1. MANAGEMENT OF FIBROIDS
Hari Dev
2008 MBBS

2. Bimanual Examination

3. HEMATOLOGICAL INVESTIGATIONS
• Hemoglobin
• Total count, differential count
• Bleeding time, clotting time
• Blood sugar
• TFT- thyroid function test
• Renal function test

4. IMAGING MODALITIES
• Ultrasound
• Sonohysterography
• Hysteroscopy

5. IMAGING MODALITIES
ULTRASOUND
• Confirm Diagnosis
• Size , Number
• To detect small submucous fibroids
• Detect distorsion of the cavity
• Rule out ovarian tumour , adenomyosis
• Ascitis?
• Assess kidney and ureters..

6. ULTRASOUND SCAN

7. TREATMENT
Small, asymptomatic fibroids do not
require removal, observed every 6
months.

9. EXPECTANT MANAGEMENT- CRITERIA

11. DRUGS USED

13. PROBLEMS…..

14. SURGICAL Management- Indications

16. MYOMECTOMY
• Victor Bonney
• Option for those who desire further child
bearing or wish to preserve uterus
• Women presenting with infertility and
miscarriage – other causes should be ruled out.
• Best for intramural and submucous fibroids

18. How to limit blood loss??

19. SURGICAL PROCEDURE
• Anterior incision in uterus..
• Bonney’s hood incision – single posterior
fibroid.

20. OPEN MYOMECTOMY

21. Hysteroscopic Laparoscopic
Submucous fibroids Subserous, intramural
Pedunculated fibroids easliy removed. Less hospital stay
Preoperative TVS & Sonohysterography Less postop pain
ideal.
Myomas < 5cm and of which >50% cosmetic advantage
projecting into cavity
Vaginal – pedunculated submucosal myomas

22. Complications

26. HYSTERECTOMY - Abdominal
Steps
1.Opening abdomen – Pfannensteil incision,
uterus elevated with left hand , forceps placed
on either side of cornua.
2.First pedicle – round ligament [ 0/1 vicryl], if
needed trace ureter.
- if ovaries removed – infundibulopelvic lig.
- if ovaries retained –tube & ovarian lig. cut

27. 3. Bladder dissection – dissect bladder from anterior
cervix, bladder pushed down
4. Second pedicle - uterine vessels seletonised,
clamped, cut and ligated. Clamp placed
perpendicular to uterine artery at CU junction.
5. Third pedicle - cardinal ligaments and uterosacrals
clamped , cut ligated.
6. Vaginal angles and vaginal edges- 2 clamps used to
clamp across vagina.suture taken thru lt. vaginal
clamps and uterosacrals.
7. Closure of abdomen.

29. Complications

32. Vaginal vault closed anteropsteriorly with interrupted mattress or continous
suture with 0 vicryl.

33. Complications
1.Immediate – haemorrhage
- injury to bladder / rectum
2.Late – reactionary & secondary
haemorrhage.
- haematoma, abscess
- vesicovaginal , uterovaginal or
rectovaginal
fistulae.
3.Sequelae - Vault prolapse

34. Uterine artery embolisation (UAE)
• Symptomatic women who don’t want surgery
• Prerequisites
– Accurate diagnosis
– No suspicion of malignancy
– Patient warned of failure
– Informed consent

35. • C/I
– Pregnancy
– Pelvic infection
– Pelvic malignancy
– Contrast medium allergy
– Adenomyosis
– Pedunculated submucous fibroids
– Pedunculated subserous fibroids
– Infertility

36. • Technique
– Aim to occlude both uterine arteries to induce ischemic
necrosis of fibroids
– Done in the immediate postmenstrual period
– Transfemoral approach on the right side
– Embolisation using polyvinyl alcohol particles
– B/l done
– Discharge after 24-48 hrs
– Follow up clinically and sonologically

37. Complications
– Failure to cannulate
– Local haematoma
– s/v pain due to infarction
– Menorrhagia decreases by 90%
Postembolisation syndrome – fever, N,V
– Infection reduction in fibroid volume by 50-70%
&
– Exposure to radiation
– Persistent vaginal discharge
– Pedunculated submucous fibroids expelled vaginally
– Pedunculated subserous fibroids become infected
– Non target organ embolisation