sonohysterography is a test in which fluid is put into the uterus
through the cervix. Ultrasonography is then used to show the inside of the uterus. The fluid
provides a clear picture of the uterine lining. Laparoscopy uses a slender device (the
laparoscope) to help the doctor see the inside of the abdomen. It is inserted through a small
cut just below or through the navel. The doctor can see fibroids on the outside of the uterus
with the laparoscope. Imaging tests, such as magnetic resonance imaging and computed
tomography scans, may be used but are rarely needed.

The pathogenesis of leiomyomas is not well understood. In general, there are multiple
etiologies related to development of uterine fibroid which are genetic predisposition,
environmental factors, steroid hormones, and growth factors important in fibrotic processes
and angiogenesis. Some also suggest that this disease is heterogeneous in which different
fibroids may have different etiologies and may have multifactorial pathogenesis. Even
though, fibroid pathogenesis is not well understood, based on studies there are a few risk
factors associated with uterine fibroid. One study regarding risk factor of fibroid in Malaysia
was done among patients in Hospital Selayang and Hospital Putrajaya by Universiti Putra
Malaysia. They concluded that higher age, duration of last child birth of more than 5 years
and alcohol consumption were found to contribute significantly to the risk for uterine fibroid.
Other studies also imply a familial predisposition (genetic) to leiomyomas in some women.
There is also evidence of specific susceptibility genes for fibroids.

Evidence-Based Medicine:

Article on Innovations in Uterine Fibroid Therapy by McCarthy-Keith DM, Armstrong AY.

Surgical treatment of fibroids

Hysterectomy is the mainstay of traditional fibroid therapy, but myomectomy is a surgical

alternative for women desiring uterine preservation. Hysterectomy may be preferred over
myomectomy because it eliminates current symptoms as well as the possibility of recurrent
symptoms in the future. Laparoscopic and robot-assisted techniques have brought innovation
to standard surgical management. Large fibroids that were once routinely removed through a
laparotomy incision may now be removed laparoscopically, with tissue morcellation to
facilitate their removal from the abdominal cavity. Morcellation can be performed manually;
however, automatic morcellators significantly reduce operating time and can be used to
remove fibroids weighing up to 500 g. Laparoscopic myomectomy has the advantages of
shorter hospital stay, less postoperative pain and faster recovery compared with the
abdominal approach.

Minimally invasive treatment of fibroids

Uterine artery embolization effectively reduces fibroid volume, improves quality of life and
offers uterine preservation; although the effect of this treatment on future fertility is unclear.
The procedure is performed through a right or left femoral arterial puncture and the uterine
artery is catheterized via catheterization of the hypogastric artery. A uterine arteriogram is
performed, followed by injection of an embolic agent into the uterine arteries. The embolic
particles preferentially flow into the large fibroid vessels, primarily occluding these, while
maintaining some uterine artery blood flow. Several embolic agents are currently in use,
including polyvinyl alcohol (PVA) particles, PVA microspheres and tris-acryl gelatin
microspheres.

Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) is a thermoablative

treatment was approved by the FDA for the treatment of symptomatic uterine fibroids in 2004
which also offers uterine preservation and eliminates the need for general anesthesia. MRI to
localize fibroids and to monitor ultrasound-directed thermal ablation of the fibroid targets.
This allows optimal fibroid characterization and precise target definition throughout the
procedure, and response to treatment can be assessed immediately by post-treatment MRI.
MRgFUS reduces fibroid volume and is indicated for the treatment of symptomatic fibroids
in women desiring future fertility.

Conclusion

Current fibroid therapies offer a glimpse of the future, which will undoubtedly focus on the
minimally invasive approach to the management of this disease that affects so many women.
Future investigations will most likely attempt to elucidate the molecular mechanisms of
fibroid growth and regulation and then translate this understanding into the development of
novel therapies. Medical therapies directed at specific gene targets or signaling pathways in
fibroids will most likely surpass traditional therapies based on steroid hormone regulation.
Surgical management of fibroids will continue to be a practical option for women desiring
definitive treatment and for the proportion of women who experience fibroid recurrence or
treatment failures with other therapies.
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