Dasgupta’s Recent Advances in Obstetrics and Gynaecology Pratik Tambe, Rohan Palshetkar, Nandita Palshetkar
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table
A
Abortion
complete 127, 128, 129f
incomplete 127, 128, 129f
induced 159
inevitable 127, 128, 128f, 159
missed 127, 129, 130f
spontaneous 127
threatened 127, 127f, 159
Abruptio placenta 146
Acquired immunodeficiency syndrome 65
Acupuncture 113
Adenomyosis 14
Adnexal masses 178, 179
Adnexectomy, laparoscopic 42
Adventitia, denudation of 43
Airway malformations, congenital pulmonary 177
Amenorrhea 131
American Academy of Pediatrics 74
American Association for Surgical Trauma Ureteric Injury Grading Scale 44
American College of Obstetrician and Gynaecologists 74
classification 91
guidelines 107
American Fertility Society 191
American Medical Systems 28
Amniocentesis 159
iatrogenic 156
Amniotic band syndrome 177
Amniotic fluid, spectrophotometric analysis of 165
Amniotomy 113, 115
high 114
low 114
Analgesia, labor 115
Androgen 32
replacement therapy 35
Anemia 157
fetal 166
Anesthesia 25, 149
Aneurysm clips 180
Antibody test, indirect 161
Anti-D immunoglobulin 158
Antiglobulin test, indirect 160
Anti-human globulin 161
Antiphospholipid antibody syndrome 126
Antiprogesterones 113
APGAR scores 116
low 118
Apogee repair 28
Appendicitis 179
Apt test 147
Apt-Downey test 147
Arginine vasopressin, structure of 83f
Arterial catheterization, preoperative 107
Artificial insemination, posthumous 65
Ascites 166
Asherman's syndrome 105, 197
Ashok Anand stitch 150, 151, 152f
Aspirin 130
Assisted reproductive technology 61, 65, 145
regulation Bill, 2014 69
Atosiban 73, 83, 84f, 86
administration of 83
pharmacokinetics of 82
structure of 82, 83f
Atrophy, vulvovaginal 35, 39
Autoimmunity 67
B
Balloon dilators 113
Battledore placenta 145
Bazedoxifene 36
Beta-human chorionic gonadotropin 120, 178
Beta-sympathomimetics 80
Bishop score 113, 117
Bladder
injuries 41, 43
reconstruction 138
Blastomeres, embryonic 137
Blighted ovum 129
Blood
clots 38
count, complete 148
production 155
sampling, fetal 159, 167
transfusion, preparation of 168
Blunt trauma abdomen 159
Boari flap 48, 48f
complications 48
Body mass index 105
Bone loss, prevention of 39
Breast
and nipple stimulation 113
cancer 38
family history of 31
tenderness 35
Bronchodysplasia 73
Buccal oxytocin 113
Burch colposuspension 42, 55f
C
Calcium 30
channel blockers 80
Cancer, colorectal 38
Carcinoma
cervix 99
endometrium 99
ovary 99
Cardiac prosthetic valve, mechanical 180
Cefotetan 187
Cefoxitin 187
Ceftriaxone 187
Centers for Disease Control and Prevention 184
Central Drug Research Institute 188
Central nervous system anomalies 176
Cerebellar anomalies 176
Cerebrovascular liver 36
Cervical
arteries 150f
canal 122
carcinoma 146
fibroid 6, 146
length 78
polyp 146
pregnancy 124
tissue, loss of 78
Cesarean section 5, 145, 149
emergency 42
lower segment 146
previous 105, 114
classical 112
rate 116, 117
scar pregnancy 179f
Chemotherapy 67
Chhaya 188
Chorionic sac 123
Chorionic villus sampling 156
Circle of Willis 165f
Classical classification 142, 143t
Clindamycin 187
Coagulopathy 14
Combined therapy 34
Computed tomography 179
Conjugated equine estrogen 32, 33
Contraception
emergency 188
recent advances in 183
Contraceptive
long-acting reversible 186
patch, transdermal 186
pill, oral 183, 185
Cook double balloon dilators 113
Coombs test, indirect 160, 162, 163
Corpus callosum 176
Cortical development, malformations of 176
Corticosteroid-binding globulin 32
Corticotropin-releasing hormone 76
Cough test 51
Crown-rump length 124
Cryoablation 17
Cryobank 61
Cryopreservation 61, 64fc
techniques of 63
Cryoprotectants 64
Cyclical hormone therapy, prompt initiation of 140
Cystic hygroma 177, 178f
Cysts, bronchogenic 177
Cytosolic phospholipase A2 81
D
da Vinci systems 95
Danazol 8
Danish Osteoporosis Prevention Study 37
Deep breathing exercises 30
Dehydroepiandrosterone 35, 76
sulfate 183
use of 35
Delivery
route of 169
timing of 107, 169
Depot medroxyprogesterone acetate 186
Diabetes 65, 67, 112
Diacylglycerol 81
Diathermy 43
Diethylstilbestrol 191
Diffusion-weighted imaging 173
Dilators, mechanical 116
Dimethyl sulfoxide 64
Dinoprostone 113
gel 117t
group 117
Donor
payment 62
program 67
types of 68
Down syndrome 126
Dropping down theory 144
Drosperinone 34
inhibit 3-beta hydroxysteroid dehydrogenase 183
Dysmorphic uteri technique 197
E
Early pregnancy, bleeding in 126
Ectopic pregnancy 119, 120, 127, 131, 134f, 159, 178
scar-related 122
Edema, pedal 158
Electrocautery 43
Electronic fetal heart rate monitoring 111, 115
Endometrial ablation 16
Endometrial damage 105
Endometrial resection 16, 17
Endometriosis 31, 42, 43
Endometrium, transcervical resection of 17
Epidermal growth factor receptor 105
Epithelial ovarian malignancy 184
Erythroblastosis fetalis 154
Estradiol 33
spray 32
valerate 33
Estrogen 31, 32, 130
plus-progestin 37, 38
summary of 33t
transdermal 32
Ethinyl estradiol 32, 33
Ethylene glycol 64
European Society for Gynaecological Endoscopy 191
European Society of Human Reproduction and Embryology 191
External cephalic version 159
F
Fallopian tube 131, 132
Fecal incontinence 22
Female urinary incontinence diagnosis 51t
Femilift CO2 laser 58
Fertility 5
preservation 67
Fertilization, repetitive 68
Fetal
anemia, noninvasive diagnosis of 164
factors 77
fibronectin 77, 78
head 91
heart 166
hemolytic disease 158fc
indications 112, 175
magnetic resonance imaging, technique of 174
monitoring 115
skull 91
Fetus
delivery of 92, 149
hemolytic disease of 158
Fibroid 4, 19f
ablation 10
intramural 4
mapping of 6
metastatic 4
submucous 4, 105
subserous 4
uterus 3
clinical features 5
diagnosis 5
etiology 3
management of 6, 7fc
Flow cytometry 161
Fluid-attenuated inversion recovery 173
Focal lacunar flow 106
Foley's catheter 113, 197
Follicle-stimulating hormone 183
Freezing techniques, conventional 63t
French College of Gynecologists and Obstetricians 51
Frozen donor egg banking, method of 68
G
Gallbladder disease 31
Genetic disorders 140
Genital
herpes infection, active 112
malignancy, protection against 184
prolapse 22, 23
fertility preserving surgical management of 23
surgical management of 27
tract, lower 93
Genitourinary infections 76
Genitourinary tract anomalies 176
Gentamicin 187
Gestation, multiple 145
Gestational sac 122, 128f, 178
Gestational trophoblastic disease 179
Glycerol 64
Gonadal dysgenesis 67
Gonadotropin 130
releasing hormone 6, 7
analogs 195
H
Headaches 31
Healthy myometrium, absence of 122
Heart disease 37, 112
Heavy menstrual bleeding 16
Hematoma 44, 48
Hematuria 44, 48
Hemolytic disease, neonatal 158fc
Hemorrhage 93
antepartum 112, 142, 159
decidual 77
massive intraoperative 43
perigestational 127f
postpartum 5
severe 197
subchorionic 127
Hemorrhagic fluid 178
Hemostatic suturing techniques 123
Heparin 130
Hepatitis 65, 67
infections 65
Hernia, congenital diaphragmatic 176, 177
High-intensity focused ultrasound 9, 19
Hip fracture 38
Holoprosencephaly 176
Hormonal assay 68
Hormone therapy
combined 35t
contraindications of 31
Human chorionic gonadotropin 130
Human gametes
handling of 70
storage of 70
Human immunodeficiency virus 65
Human sperms, cryopreservation of 61
Hydatidiform mole, gross appearance of 134f
Hydramnios 112
Hyperechoic serosa, disruption of 106
Hyperplasia 14
Hyperstimulation 118
Hypertension 65, 67, 112
Hypertensive disorders 105
Hypoactive sexual desire disorder 35
Hypothalamus-pituitary axis 13
Hysterectomy 11
abdominal 11, 42
cesarean 42
laparoscopic 42
obstetric 151
subtotal 42
Hysterosalpingography 191, 192, 193f
Hysteroscopic scissors 196
Hysteroscopy 193, 195f
ambulatory 14
second-look 198
I
Icterus gravis neonatorum 157
Immunoprophylaxis 158
Implanon 186
Implantation bleeding 127, 131
In vitro fertilization 68, 105, 112, 126
Incision 149
Indian Council of Medical Research 69
Infections 76, 78
congenital 176
Injury
extent of 46
grade of 44t
isolation of 46
laparoscopic 43
mechanisms of 43
sites of 43t
types of 41, 45
Inositol 1,4,5-triphosphate 81
Insulin pump 180
International Continence Society 50
International Federation of Gynaecology and Obstetrics 13
classification 4, 4f
Intraperitoneal transfusion 167
Intrauterine
adhesions 145
contraceptive
device 197
disease 131
device 6, 7, 187
recent modification of 187
fetal
death 112, 114, 177
therapy 140
growth restriction 112, 146
insemination 65
transfusion 167
Intravascular transfusion 167, 168f
Intrinsic sphincter deficiency 50
Ischemia 43
Isoimmunization 154
pathophysiology of 158fc
J
Jadelle 186
Joshi sling 25
K
Khanna's sling 24, 25
Kidney disease 36
Kleihauer-Betke test 161
Kronos early estrogen prevention study 37
L
Labor
induction of 111, 112, 112b, 113, 114, 116
method of induction of 113
planning induction of 113
third stage of 150
Laceration 44
Lamicel 113
Laminaria tents 113
Laparoscopy 11
Laparotomy 11, 134f
Laser 43
ablation, transcervical resection of 17
Leiomyoma 3, 14
Lethal fetal malformation 112
Letrozole 8
Levofloxacin 187
Levonorgestrel-releasing intrauterine device 8
system 7, 15, 16f, 34
Ligatures 43
Liley's chart 166
Limb abnormalities 184
Live pregnancy, ultrasonography suggestive of 127f
Loop electrosurgical excision procedure 78
Lower uterine segment, vascular supply of 144f
Luteal phase defect 126, 127, 130
M
Magnesium sulphate 80
Magnetic resonance imaging 6, 106, 107, 122, 172, 173, 175, 193
basics of 172
Malaria 77
Malignancy 14
gynaecological 99t
Malignant gynaecological surgeries 98
Maternal hypothalamus-pituitary-adrenal axis 76
Matrix metalloproteinases 80
Mayer-Rokitansky-Küster-Hauser syndrome 139
McIndoe vaginoplasty 139
Medroxyprogesterone acetate 33
Membranes
premature rupture of 79, 112
stripping of 113, 114
Menopause 30
genitourinary syndrome of 39
hormone therapy 30
indications of 31
premature 67, 140
Methotrexate 121, 122, 133
Metroplasty, hysteroscopic
lateral 196f, 197f
outpatient 197, 199
Micronized estradiol 32
Microscopic Du test 161
Microwave endometrial ablation 17
Middle cerebral artery 163, 164, 165f
peak systolic velocity 165f
Midurethral tape 54
Mifepristone 9, 113, 117
Migraine 31
Minimally invasive surgery 95
Misoprostol 113, 115, 117, 117t
oral 118
Missed pill 185
management of 185
Mitogen-activated protein kinase 81
Molar pregnancy 127, 133, 134
Monoclonal antibodies 160t
Multicystic dysplastic kidney 176, 177f
Myomectomy 10, 11, 145
hysteroscopic 11
previous 105
Myosin light-chain 81
N
National Institute for Health and Care Excellence 121
Natural killer cells 80
Necrotic tissue, debridement of 45
Nestorone 183
Nitric oxide donors 80, 113
Nomegestrol acetate 183
Nonpeptide antagonist 82
Nonsteroidal anti-inflammatory drugs 6, 7
Norethisterone 34
acetate 33
North American Menopause Society 39
Nurses’ Health Study 184
O
Office hysteroscope 195
Ofloxacin 187
Oligohydramnios 112
Omentum 46
Onapristone 113
Oocytes
banking 61, 66
congenital absence of 67
cryopreservation 67
benefits of 68
methods of 68
donor 67
evaluation of 68
sourcing of 67
Oophorectomy 67
Oral contraceptive pill, combined 184
Oral Contraceptives-Safety of Estrogens in Lupus Erythematosus National Assessment Study 185
Oral misoprostol, use of 118t
Organ system, immature 73
Ormeloxifene 188
Ospemifene 36
Ovarian
cyst, functional 188
insufficiency, premature 140
pregnancy 124
Ovulation induction 130
Oxford Family Planning Association 184
Oxytocin 80, 81, 170
antagonists 80
induction 117
infusion 113, 115, 117t
receptor 80, 81
antagonist 82
linked signaling pathways 81f
structure of 83f
P
Pain 131
abdominal 122, 131
flashing 119
shoulder tip 119
PALM-COEIN classification 13, 14f, 15f
Parturition, mechanism of 79
Peak systolic velocity 163, 164
Pelvic
adhesions 43
anatomy, distorted 43
artery embolization 108f
contraction, gross degree of 112
floor disorders 22, 23
prevalence of 22
floor muscles 23
assessment of 52
training 53
floor relaxation 93
infection 187
inflammatory disease 42, 43, 121
mass 132
organ prolapse 22, 98, 138
pathogenesis of 23
pain 131
tumor 112
Peptide
antagonist 82
oxytocin receptor antagonists 82
Percutaneous epididymal sperm aspiration 63
Perigee repair 28
Peritoneum 46
Phosphatidylinositol 4,5-bisphosphate 81
Phospholipase 81
Phytoestrogens 30
food-containing 30
Placenta
accreta 104, 105f, 178, 197
incidence of 104
ultrasonography features of 106f
increta 105
large 145
low lying 143
percreta 105
previa 105, 142, 144f, 146, 146t, 148, 179f
central 143
major 143
marginal 143
minor 143
partial 143
posterior 112
previous 145
Placental
abnormalities 145
abruption 146, 146t
barrier 156
factors 77
growth factor 105
insufficiency, severe degrees of 112
lacunae, abnormal 106
migration 144
tissue penetrating uterine wall 109f
vasculature, color flow Doppler of 146
Placentomegaly leads 158
Plasmapheresis 168
Plus doxycycline 187
Polyclonal antibodies 160t
Polyethylene glycol 161
Polyp 14
Polyvinyl alcohol 10
polymer 115
Postvoid residual urine volume 52
Pouch of Douglas 25
Prednisolone 130
Pregnancy 5, 131
abdominal 124
anembryonic 129
failure 68
interstitial 123
Preterm birth 74
Preterm labor 73, 79fc, 83
management of 80
prediction of 77
Preterm premature rupture of membrane 17, 77
Processing sperm 63
Profuse uteroplacental neovascularization 105
Progesterone 8, 3133, 36, 130
natural 34
newer 34
only pill 184
oral 8
serum 130
side effects of 34
Progestins 183
Progestogens, summary of 34t
Prolapse, assessment of 52
Prolift repair 28
Prophylactic forceps 90
delivery 92
Prostaglandin E2 gel
efficacy of 117
endocervical 114
Prostaglandin synthase inhibitors 80
Prosthetic mesh 28
Protein kinases type C 81
Proton density 173
Psoas hitch 47f, 48
Puberty 13
Purandare's cervicopexy 23, 25
Purse-string technique 123
Q
Queenan's chart 166
R
Radiation therapy 67
Radical hysterectomy, open 99
Radiofrequency ablation 17
Raloxifene 36
Randomized controlled trials 57, 121, 184
Rectovaginal fistula 93
Red blood cell 154
Renal autotransplantation 48
Respiratory distress syndrome 73
Reticulum, sarcoplasmic 81f
Retroplacental sonolucent zone, loss of 106
Retropubic suspension procedures 54
Rhesus
antibody titer tests 161
blood group system 155
factor 154
isoimmunization 154
negative
first sensitized pregnancy, management of 163
immunized pregnancy 164fc
isoimmunized pregnancy, management of 163
unimmunized pregnancy 162, 162fc
Rhoa associated protein kinase 81
Robot, learning curve of 100
Robotic
application 96
approach, role of 97t
assisted approach, role of 99t
endoscope holder 100
radical hysterectomy 99
surgery 20
technology, overview 96
training 101
tubal anastomosis 98
Rose trial 140
Rosetting test 161
Royal College of Obstetricians and Gynaecologists 80
Guidelines 91, 107
Rudimentary horn ectopic pregnancy 123
S
Sacral promontory 26f
Sacrocolpopexy, abdominal 28, 98
Sacrospinous fixation 28
Saheli 188
Saline, extra-amniotic instillation of 113
Salpingostomy 133
Salpingotomy 133
Scalp 91
Scar ectopic pregnancy 122
Selective estrogen receptor modulators 68, 30, 36
Selective progesterone receptor modulator 8, 188
Semen
analysis 66
bank 61, 65
set up 61
collection 62
cryopreservation 63
samples 66
Sepsis 93
Sexually transmitted diseases 65, 67
Shirodkar's sling 25
operation 23
Shock 119
Skin edema 166
Sling operations 24, 27
conservative 22, 28
Snow storm appearance 134
Society of European Robotic Gynaecological Surgery 101
Soft tissue trauma 93
Sonawalla's sling 24, 25
Sperm
bank 61
establishment of 61
cryopreservation 63, 64
donor 61, 62
recipient's selection of 62
recruitment of 61
integrity 64fc
Standard operating procedures 65
Steady state free precession 173
Stem cell
embryonic 136
engraftment 137
hematopoietic 137
therapy 136
types of 137
Stent, placement of 48
Stress urinary incontinence 23, 50, 54, 59f, 138
classification of 53
CO2 laser for 59f
evaluation of 50, 54fc
laser treatment of 58
urodynamic studies tracing of 53f
Stroke 38
Surgery
conventional approach of 54
gynaecological 96
procedure of 194
timing of 195
Surgical repair, complications after 48t
Syncope 119
Systemic lupus erythematosus 77, 112, 185
T
Tension-free transvaginal tape 55
placement 56f
Tension-free vaginal tape 28
obturator 28
Testicular sperm extraction 63
Testosterone 35
Thalassemia 65
Thawing
techniques 64
types of 64fc
Thermal
balloon ablation 17
injuries 43
Thin myometrial layer around sac 123
Thoracic anomalies 176
Thrombophlebitis, superficial 31
Thrombosis 77
Thyroxine-binding globulin 32
Tibolone 32, 36
Tissue layers, embryonic 137
Tracheoesophageal fistula 184
Traditional laparoscopic radical hysterectomy 99
Transobturator
tape 28, 55
placement 56f
vaginal tape 56, 57f
Transureteroureterostomy 46f, 48
Transvaginal sonography 6, 122, 129f, 198
classification of 142, 143t
Transvaginal ultrasound 68, 146
three-dimensional 146, 192
Trauma 26
iatrogenic 48
Trisomy 21 126
Truly elective forceps delivery 92
T-shaped uterus 191
classification 192f
hysterosalpingography appearance of 193f
three-dimensional ultrasound measurements of 194f
Tubal ectopic pregnancies 121
Tumors, gynaecological 139
Turbo inversion recovery magnitude 173
Turner's syndrome 67
Twin pregnancies 177
Twin reversed arterial perfusion sequence syndrome 177
U
Ulipristal acetate 7, 8, 188
Ultrasound
four-dimensional 146
three-dimensional 192
two-dimensional 192
Ureter
anatomical course of 42
mobilizing 46
Ureteric
ends, spatulation of 45
injury 41, 45t
incidence of 42t
prevention of 44, 44b
risk of 42t
surgical repair of 45
obstruction 48
reflux 48
resection 48
Ureterocalycostomy 47f, 48
Ureterocystostomy 48
Ureteroneocystostomy 47f, 48
Ureteroureterostomy 46f
technique of 46
Urethral
mobility 51
valves, posterior 176
Urinary bladder, invading 106
Urinary incontinence 22
diagnosis score, questionnaire for 50
mixed 58
Urinary stress 58
Urinary tract infection 48, 52, 97
Urine analysis 52
Urological injuries 41
Uterine
abnormality, congenital 145
anomalies, congenital 191
artery
angiography of 144f
occlusion 10
contralateral 18fc
embolization 7, 9, 17, 19f, 123
bilateral 150f
bleeding, abnormal 13, 20
bulging 107
cavity 122, 123
changes 132
contractility 83, 84f
degenerated 146
electrical myography 83
fibroid 3, 12, 31
management 6, 7f
incision 149, 152f
isthmus, anterior part of 122
overdistension 77
polyp 146
scar, previous 145
segment, lower 144, 152f
Uterosacral ligament 43
Uterus
arcuate 199
enlarged 43
subinvolution of 5
V
Vaginal bleeding 122, 131
Vaginal delivery 117
success of 118
Vaginal hysterectomy 42
laparoscopic assisted 42, 43
Vaginal misoprostol 118
use of 118t
Vaginal paravaginal repair 28
Vaginal preparation 32
Vaginal reconstruction 139
Vaginal ring 185
Vaginal sonography 132
Vaginosis, bacterial 76
Vasa previa 146
Vascular endothelial growth factor 105
Venereal disease research laboratory test 68
Vesicovaginal fistula 93
Virkud's classification sling operations 24, 25t
Virkud's composite sling 24, 25
operation 24f, 25
Vitamin
A 30
B 30
C 30
D 30
E 30
Vitrification 68
W
Walnut Creek Cohort Studies 184
Wertheim hysterectomy 42
Wound infections 48
X
X-linked diseases 68
Z
Zygotes 126
×
Chapter Notes

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1Gynaecology
  • ❖ Fibroid Uterus
  • ❖ Modern Modalities in the Management of Abnormal Uterine Bleeding
  • ❖ Conservative Sling Operations for Pelvic Organ Prolapse
  • ❖ Menopause Hormone Therapy
  • ❖ Ureteric Injuries
  • ❖ Stress Urinary Incontinence
  • ❖ Semen and Oocyte Banking2

Fibroid UterusCHAPTER 1

Sujata Dalvi,
Ameya Purandare
 
INTRODUCTION
Uterine fibroids also known as “leiomyomas” are the most common benign smooth muscle tumors of genital tract. Many women with fibroids are asymptomatic and do not require any clinical intervention. Around 25% of women during reproductive life and over 40% women above the age of 50 years are affected by these tumors.1
 
ETIOLOGY
 
Pathogenesis
The exact cause is unknown. However, it runs in families and has genetic predisposition. It appears to be partly determined by hormonal levels. Current working hypothesis is genetic, prenatal hormone exposure, and effect of hormone—growth factors, xenoestrogens. Risk factors are obesity, diabetes, polycystic ovaries, hypertension, and nulliparity. First degree relatives have 2.5-fold increase and 6-fold increased risk of early onset.1 Fibroids are dependent on estrogen and progesterone to grow and hence are relevant only during reproductive years.
 
Pathophysiology
They are composed of the same smooth muscle fibers as uterine wall but are much denser. They grossly appear round, well circumscribed, may not be encapsulated, and solid nodules usually white with whorled appearance on histological examination. The size varies from small to very large.4
 
Location/Classification
The symptoms and its effects depend upon the site and size of fibroid. Small fibroid may be symptomatic, if located within cavity whereas large one may go unnoticed, if located on outside of uterus.
Subserous fibroids are located on surface of uterus. They grow outward and can be pedunculated or sessile. Occasionally pedunculated can get detached and become parasitic fibroids.
Intramural fibroids are located within myometrium and the most common type. Mostly asymptomatic, unless large or extend into uterine cavity.
Submucous fibroids are located within muscle just below endometrium and distort endometrial cavity. Even small one may lead to menorrhagia and infertility. Few may have pedicle attached to endometrium and are known as pedunculated fibroid.
Fibroids may be found in cervix, broad ligament, round ligament or uterosacral ligaments. Cervical fibroids can be pedunculated or sessile. Broad ligament fibroids can be true or false. False are the ones that arise from isthmus of uterus and grow toward broad ligament. Here, the ureter is displaced laterally and outwards.
International Federation of Gynaecology & Obstetrics (FIGO) classification is most commonly used because it offers broad fibroid distribution map. It also employs location of fibroid in relation to endometrium and serosal surface (Fig. 1).
Fibroids may be single or multiple. Secondary changes may develop within fibroids like hemorrhage, necrosis, calcification or cystic. During pregnancy, red degenerative changes may occur. They tend to shrink in size after menopause, but postmenopause hormone therapy may cause symptoms to persist. Less than 1% of uterine fibroids can cause cancer known as leiomyosarcoma.2
Metastatic fibroids are the fibroids of uterine origin that are found in extrauterine location and are also known as “parasitic fibroids”.
zoom view
Fig. 1: FIGO Classification.
5Though rare but are found with increasing frequency following laparoscopic myomectomy or hysterectomy where morcellation has been used. The sites may be omental, peritoneal surface, lymph nodes, vessels, and rarely lung and heart.
 
CLINICAL FEATURES
Some women with fibroids are asymptomatic. It could be an incidental finding on clinical examination.
There is dull abdominal pain with feeling of heaviness in lower abdomen with low backache. This pain may increase during menstruation. Women will large fibroids may complain of distention with discomfort in lower abdomen. Subserous pedunculated may undergo torsion and patients may present with symptoms of acute abdomen. Occasionally, degenerating fibroid can cause severe localized pain. Rapidly growing fibroid can be suspicious of malignancy. In case of submucous polypoid fibroid, pain is dull, dragging or spasmodic and continuous with feeling of mass coming out per vaginum.
Menorrhagia and dysmenorrhea are commonly found in women with submucous fibroid. However, intramural fibroids with endometrial hyperplasia may complain of heavy menstrual flow. Some may complain of easy fatigability, weakness, and lethargy due to anemia following heavy menstrual flow.
  • Fertility: Majority with uterine fibroid have normal pregnancy outcome.2 Submucous fibroid may interfere with functioning of uterine lining and implantation of embryo which could be the cause of infertility. However, in 3% of women with fibroids, infertility may be related to fibroids and that may need treatment.
  • Pregnancy: During pregnancy, fibroid may be the cause for miscarriage, threatened abortion, preterm labor, abnormal fetal lie-position, incoordinate uterine contraction, placental abruption, difficulty in Cesarean section, postpartum hemorrhage, and subinvolution of uterus.
  • Co-existing disorders: Depending on size and location, fibroids can have pressure effects on urinary tract leading to urinary retention or hydronephrosis and gastrointestinal tract leading to constipation and bloating sensation. It may be present with endometriosis or adenomyosis.
  • Examination: On abdominal examination, fibroids more than 12 weeks in size will be palpable in lower abdomen arising from pelvis, firm, may be mobile, smooth or with irregular bosselated feel. Cervical fibroid/polyp is usually diagnosed on speculum examination. During pelvic examination, fibroids will be palpable as firm, round mass on surface of the uterus with no palpable adnexal structures. At times, uterine fibroids need to be differentiated from ovarian mass. For this, one needs to push the mass and feel for its impulse on cervix and vice versa. In case of fibroid, impulse is felt but not in ovarian tumor.
 
DIAGNOSIS
Imaging modalities especially ultrasound has been the gold standard to evaluate uterine fibroids.2 Ultrasonography (USG) depicts fibroids as focal 6masses with heterogenous texture usually causing shadowing of USG beam. The exact location, dimension, number, distance from uterine cavity, indentation in endometrial cavity—called “mapping of fibroids” can be done on USG. Cervical fibroids are better diagnosed on transvaginal sonography (TVS). Three-dimensional (3D) USG is useful for accurate diagnosis of location and any degenerative changes in fibroid.
The incidence of sarcoma in fibroids is rare.2 Imaging modalities like USG, magnetic resonance imaging (MRI) cannot clearly distinguish benign leiomyoma from malignant leiomyosarcoma.3 Fast or unexpected growth especially after menopause can arouse suspicion of sarcoma. With advanced malignant lesion, there may be an evidence of local invasion that is diagnosed on MRI.
Submucous fibroid can also be diagnosed on hysterosalpingogram or sonohysterography.
 
MANAGEMENT (FLOWCHART 1)
Most fibroids do not need any treatment unless symptomatic. After menopause, they regress in size due to sex hormonal depletion, thus causing “spontaneous cure” with few exceptions. The malignant potential of fibroids is less than 1% and thus the main aim of treatment is to provide relief of symptoms and improve quality of life. The treatment should be efficient with minimum risk and noninvasive and nonaggressive.
 
Options for Uterine Fibroid Management (Fig. 2 and Table 1)
 
Symptomatic Relief
Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to relieve pain.
Tranexamic acid is procoagulant and hence reduces blood loss during menstruation. It is helpful in women with uterine fibroids with moderate to heavy flow. It is prescribed only at times of heavy flow and is usually well-tolerated with few side effects.
Medical therapy: Uterine fibroids being tumor of hyperestrogenic environment, medical therapy that lowers estrogenic levels are effective. Gonadotropin-releasing hormone (GnRH) agonists and antagonists, danazol, cabergoline, aromatase inhibitors like letrozole, selective estrogen receptor modulators (SERMs) (modify estrogen response), progesterone, levonorgestrel-releasing intrauterine device (LNG-IUD) and selective progesterone receptor modulators (SPRMs) are effective in relieving symptoms and reducing size of fibroids.
  • GnRH agonists: Reduce size of fibroids by 50% in 3 months. Reference dose—3.75 mg intramuscular injection once a month for 3 months. It causes hypoestrogenism leading to hot flushes, vaginal dryness, and bone loss. Stoppage of treatment causes regrowth of fibroid and recurrence of symptoms. Long-term treatment (6 to 12 months) involves high cost and significant side effect of bone loss. Add back therapy using tibolone helps in reducing side effects. However, they are useful in reducing perioperative blood loss when given for short periods pre-myomectomy.7
zoom view
Flowchart 1: Management of fibroid uterus.
(LNG-IUS: levonorgestrel-releasing intrauterine system; NSAIDs: nonsteroidal anti-inflammatory drugs; UF: uterine fibroid; UPA: ulipristal acetate; UAE: uterine artery embolization)
zoom view
Fig. 2: Options for uterine fibroid management.
(IUD: intrauterine device; NSAIDs; nonsteroidal anti-inflammatory drugs; GnRH: gonadotropin releasing hormone; SERMs: selective estrogen receptor modulators; UAE; uterine artery embolization)
8
Table 1   Summary of recommended treatment options for uterine fibroids.
Patient characteristics
Treatment options
Asymptomatic women
Clinical surveillance
Infertile women with distorted uterine cavity (i.e. submucosal fibroids) who desire future fertility
Myomectomy
Symptomatic women who desire future fertility
Medical treatment or myomectomy
Symptomatic women who do not desire future fertility but with to preserve the uterus
Medical treatment myomectomy, uterine artery embolization, magnetic resonance-guided focused ultrasound surgery
Symptomatic women who want definitive treatment and do not desire future fertility
Hysterectomy by least invasive approach possible
  • Danazol: It is an androgenic steroid, helps in relieving fibroid related symptoms by reducing volume by 18–23%.1 It can be used only for short period due to androgenic side effects and liver dysfunction.
  • Cabergoline reduces aromatase activity.
  • Letrozole: It is as effective as GnRH agonists in reducing volume of fibroid with lesser side effects of hot flushes.
  • Selective estrogen receptor modulators: Like tamoxifen or raloxifene are useful with modest overall benefits.
  • Oral progesterone is useful in reducing menstrual blood flow. Preparations like lynestrenol or pregnane induce small reduction in size of fibroid and hence not very useful.
  • Levonorgestrel-releasing intrauterine device: LNG-IUD helps in reducing increased menstrual bleeding and restoring hemoglobin level. It is useful if fibroids are small and there is minimal distortion of endometrial cavity.
  • Selective progesterone receptor modulators:4 Progesterone response is mediated through progesterone receptors (PR) present in the uterus. Activation of progesterone responsive genes has been linked with enhanced proliferation of fibroid cells. SPRMs exhibiting mixed agonist and antagonist activity offer new approach to medical therapy. SPRM class members include mifepristone and ulipristal acetate (UPA). SPRMs exert antiproliferative and proapoptotic effect on leiomyoma cells that explains mechanism by which fibroid volume is reduced. SPRMs are also associated with morphological changes in the endometrium like cystic glands and stromal and vascular changes recognized and termed as progesterone receptor modulator associated endometrial changes (PAEC). These changes are not related to cancer or precancerous but are benign and reversible. These induce amenorrhea and have fewer side effects especially low rate of hot flushes compared to GnRH agonists. In most women, menstruation resumes within 1 month of stopping therapy.9
The use of SPRMs facilitates surgery, allows modification of surgical approach (reduction in fibroid volume), restores hemoglobin level, and at times allows surgery to be postponed. The reduction in fibroid volume has been around 30%.
  • Dose: UPA—oral 5 mg, once a day for 3 months.
    • Long-term treatment:5 It can be given in 4 cycles of 3 months each. Patient should be re-evaluated after every cycle, considering various options. Combination of another treatment option like LNG IUD can be considered after UPA therapy. In case of relapse of symptoms, more treatment options are given. After therapy, USG is recommended and later annually.
    • Side effects include headache, nausea, abdominal pain, and occasional hot flushes. Although it suppresses ovulation, non-hormonal contraceptives are recommended. It is contraindicated in pregnancy and lactation. After therapy, if endometrial thickness persists, then endometrial biopsy is recommended to exclude malignancy. Some women may develop ovarian cysts.
  • Mifepristone (RU 486)6 is an antiprogestin drug that can shrink fibroid to an extent comparable to GnRH analogs. But this treatment can be associated with hyperplasia of endometrium.
    • Dose: 10/25 mg tablets—once a day for 3 months.
 
Nonsurgical Treatment
With evolution of minimally invasive surgical and nonsurgical techniques and changing attitude toward uterine preservation, popularity of conservative treatment options has escalated. Uterine artery embolization (UAE) is minimally invasive angiographic procedure that is increasingly being used as an alternative to surgery for symptomatic fibroids. Other conservative procedures include MRI-guided percutaneous laser ablation, interstitial laser photocoagulation, and high intensity focused ultrasound (HIFU) energy.
  • Uterine artery embolization: Uterine artery embolization7 has been used successfully for management of acute pelvic hemorrhage. Its use for symptomatic fibroids was first reported in France by Ravina et al. in 1995. Since then it has been used in select patients. It has shown to decrease leiomyoma by 35–70%. Women with symptomatic fibroids in absence of adnexal pathology are suitable candidates. Exclusion of women with adenomyosis is necessary as it responds less well. Subserous pedunculated fibroids also need to be excluded as there is risk of ischemic necrosis and potential for fibroid to become free in peritoneal cavity causing irritation, infection, and bowel adhesions. Other contraindications are suspected pelvic infections, immunocompromised, contrast allergy, pervious pelvic irradiation or coagulopathies. It is useful in women who are not ideal candidates for surgery like morbidly obese, diabetic or with medical problems. It is usually not offered to patients who desire future fertility as effects of embolization on reproductive potential have not been established. The incidence of fibroid recurrence after UAE is unknown.10
  • Pre-procedure: Complete evaluation including uterine imaging, cervical cytology, and endometrial biopsy where necessary should be done. Complete blood count, coagulation and hormonal profile about ovarian reserve need to be done. Imaging with color Doppler is needed to assess viability of fibroid as calcified and degenerative fibroids respond poorly to embolization. Few interventional radiologists prefer contrast-enhanced MRI preprocedure, if feasible.
    Procedure is carried out under anesthesia, where internal iliac followed by uterine arteries are catheterized. Once catheter placement is confirmed and vascular supply to fibroid and uterus is demonstrated, multiple small particulate emboli in the form of polyvinyl alcohol (PVA) particles are injected into circulation. The aim is to occlude both uterine arteries selectively, resulting in fibroid devascularization and subsequent shrinkage. Owing to rich collateral circulation, normal myometrial tissue revascularizes. The procedure is considered complete if arterial blushing is achieved rather than stasis. This improved precision allows targeted fibroid embolization with concurrent reduced unnecessary devascularization of myometrium and ovarian vessels. Individual procedure takes about 45–50 minutes and every effort should be made to minimize total fluoroscopy time and number of image sequence to reduce radiation penalty to ovaries.
  • Postprocedure: Patient complains of abdominal pain, nausea, and vomiting. NSAIDs, anti-emetics, and anti-inflammatory are given to relieve symptoms. Post-embolization uterine imaging needs to be done within 6 months and if possible with contrast-enhanced MRI. Complications like bleeding from puncture site, infection, misembolization, post-embolization syndrome (general malaise, low grade fever, pelvic pain, nausea, vomiting), persistent vaginal discharge, transcervical fibroid expulsion, and occasionally transient amenorrhea can occur.
Uterine artery occlusion (UAO) is currently under investigation as an alternative to UAE. It involves clamping of uterine arteries as opposed to injecting polyvinyl alcohol beads. (Ref)
Fibroid ablation: The term “ablation” means tissue destruction with concentrated energy. It is also known as myolisis.1 It uses different sources of energy like ultrasound, radiofrequency (RF) or laser. USG or MRI selects points where energy must be guided and USG-guided puncture with RF or high frequency magnetic resonance guided focused ultrasound surgery (MRgFUS). MRgFUS uses precisely focused and high power acoustic beam. It being noninvasive, nonsurgical does not remove the tissue but try to destroy targeted tissue, thereby decreasing heavy menstrual flow and reducing fibroid size. However, fertility issue may be compromised and may need surgical intervention and hence not much carried out.
 
Surgical Therapy
  • Myomectomy: Selective removal of fibroid and anatomical reconstruction of uterus has been carried out for women who want to retain the uterus. 11Depending upon the number, size and location of fibroid the optimal surgical approach can be chosen.
  • Abdominal myomectomy—laparoscopy or laparotomy: Depending upon skill of surgeon and size of fibroids, myomectomy can be done through both methods. Preoperatively, it is essential to carry out latest mapping of fibroid on USG so that precise incision can be taken and to know the possibility of inadvertent opening of endometrial cavity depending upon its distance from the cavity. Before taking incision on myoma, injection vasopressin diluted (1 amp = 20 units in 100 cc of normal saline) should be injected (if not contraindicated) at the base of fibroid till blanching effect is seen. This reduces the blood loss and keeps the operative field clear. After enucleation of fibroid and hemostasis, the fibroid bed should be sutured to obliterate the dead space. In case, the endometrial cavity is opened, it is sutured first and then myometrium with serosa. Delayed absorbable suture materials like polyglactin, PDS or barbed sutures are used. Adhesions preventing barriers like Seprafilm or Interceed are used. In case of laparoscopic myomectomy, myomas should be removed with morcellators within bag to prevent spillage of fibroid fragments in peritoneal cavity. Occasionally incision can be extended to remove myomas to avoid morcellation. Fertility treatment if necessary is advisable after 3–6 months after the procedure. It is advisable for patients to have an elective caesarian section after myomectomy.
  • Myomectomy at C section: Fibroids situated over LUS or around the isthmus are likely to come in way of taking uterine incision and create difficulty in delivering fetus. In such cases, it is advisable to enucleate fibroid first, achieve as much of hemostasis as possible, deliver the fetus and then suture uterine incision and fibroid bed. Pedunculated fibroid can also be removed at the time of C section.
  • Hysteroscopic myomectomy: It is preferred in case of submucous fibroid less than 5 cm. In case of submucous fibroid of greater than 5 cm, it is advisable to do laparoscopic myomectomy. It can be done with resectoscope using monopolar electrocautery with glycine as distention medium. The only side effect being fluid overload due to absorption. With the availability of bipolar resectoscope, normal saline can be used as distention medium, thereby reducing side effect of fluid overload. In case of pedunculated fibroid, the pedicle should be cut so that the whole fibroid can be removed. In case of sessile submucous fibroid, try and remove as much of fibroid as possible till its surface flushes with rest of myometrium.
Recurrence of fibroid may occur if small seedling fibroids are left behind following any conservative procedures and may cause symptoms.
Hysterectomy: This option is radical and definitive treatment for uterine fibroids particularly for women who does not wish to conceive and/or are above age of 40 years. Depending upon size and location of fibroid, total hysterectomy can be done via vaginal or abdominal route. Vaginal route is least invasive with faster recovery. Abdominal route can be laparoscopic or open, depending upon size of fibroid and surgical expertise.12
 
CONCLUSION
  • Uterine fibroids are benign smooth muscle tumors of uterus.
  • The exact cause is unclear however it runs in families and is hormone-dependent.
  • They vary in number, size, and location.
  • Depending upon site and size, symptoms vary from asymptomatic to pain and heavy menstrual flow, during reproductive years.
  • Occasionally, it may interfere with fertility and very rarely it can become malignant.
  • Treatment varies from no treatment in asymptomatic fibroid to medical therapy and noninvasive to minimally invasive to open surgical therapy.
REFERENCES
  1. Wikipedia. Uterine fibroid. [online] Available from https://en.wikipedia.org/wiki/Uterine_fibroid [Accessed December 2018].
  1. Mayo Clinic. Uterine fibroids: Symptoms and causes. [online] Available from https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/…/syc-20354288 [Accessed December 2018].
  1. MedicineNet.com. Stöppler MC, Shiel WC (Ed). Uterine fibroids (Benign Tumors of the Uterus). [online] Available from https://www.medicinenet.com/uterine_fibroids/article.htm [Accessed December 2018].
  1. Safrai M, Chill HH, Reuveni Salzman A, et al. Selective progesterone receptor modulators for the treatment of uterine leiomyomas: Obstet Gynecol. 2017;130(2): 315–8.
  1. Pourcelot AG, Capmas P, Fernandez H. Place of ulipristal acetate in management of uterine fibroid, preoperative treatment or sequential treatment? J Gynecol Obstet Hum Reprod. 2017;46(3):249–54.
  1. Kulshrestha V, Kriplani A, Agarwal N, et al. Low dose mifepristone in medical management of uterine leiomyoma – an experience from tertiary care hospital from North India. Indian J Med Res. 2013;137(6):1154–62.
  1. Khaund A, Lumsden A. Fibroid Embolization: Progress in Obstetrics & Gynecolgy. John Studd. 2007;17:333–42.