Nursing Management

of
MYOMATOUS/UTERINE
FIBROIDS
Presented by
Horace Williams
MScN, BScN, Cert. Psychiatry. Dip.
RN
Department of Nursing
NCU

Objectives

Key Terminologies

DEFINITON &
INCIDENCE OF
FIBROIDS

What is a leiomyoma
It is a benign neoplasm of the muscular wall
of the uterus composed primarily of smooth
muscle
Can be solitary or multiple in the lining

(intracavitary), muscle wall (intramural)

and outside (serosal) surface of the uterus

(Smeltzer et al., 2010)

What is the incidence of leiomyomas

They are the most common pelvic tumors
It is found in 25% of white women & 50% of
black women
Occur in 20-40% of women during
reproductive life
Genetically predisposed and most times
benign
Usually develop in women between 25-43
years old
Fibroids are a common reason for
hysterectomy due to menorrrhagia which
can be difficult to control
(Smeltzer et al., 2010)

ETIOLOGY AND
PATHOPHYSIOLOGY
OF FIBROIDS

Unknown
Each individual myoma is unicellular in
origin
Estogens a possible factor
no evidence that it is it has been
implicated in growth of myomas
Myomas contain estrogen receptors in
higher concentration than surrounding
myometrium

Myomas may increase in size with

estrogen therapy & in pregnancy &
decrease after menopause
They are not detectable before puberty
Progestrone increase mitotic activity &
reduce apoptosis resulting in increased
size
There may be genetic predisposition

PATHOPHYSIOLOGY
Fibroid are frequently multiple
They may reach 15 cm in size or even larger
They are usually Firm, spherical or irregular
lobulated
Usually encoated within a false capsule
Can be easily enucleated from surrounding
myometrium

CLASSIFICATION
OF FIBROIDS

Submucous
leiomyoma
Pedunculated
submucous
Intramural or
interstitial
Subserous or
subperitoneal
Pedunculated
abdominal
Parasitic
Intraligmentary
Cervical

CLINICAL
MANIFESTATIONS

1-SYMPTOMS

Symptomatic in only 35-50% of patients

Symptoms depend on location, size,
changes & pregnancy status
1-Abnormal uterine bleeding
The most common 30% of patients
Heavy / prolonged bleeding (menorrhagia)
leads to iron deficiency anemia

1-Abnormal uterine bleeding

Submucous myoma produce the most
pronounced symptoms of menorrhagia, pre
& post-menstrual spotting
Bleeding is due to interruption of blood
supply to the endometrium, distortion &
congestion of surrounding vessels or
ulceration of the overlying endometrium
Pedunculated submucous results in areas of
venouse thrombosis & necrosis on the
surface leading to intermenstrual bleeding

2-PAIN
Vascular occlusion results in necrosis,
infection
Torsion of a pedunculated fibroid leads to
acute pain
Myometrial contractions to expel the myoma
Red degenration results acute pain
Heaviness fullness in the pelvic area lead to
feeling a mass
If the tumor gets impacted in the pelvis this
results in pressure on nerves leading to back
pain radiating to the lower extremities
Dysparunea if it is protruding to vagina

3-PRESSURE EFFECTS
If myoma is large it may distort or obstruct
other organs like ureters, bladder or
rectum leading to urinary symptoms,
hydroureter, constipation, pelvic venous
congestion & LL edema
Rarely a posterior fundal tumor results in
extreme retroflexion of the uterus
distorting the bladder base leading to
urinary retention

Parasitic tumor may cause bowel

obstruction
Cervical tumors results in serosanguineous
vaginal discharge, bleeding, dyspareunia or
infertility

()

4-INFERTILITY
The relationship is uncertain
27-40% of women with multiple fibroids
are infertile but other causes of infertility
are present
Endocavitary tumors affect fertility more
5- SPONTANEOUS ABORTIONS
incidence before myomectomy 40%
after myomectomy 20%
More with intracavitary tumors

DIAGNOSTIC
TESTS USED TO
DETECT FIBROIDS

EXAMINATION
Most myoma are discovered on routine
bimanual pelvic exam or abdominal
examination
Retroflexed retroverted uterus obscure the
palpation of myomas
LABORATORY FINDINGS
Anemia
Depletion of iron reserve
Rarely erythrocytosis results in pressure on the
ureters leading to back pressure on the kidneys
results in increased erythropoietin

Acute degeneration & infection results in increased

ESR, leucocytosis and fever
IMAGING
Pelvic ultrasound is very helpful in confirming the
diagnosis & and excluding pregnancy / particularly in
obese patients
Saline hysterosonography (HSG) can identify
submucous myoma that may be missed on ultrasound
HSG will show intrauterine leiomyoma

()

Magnetic Resonance Imaging (MRI): highly

accurate in delineating the size, location and
numbers of myomas , but not always
necessary
Intravenous Pylegram (IVP) : will show ureteral
dilatation or deviation and urinary anomalies
Hystroscopy : for identification and removal of
submucous myomas

()

COMPLICATIONS
OF FIBROIDS

1-COMPLICATIONS IN PREGNANCY
Less than 2/3 of women with fibroids and
unexplained infertility conceive after
myomectomy
Red degeneration
In the 2nd or 3rd trimester of pregnancy
rapid increase in size leads to vascular
deprivation results in degeneration

Causes pain & tenderness

May initiate preterm labor
Managed conservatively with bedrest &
narcotics and tocolytics if indicated
After the acute phase pregnancy will
continue to term
DURING LABOR
Uterine inertia
Malpresentation
Obstruction of the birth canal
Cervical or isthmeic myoma necessitate CS
Post Partum Hemorrhaging

COMPLICATIONS IN NON PREGNANT

WOMEN
Heavy bleeding with anemia is the most
common
Urinary or bowel obstruction from large
parasitic myoma is much less common
Malignant transformation is rare
Ureteral injury or ligation is a recognized
complication of surgery for Cx myoma
No evidence that COCP increase the size of
myomas

Postmenopausal women on Hormone

Replacement Therapy must be followed up
with pelvic exam or ultra sound every 6
months

()

MEDICAL
MANAGEMENT OF
FIBROIDS

MANAGEMENT DEPENDS ON:

Age
Parity
Pregnancy status
Desire for future pregnancy
General health
Symptoms
Size
Location

(Smeltzer et al., 2010)

EMERGENCY TREATMENT- A
Blood transfusion/ PRBC to correct anemia
Emergrncy surgery indicated for:
- infected myoma
-acute torsion
-intestinal obstruction
Myomectomy is contraindicated during
pregnancy
()

SPECIFIC MEASURES - B
Most cases asymptomatic NEEDS no
treatment
Postmenopausal NEEDS no treatment
Other causes of pelvic mass must be
excluded
The diagnosis must be certain
Initial follow up every 6 months to
determine the rate of growth of the myoma
Surgery is contraindicated in pregnancy
The only indication for myomectomy in
pregnancy is torsion of a pedunculated
fibroid

Myomectomy is not recommended during

Caesarian Section (CS)
Pregnant women with previous multiple
myomectomy / especially if the cavity was
entered should be delivered by CS to
reduce risk of scar rupture in labor

PHARMACOTHERAPY
GNRH AGONISTS (Leuprolide)
Treatment results in:

1- Reduced size of the myomas by a

maximum of 50%
2- This shrinkage is achieved in 3 months
of treatment
3-Amenorrhea & hypoestrogenic sideeffects occur
4-Osteopososis may occur if treatment last
greater 6 months

SUPPORTIVE MEASURES - C
PAP smear & endometrial sampling for all
patients with irregular bleeding
Before surgery
-Correct Hemoglobin levels
-Prophylactic antibiotics
-Mechanical & antibiotic bowel preparation if
difficult surgery is anticipated
Prophylactic heparin postoperative

()

SURGICAL MEASURES - D
1- Evaluation for other neoplasia
2 - Myomectomy
For symptomatic patient who wish to
preserve fertility
Open myomectomy
Laparoscopic myomectomy
Hysteroscopic myomectomy (Smeltzer et al., 2010)
3-Hysterectomy
Vaginal hysterectomy
Abdominal hysterectomy
4 - Uterine artery embolisation (Dutton, Hurst,
Mcpherson et al., 2007)

Nursing management post

hyesterctomy/myomectomy up coming
lecture
41 year old G3P3 AAF presents to clinic
with c/o abdominal bloating, pelvic pain,
and pressure. C/o feeling her uterus
through her abdomen as if she was
pregnant, but she had a BTL 8 yrs ago.
Menses are q28days with heavy bleeding
and large clots, lasting 9 days. Exam
reveals a 14-week irregular shape, mobile
uterus and normal adnexa bilaterally.