CASE PRESENTATION- FIBROID
UTERUS
• Mrs. A
• 45years
• Educated – 10th standard
• Home maker
• Married to Mr. A, factory worker
• SES- class 2 (according to modified BG Prasad's
classification)
• Date of admission- 5/3/2024
• Examined on- 6/3/2024
• Presenting complaints- heavy menstrual bleeding
since 6months
• History of presenting illness-
Apparently normal 6months back, after which she
developed heavy menstrual bleeding
Regular cycles of 28-30days, bleeds for 7-8days
Using 5-6pads/day, completely soaked
Associated with passage of clots of size more than 1 rupee
coin.
• History of easy fatigability present, but able to do
normal activities
• No h/o intermenstrual bleeding
• No h/o dysmenorrhea
• No h/o abdominal pain/ distension
• No complaints of increased frequency of micturition
and constipation.
• No history of weight loss, decreased appetite
MENSTRUAL HISTORY
• Age of menarche- 12years
• Previous cycles- 28-30days, 2-3days of normal flow,
using 1-2 pads /day, no history of passage of clots/
dysmenorrhea.
• Present cycles (Since 6months)- regular, 28-30days,
heavy flow for 7-8days, using 5-6pads/day,
completely soaked associated with passage of clots,
no dysmenorrhea
• LMP- 13/2/2024
OBSTETRIC HISTORY-
• Married for 26years, non consanguineous marriage
• Obstetric score- P2L2, both Full term normal vaginal
deliveries at hospital.
• Last child birth- 23years ago
• Laparoscopic sterilization done 23years back
PAST HISTORY-
• Not a known case of Diabetes mellitus,
Hypertension, Tuberculosis, Asthma, epilepsy,
thyroid or cardiac disorders .
• No h/o blood transfusions
FAMILY HISTORY-
• No history of similar complaints in mother and
sister.
PERSONAL HISTORY-
• Mixed diet
• Sleep and appetite normal
• No bowel or bladder irregularities
• No substance abuse
EXAMINATION
GENERAL EXAMINATION-
• Conscious, oriented and cooperative
• Height- 160cm ; Weight- 56kg ; BMI- 21.87kg/m2
• Pallor- present(+)
• Icterus , cyanosis, clubbing, lymphadenopathy ,
edema- absent
• PR- 88bpm
• BP- 120/80mmhg
• Thyroid, breast and spine- normal
SYSTEMIC EXAMINTAION
CNS- higher mental function normal, no neurological
deficit
CVS- S1 S2+, no murmurs
Respiratory system- NVBS +, no added sounds
PER ABDOMEN EXAMINATION
Inspection:
- Umbilicus is central and inverted
- Lower abdominal fullness present
- Infraumbilical transverse scar of 2cm is present at a
distance of 1cm from the umbilicus, healed by
primary intention suggestive of laparoscopic
sterilization scar.
- All quadrants move equally with respiration
- Hernial orifices intact
- No engorged veins.
Palpation:
- Solitary mass corresponding to 16 weeks gravid
uterus present
- Borders : Upper and lateral borders was well
appreciated and lower border could not be
appreciated.
- Surface : irregular
- Firm in consistency
- Non tender
- Horizontal mobility present.
Percussion:
- Dullness present at infraumbilical quadrant and
resonant in rest of the quadrants
- No shifting dullness
Auscultation:
- Bowel sounds present
Gynecological examination
Local examination:
- External genitalia normal
- No mass per vagina
Per speculum:
- Cervix :Pointing downwards and forwards and deviated
to left side.
-External os : Transverse slit was noted.
- No white discharge and no bleeding from cervical os
was noted.
- Vagina looks pale
Bimanual examination:
Cervix felt in mid position, no cervical motion
tenderness
Mass of 16 weeks pregnant uterus size
Mobile, irregularly enlarged
Mass felt through anterior fornix more towards right, firm
in consistency, non tender
Mass is not felt separately from uterus
Movement of cervix transmitted to the mass and vice versa
Bilateral fornices free, non tender
POD free
Per rectal examination:
- Rectal mucosa free
• SUMMARY
- 45years old multiparous, sterilized belonging to class 2
socioeconomic status(modified BG Prasad's classification)
presented to gynec OPD with heavy menstrual bleeding during
regular cycles since 6months, with no significant personal and
family history. On examination BMI was normal, pallor
present and vitals and systemic examination within normal
limits. Per abdomen examination showed solitary mass
corresponding to 16 weeks gravid uterus, firm in consistency,
irregular surface, non tender.
Gynecological examination revealed a mass of 16 weeks
pregnant uterus size which was mobile, irregularly enlarged
and mass felt through anterior fornix more towards right,
firm in consistency, non tender.
Mass is not felt separately from uterus, Movement of cervix
transmitted to the mass and vice versa .bilateral fornices
free, non tender, pouch of douglas was free.
• History and clinical features are suggestive of
abnormal uterine bleeding probably
leiomyoma.
• USG abdomen and pelvis
Uterus- an intramural fibroid noted in anterior wall
measuring 4x3cm; multiple subserosal fibriods(4-5)
largest in right lateral wall measuring 9x7.5cm, ET-
5.8mm, ovaries- normal
• Blood group- B positive
• PAP smear- Negative for intra epithelial neoplasia.
• Endometrial biopsy- proliferative endometrium
• Hb- 7.9g/dl, RBS- 118mg/dl, HbA1c- 4.7%
• All other investigations are within normal limits
THANK YOU
