Normal and abnormal puerperium

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Normal and Abnormal Puerperium

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Synonyms

leiomyoma of uterus

leiomyomas

fibromyomas

myofibromas

fibroids

fibromas

myomas


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Incidence

Most common solid pelvic tumors

Develop in 20 ～ 25% of women during reproductive years

30 ～ 50 years old


Correlative Factors

An estrogenic milieu may be necessary

Progesterone function

Growth factor and their receptor ： epithelial growth factor （ EGF ） Insulin-like growth factor （ IGF ） platelet-derived growth factor

Puberty

Menopause

Estrogen Progesterone


Pathology


Gross AppearanceRare only a single ， usually many existWell-circumscribed ， nonencapsulatedA pseudocapsule is present.The consistency is usually firm or even hard except when degeneration or hemorrhage has occurred.color ： light gray or pinkish whitecut section ： an intertwining pattern or

a whorl-like arrangement ； bulgy

Pseudocapsule


Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the uterus.


Microscopic Appearance

Composition ： smooth muscle

connective tissue

The nonstriated muscle fibers are arranged in bundles of various sizes that run in multiple directions.


Classification （ 1 ）

According to growth location ：

• Myomas on the body of uterus （ 90% ）• Myomas on the cervix of uterus （ 10% ）


Classification （ 2 ）According to the relation to uterine muscle ：• Submucous （ 10 ～ 15% ）• Intramural （ 60 ～ 70% ）• Subserosal （ 20% ）

Few leiomyomas are actually of a single “pure” type.

— hybrids


Clinical Manifestation


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Symptoms

menorrhagia and prolonged menstrual period ：commonPelvic pain ：

occurs in pregnancy if undergoing degeneration or torsion of a pedunculated myomaPelvic pressure ： urinary frequency

bowel difficulty （ constipation ）Spontaneous abortionInfertility

Menorrhagia

Pedunculated

spontaneous abortion

Infertility


Signs

A palpable abdominal tumour

Pelvic examination ： uterus — enlarged and irregular ； hard


Degeneration

Hyaline degeneration

Cystic degeneration

Red degeneration

Sarcomatous change

The others ： fat degeneration

calcification

the secondary infection

Result from the diminished vascularity of the

connective-tissue element


Red DegenerationOccasionally seen as a complication of pregnancy（ during pregnancy or immediate postpartum period ）

The pathogenesis is unknown ， may be the result of the accumulation of blood in the tumour because of venous obstruction.

The cut surface resembles raw meat.

Clinical features ： a cause of pain （ acute ） fever rapid growth ， tender


Here is a very large leiomyoma of the uterus that has undergone degenerative change and is red (so-called "red degeneration"). Such an appearance might make you think that it could be malignant. Remember that malignant tumors do not generally arise from benign tumors.


Sarcomatous Change

Rare ： 0.4% ～ 0.8%

More common at 40 ～ 50 years old

Usually occur in intramural fiboids

grow quickly

vaginal bleeding


Diagnosis

History

Bimanual examination

Ultrasonography （ B–ultrasound examination ）

Hysteroscopy

Laparoscopy

Hysterography

Hysteroscopy

Laparoscopy


Differential Diagnosis

Pregnancy

Ovarian tumour

Adenomyosis

Malignant tumors of uterus

• sarcoma of uterus

• endometrial carcinoma

• cervical cancerwww.freelivedoctor.com

Treatment


Observation and Follow Up

Small ， asymptomatic fibroids need not be treated ， especially near menopause.

Interval ： 3 ～ 6 months


Medical Treatment

Androgenic agents ： testosterone propionate

GnRH-a ：• induce a hypoestrogenic pseudomenopausal

state

• not recommended for longer than 6 months

• “add-back” regimens


Surgery Treatment（ 1 ）Indications ：

greater than 10 weeks’ gestational size

menorrhagia ， lead to anemia

have pressure symptoms

grows rapidly

failure of medical treatment


Surgery Treatment（ 2 ）Method ：

Myomectomy—conservative therapy preserve fertility

significant risk of recurrence

Hysterectomy— radical therapy

Subtotal hysterectomy

hysterectomy

myomectomy

Only true “cure” for leiomyomas


Surgery Treatment（ 3 ）Approach ：

• trans-abdominal

• trans-vaginal

• laparoscopic or hysteroscopic


It is important to individualize the choice of therapy.


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Uterine Leiomyomas Complicating Pregnancy

impact on pregnancy ： abortion

impact on delivery ： premature labour fetal malpresentation retained placenta placenta previa need for operative delivery （ birth canal obstruction ） postpartum hemorrhage

Conservative treatment


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Critical PointsMay be related to superabundant estrogen.Well-circumscribed ， nonencapsulated.

Have a pseudocapsule.Can be classified into submucosal 、 intramural and subserosal types.Different types have different features.Menorrhagia is common.Four degeneration typesIndividualized treatment ， include observation 、 medical treatment and surgical treatment.


Normal and abnormal puerperium

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