CASE WRITE UP

OBSTETRIC

AND

GYNECOLOGY

DEPARTMENT

AUTHOR :
MOHAMAD IDHAM BIN BAHARUDIN
111 303 239
GROUP A2

REVIEWING FACULTY
PROF. SOMSUBHRA DE.

History and Examination

Patient profile
Name: Rokiah bt Harun
Age: 32 years old
Parity index : P2
Address : Masjid Tanah, Melaka
Occupation : Housewife
Date of Admission : 20/07/2015
Date of Examination : 21/07/2015

Chief Complain
Patient came with chief complain of excessive bleeding per vagina during menses for 4 months and
mass per abdomen for 1 month

History of Presenting illness

Patient noticed she had developed excessive bleeding per vagina during menstruation when she had to
change 5-6 pads/day compare 1-2 pads/day from previous menstruation. She also noticed that her
menstruation lasted for about 8 days. Flow is associated with passage of clots. She also complain of
pain in the lower abdomen that starts with the onset of menstruation and increased subsequent days.
The pain is dull aching in nature, not radiating, present continuously and associated with cramp.
Patient also accidently founds a mass in her lower abdomen in the suprapubic region 2 weeks,
insidious in onset, non progressive and not associated with pain.
However, there is no history of disharge per vaginam, symptoms of anemia, symptoms of urinary tract
infection, dysparenuia, or any history of bleeding disorder. At Melaka GH, ultrasound was done and
revealed a hypoechoic mass in the uterus.

Past Obstetric History

She had been married for 8 years. Her first son is 7 years old, born via spontaneous vaginal delivery at
General Hospital Melaka with birthweight of 3 kg. It was an uneventful pregnancy. Her second was a
daughter; now 5 years old, delivered with forceps assisted at General Hospital Melaka with
birthweight of 2.8kg and it was uneventful pregnancy.

Menstrual History
She attained her menarche at 14 years old, regular with past cycle of 28 days with 4 to 5 days of flow.
For the past 4 months, 29 days with 8 days of flow associated with pain and passage of clots. Pap
smear was done 2 years ago and the result are normal. No history of using oral contraceptive pills.

Past medical history

Nothing significant

Past Surgical history

She had appendectomy at the age of 17 years old.

Family history
Patient is the eldest out of 3 sister. Her mother had hypertension and already passed away. There is no
family history of diabetes mellitus nor malignancy.

Personal history
Patient is a housewife. Her sleep was not disturbed and appetite was good. She eat balanced diet. She
does not smoke or consume alcohol. She is not allergic to any medication or foods.

Socialeconomic
She has been married for 8 years. Her husband is 31 years old, work as technician. Her husband is non
smoker and non alcoholic.

Summary
Rokiah bt Harun, 30 years old, Para 2, came with chief complain of menorrhagia and mass per
abdomen for further investigation and treatment.

General examination
Patient is lying down comfortably in supine positon on bed. Her height is 157 cm, weight is 70kg and
BMI is 28.45 kg/m2.
Hand no pallor, cyanosis, clubbing
Vital sign
-

Pulse : 80beats per minute, regular rhythm, normal volume and character
Blood pressure : 110/70mmHg.
Respiratory rate : 18 beats per minute
Temperature : Afebrile

Eys: no pallor, no icterus

Oral cavity : tongue look moist and pink, oral hygiene fair.
Neck : no obvious swelling seen, no lymphadenopathy
No pedal edema present

Abdominal examination
Inspection

Abdomen is not distended

Umbilicus are centrally placed, flat and inverted
All quadrants moves symmetrically with respiration
No scars are seen

Palpation
Soft, non tender. There is mass felt at hypogastric region. The size of the mass is approximately 4x5
cm. It is firm and hard in consistency, surface is smooth, there is no tenderness, able to move
horizontally but not vertically.. The lower border of the mass cannot be felt. No organomegaly
Percussion
Dull note over the mass. No shifting dullness
Auscultation

Normal bowel sounds are heard

Diagnosis

Uterine Fibroid

Investigation
Full blood count
Hb

11.0 g/L

TRBC

4.15 x10^12/L

HCT

34.0g

MCV

82fL

MCH

25.5 pg

MCHC

30.8 g/dl

Platelets

258 x10^9/L

TWBC

10.1 x10^9/L

Lymphocytes

2.9 x10^3/uL

Neutrophil

6.6 x10^3/uL

Monocytes

0.4x10^3/uL

Eosinophil

0.2 x10^3/uL

Basophil

0.0 x10^3/uL

PT/APTT
PT test

12.4sec

PT control

12.9 sec

PR

0.96

INR

0.95

APTT
ApTT test

41.1 sec

ApTT control

34.5 sec

ApTT ratio

1.19

Renal Function
Urea

6.4 mmol/L

Sodium

141 mmol/L

Potassium

3.5 mmol/L

Chloride

100 mmol/L

Creatinine

63 umol/L

Liver Profile

Total bilirubin

7.7 umol/L

Total protein

80 g/L

Albumin

42 g/L

Globulin

38 g/L

Alkaline phosphatase

80 u/L

ALT

29 u/L

Ultrasound findings : Single hypoechoic mass in the submucosa of the uterus. The size is 4x6 cm.

Discussion
Uterine fibroids are very common, benign, smooth muscle tumors of the uterus that can be
referred as leiomyomas. Uterine fibroid incidence increase as women grew older with 20-50% of
cases occur to women older than 30 years old[1]. .A study in Malaysia show that, fibroid as the most
common indication for hysterectomy leading by 47.8% in 9 state of Malaysia [2]. However, most
fibroids are asymptomatic, thus most women with fibroids are not diagnosed. This unable us to
correctly get the true incidence of fibroids.
Exact etiology of fibrois are not well known. But some risk factors such as obesity, age more
than 40, nulliparity and family history of fibroids are associated with fibroids. Some studies show that
hypertension have higher risk of fibroid by smooth muscle injury or cytokine release [3]. Some
protective factors from fibroids have been found such as increasing parity, cigarette smoke, prolonged
use of oral contraceptives and postmenopausal. In this patients, she only had obesity as the risk factor
for fibroids.
Most of women with fibroids are asymptomatic. Some of them will develops menorrhagia,
pelvic pain, obstuctive symptoms, infertility and if they are pregnant, miscarriages. Menstrual
abnormalities are the most commons symptoms associated with uterine fibroid tumors A study shows
that 11% of symptomatic menorrhagia cases are cause by uterine fibroid[4]. Fibroids came with many
types such as subserosa, submucosal, intramural, and pedunculated. In which submucosal fibroids are
often associated with the causes of menorrhagia where they disrupt the local growth factors causing
vascular abnormalities but no evidence that support that this type of fibroid are more likely to causes
menorrhagia compare to other type[5]. This patient came with menorrhagia and blood clots, and
submucosal fibroid was found by ultrasound which suggestive according to the study.
Patient last child birth is 5 years ago, which may suggestive that the patient suffer from
infertility. But the role of fibroid tumors in infertility is still controversial because many of the

research are retrospective and non randomized. A study show that intramural fibroid can distrupt in
vitro fertilization by distorting the uterine cavity[6]. Although there is no clear evidence yet,
unexplained infertility are often found in patients with multiple fibroid, intramural and submucosal
fibroid, fibroid larger than 5 cm[7].
If the patient is pregnant, this fibroid of her can cause quite a few effect on her pregnancy. The
most common effect is miscarriages especially submucosal and intramural fibroid. This type of fibroid
can thin out the lining and decreases the blood supply to the developing fetus and can also causes
inflammation to the lining above it. This will ultimately lead to miscarriages. Other than that due to the
distortion of uterine cavity, fetus may have malpresentation which may lead to operative delivery or
prolonged labour. Fibroid also causes poor coordination of uterine contraction that will lead to uterine
atony and increase bleeding after 3rd stage of labour. It can also causes abnormally situated placenta
and abruptio placentae for patient with retroplacental fibroids.
Pregnancy also have an effect to the fibroids. Fibroids may increase in size during pregnancy.
This may lead red degeneration of fibroids which may manifests as abdominal pain, pyrexia with
nausea vomitting due to ischaemic necrosis. This condition usually occurs in late 1st and early 2nd
trimester of pregnancy.
Fibroids can be treated either via medical treatment or surgical treatment. Surgical treatment is
the definitive treatment for fibroids. Myomectomy is a common surgical done in women with
symptomatic fibroids who still desire to retain fertility. This surgical option must be given to this
patient as she is still young and she may want to have another baby. Myomectomy can be performed
by laparotomy, laparoscopic or hysteroscopic resection depending on the number, size and location of
the fibroids. Laparascopic approach is attempted only for 1 or 2 fibroids not larger than 5 to 8 cm[8].
Myomectomy is associated with more intraoperative bleeding but less injury to other pelvic organ
likes bladder and ureter [9] and have less risk of complication such as wound infection, febrile
morbidity and blood transfusion [10]. However, patient may have adhesion following surgery and this
may affect future fertility if the scarring involve fallopian tubes and ovaries.
Other than myomectomy, we can suggest hysterectomy to the patient that did not desire to
retain fertility. As mention before, fibroids is the leading cause of hysterectomy. The most common
type of hysterectomy is total abdominal hysterectomy.

Other than that, hysterectomy can be

performed by vaginal approach or by minimally invasive laparoscopic, providing tthat the uterus is not
too large. Hysterectomy are found to be 100% effective in relieving symptoms of bleeding, pressure
or pain caused by fibroid [11]. We can also suggest uterine artery embolization to the patient in which

micro cathetere is introduced into the uterine artery and polyvinyl alcohol particles are then injected
which is occluded the aretries.
Medical therapy also available to the women who prefer conservative management.
Tranexamic acid and mefenamic acid can be given as a first line to reduce the blood loss. Other than
that prolonged usse of progestins ( medroxyprogesterone) can also reduce blood loss or even
amenorrhea when given to the patients. However, the side effect of this such as weight gain,
breakthrough bleeding and mood changes can be limitting [12]. Long acting progesterone also have
been found to reduce the fibroid volume that will make easier surgical. Other than that androgenic
antiprogesterone ( danazol and gestrione) can also reduce blood loss and fibroid size. However, patient
may develop androgenic side effects. We can also give gonado releasing hormone agonist for treating
amenorrhea and reducing the size of the tumors. However, this drug may cause medical menopause if
use for long period of time.

Reference

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confirmed uterine myomas. J Obstet Gynaecol 2005;25:42-4.
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Malaysia. Med J Malaysia vol53 no.3 1998.
3. Boynton-Jarrett R, Rich-Edwards J, Malspeis S, Missmer SA, Wright R. A prospective
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