Department Of Obstetric

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Department Of Obstetric
GynecologyPELVIC MASS
JORDAN UNIVERSITY OF SCIENCE AND TECHNOLOGY

• Supervised by Dr Isam Lataifeh
• Esra Sami
• Mohamed Fayez

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Introduction
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Differential Diagnosis

• Gynecological causes
• 1) uterine masses
• pregnancy
• fibroids
• endometrial carcinoma
• adenomyosis

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Differential Diagnosis

• 2) Tubal masses
• inflammatory origin
• ectopic pregnancy
• carcinoma
• 3) Ovarian masses
• functional cysts
• endometriomas
• Ovarian neoplasms

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Differential Diagnosis

• Non - gynecological causes
• bowel
• gas or faeces in sigmoid or caecum
• appendicitis
• diverticular diseases
• miscellaneous
• distended bladder, pelvic kidney
• abdominal wall hematoma
• retroperitoneal neoplasm

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History

• age
• pain (onset and type,site ), menstrual status,
  menstrual disturbances, interference with sexual
  activity , look for GIT symp (abd.bloating or
  fullness ,constipation or change in stool
  caliber)
• parity, gravidity (obs hx),
• previous personal (past surgical medical) and
  family history
• family history breast( BRCA family Risk ),
  ovarian , GI tumors ( Fibroids have a familial
  pr)
• weight loss

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Physical Exams

• General exam (VS ,weight, hydration, anemia)
• Lymphadenopathy (supraclavicular)
• chest breast exam
• abdominal exam masses and tenderness etc
• bimanual exam
• (size,shape,irregularity ,mobility ,
  consistency)
• ( sensitivity and specificity of pelvic exam
  R both only 50 )
• rectovaginal exam (post.uterine surface,
  uterosacral ligament , POD, rectum )

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FIBROIDS

• tumors or lumps made of muscle cells and other
  tissue that grow within the wall of the uterus.
• may grow as a single tumor or in clusters

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Where do uterine fibroids grow?
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Where do uterine fibroids grow?

• Submucosal fibroids grow just underneath the
  uterine lining.
• Intramural fibroids grow in between the muscles
  of the uterus.
• Subserosal fibroids grow on the outside of the
  uterus.
• Pedunculated fibroids grow out from the surface
  of the uterus, or into the cavity of the uterus

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Symptoms (patients history)

• GYNECOLOGICAL PROBLEMS
• 1) Abnormal vaginal bleeding
• - intermenstrual
• - menorrhagia
• - irregular bleeding
• 2) Pain
• -acute (degeneration torsion)
• -chronic pelvic pain
• -deep dysparunia pain
• -throughout menstruation

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Symptoms cont

• 3) Pressure symptoms
• - bladder pressure
• - bowel compression
• - nerve compression
• 4) Infertility
• -tube obstruction
• -interfere with implantation

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Associative Risk Factors

• Hereditary?
• Null parity
• Black women, low in asian
• Age 35-50 (reproductive age) estrogen
  progesterones role
• - Fibroids grow rapidly during pregnancy when
  hormone levels are elevated.
• - Fibroids shrink after menopause when hormone
  levels are decreased.
• Obesity is associated with the presence of
  uterine fibroids.
• genetic, hormonal, environmental

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Investigation Diagnosis

• complete blood count (CBC) - anaemia
• blood tests (bleeding disorder hormonal level)
• Most often confirmed by transabdominal ultrasound
• Transvaginal ultrasound
• endometrial biopsy rule out carcinoma

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Investigation Diagnosis

• Pelvic exams

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• Hysterosalpingography - uses a dye to highlight
  the uterine cavity and fallopian tubes on X-ray
  images.

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• Hysteroscopy - small, lighted telescope

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• MRI, CT Scan

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Management and Treatment

• Treated only if
• -symptomatic regardless of the size
• -if the size gt 12 W fetal gestational age even if
• its asymptomatic
• Medical Rx
• - Uterine Artery Embolization
• - GRHA Androgens Analogues
• Surgical Rx
• -myomectomy
• -hysterectomy

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Surgical Rx

• Myomectomy (laparoscopy, hysteroscopy, open
  laparatomy)
• -removes only the fibroids and leaves the
  healthy areas of the uterus in place
• -preserving ability to have children

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Surgical Rx

• Hysterectomy
• -removal of the whole uterus
• -done if fibroids are large abnormal
  bleeding nearly menopause not wanting
  children

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Types of hysterectomy

• Abdominal hysterectomy is a procedure that
  involves a cut into the abdomen to remove the
  uterus.
• Vaginal hysterectomy is less invasive because the
  doctor reaches the uterus through the vagina,
  instead of making a cut into the abdomen

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Medical Rx

• Uterine Artery Embolization (radiology
  intervention) - cuts off the blood supply to the
  fibroids, making them shrink
• -access to femoral artery
• -tiny tube into the vessel
• -guided to the uterus (fluoroscopy)
• -inject tiny plastic particles into artery
  supplying the fibroid
• -fibroid shrinks

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Uterine Artery Embolization
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Uterine Artery Embolization

• Advantages
• - Relief of symptoms in 85
• - non-surgical, safe
• - no significant blood loss
• - one-night stay
• - resume daily activities in short time
• Disadvantages
• -moderate to severe cramps
• -injury to uterus
• -infection

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Focused ultrasound surgery

• inside of a specially crafted MRI scanner
• visualize fibroids anatomical location, and then
  locate and destroy (ablate) them
• focused high-frequency, high-energy sound waves
  are used to target and destroy the fibroids
• single treatment session is done in an on- and
  off-again fashion, sometimes spanning several
  hours

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Focused ultrasound surgery
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Medical Rx

• Gonadotropin Releasing Hormone Agonists
• -Estrogen and progesterone levels fall,
  menstruation stops, fibroids shrink and anemia
  often improves
• Androgens
• -Danazol, a synthetic drug similar to
  testosterone, has been shown to shrink fibroid
  tumors, reduce uterine size, stop menstruation

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Obstetric Complications

• Abortions (submucous)
• Abnormal fundal height, lie and presentation
• Failure of implantations
• Abnormal labor
• Preterm labour and prematurity
• Atonic postpartum haemorrage
• sarcomatous change?