Myomectomy

MYOMECTOMY

Q. 1

All are methods of managing fibroid uterus. Except :

 A

Myomectomy

 B

Radio frequency ablation

 C

Embolisation of uterine artery

 D

Laser myomectomy

Q. 1

All are methods of managing fibroid uterus. Except :

 A

Myomectomy

 B

Radio frequency ablation

 C

Embolisation of uterine artery

 D

Laser myomectomy

Ans. B

Explanation:

Ans. is b i.e. Radiofrequency ablation

Emblotherapy :

  • Uterine artery embolization is done using polyvinyl° alcohol or gel foam°, in patients not suited for or not desirous of surgical therapy.
  • Uterine blood flow is obstructed producing ischemia and necrosis.
  • It shrinks the fibroid by 40-50% in selective young women.°
  • Results : These patients experience
  1. lowered fertility rate°
  2. risk of placental insufficiency and°
  3. uterine rupture in subsequent pregnancy° because of interference with the blood supply and embolotherapy induced necrosis of the leiomyoma.

Due to lack of long term outcome data women who desire future childbearing are not currently considered candiates for uterine artery embolisation

Post op Complications : • Pain°

  • Fever°
  • Pulmonary embolism°
  • Complete amenorrhea° Extra Edge

Indications for operating an Asymptomatic fibroid° :

  • Fibroids larger than 12-14 weeks pregnancy.°
  • Rapidly growing fibroids.°
  • Subserous and pedunculated fibroid prone to torsion.°
  • If it is likely to complicate a future pregnancy°
  • If there is doubt about its nature°
  • Unexplained infertility and unexplained recurrent abortion.° 
  • Uncertain diagnosis.°

Indications of Medical management° :

  • To treat anemia and recover Hb levels before surgery.°
  • To reduce the size of large fibroid and facilitate surgery.°
  • Treatment of women approaching menopause to avoid surgery.°
  • In women with medical contraindication to surgery or those who are postponing surgery.°
  • For Preservation of fertility in women with large myomas before conservative surgery like myomectomy.°

Indications of surgical management° : Fibroids causing symptoms like

  • Menorrhagia°
  • Pressure symptoms° : Urinary Retention (by a cervical or broad ligament fibroid)
  • Chronic pelvic pain with° severe dysmenorhea
  • Acute pelvic pain as in° torsion of a pedunculated fibroid or prolapsing Sub-mucosal fibroid
  • Infertility caused by cornual fibroid
  • Recurrent abortions due to submucous fibroid.

Q. 2

Sucheta, a 29 year old nulliparous women com­plains of severe menorrhagia and lower abdomi­nal pain since 3 months. On examination there was a 14 weeks size uterus with fundal fibroid.

The treatment of choice is :

 A

Myomectomy

 B

GnRH analogues

 C

Hystrectomy

 D

Wait and watch

Q. 2

Sucheta, a 29 year old nulliparous women com­plains of severe menorrhagia and lower abdomi­nal pain since 3 months. On examination there was a 14 weeks size uterus with fundal fibroid.

The treatment of choice is :

 A

Myomectomy

 B

GnRH analogues

 C

Hystrectomy

 D

Wait and watch

Ans. A

Explanation:

Ans. is a i.e. Myomectomy  

First lets see whether we would like to go for medical management or surgical intervention. The patient is presenting with :

  •  Severe menorrhagia°
  • Chronic lower abdomen pain°
  • Size of fihroici = 14 weekca

These 3 indications are strong enough for surgical intervention. Other indications for surgical Management are :

  • Acute pain in abdomen as in Torsion of pedunculated fibroid or prolapsing submucosal fibroid°
  • Pressure symptoms like constipation°
  • Dysuria°
  • Infertilty (when other causes of infertility have been ruled out) and habitual abortion caused by submucous fibroid.°

Now comes the question – whether Myomectomy or hysterectomy should be done.

Indication of Myomectomy : Myomectomy is specifically indicated in an infertiie woman or woman desirous of bearing child and wishing to retain her uterus.

Since, our patient, Sucheta is just 29 years and Nulliparous – Myomectomy should be done.


Q. 3 30 years old female presents in gynaec OPD with complaints of recurrent abortions and menorahagia. Her USG showed 2 sub-serosal fibroids of 3 x 4 cm on anterior wall of uterus and fundus, which is best line of management:-
 A TAH with BSO
 B Myolysis
 C Myomectomy
 D Uterine artery embolisation (UAE)
Q. 3 30 years old female presents in gynaec OPD with complaints of recurrent abortions and menorahagia. Her USG showed 2 sub-serosal fibroids of 3 x 4 cm on anterior wall of uterus and fundus, which is best line of management:-
 A TAH with BSO
 B Myolysis
 C Myomectomy
 D Uterine artery embolisation (UAE)
Ans. C

Explanation:

Laparoscopic myomectomy is  best treatment for  such  young infertile patients, but  it  requires subserosal pedunculated fibroids and surgical expertise.

Hysterectomy is advisable in patients who had completed their family.

Myolysis is myoma coagulation with laparoscopic lasers. (Nd- YAG) or bipolar needle & used in perimenopausal patients.

UAE is newer intervention for fibroid management in surgically unfit high risk patients, but it causes decreased fertility & carries risk of placental insufficiency and uterus rupture in subsequent pregnancy.


Q. 4

A 27 year old nulliparous woman complains of severe menorrhagia and lower abdominal pain since 4 months. On examination there is a 9 wks size uterus with fundal fibroid. The treatment of choice is:

 A

Myomectomy

 B

GnRh analogues

 C

Hysterectomy

 D

Wait and watch

Q. 4

A 27 year old nulliparous woman complains of severe menorrhagia and lower abdominal pain since 4 months. On examination there is a 9 wks size uterus with fundal fibroid. The treatment of choice is:

 A

Myomectomy

 B

GnRh analogues

 C

Hysterectomy

 D

Wait and watch

Ans. A

Explanation:

Resection of tumors is an option for symptomatic women who desire future childbearing or for those who decline hysterectomy.

This can be performed laparoscopically, hysteroscopically, or via laparotomy incision, and each is described in detail in the surgical atlas.

Myomectomy usually improves pain, infertility, or bleeding.

Menorrhagia improves in approximately 70 to 80 percent of patients following tumor removal.

Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 9. Pelvic Mass. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.


Q. 5

Cesarean section should be done in :

 A

Previous LSCS for transverse Lie

 B

Plastic repair of VVF

 C

Myomectomy scar after 2 years

 D

b and c both

Q. 5

Cesarean section should be done in :

 A

Previous LSCS for transverse Lie

 B

Plastic repair of VVF

 C

Myomectomy scar after 2 years

 D

b and c both

Ans. D

Explanation:

b and c both


Q. 6

What should be done to reduce blood loss during myomectomy for fibroid uterus: 

March 2012

 A

Preoperative oral contraceptive pills administration

 B

Postoperative control of hypertension

 C

Tourniquet use

 D

Intraoperative blood transfusion

Q. 6

What should be done to reduce blood loss during myomectomy for fibroid uterus: 

March 2012

 A

Preoperative oral contraceptive pills administration

 B

Postoperative control of hypertension

 C

Tourniquet use

 D

Intraoperative blood transfusion

Ans. C

Explanation:

Ans: C i.e. Tourniquet use administration

Haemorrhage should be controlled with the myomectomy clamp. If the myomectomy clamp cannot be applied as in cervical fibroid, a rubber tourniquet will serve the purpose.


Q. 7

Risk factors for the placental condition shown in the picture below  include all of the following, except? 

 A

Previous LSCS scar.

 B

Previous curettage.

 C

Previous myomectomy.

 D

Previous placenta praevia.

Q. 7

Risk factors for the placental condition shown in the picture below  include all of the following, except? 

 A

Previous LSCS scar.

 B

Previous curettage.

 C

Previous myomectomy.

 D

Previous placenta praevia.

Ans. D

Explanation:

The placental condition shown in the picture above represents Placenta accreta.

In placenta accreta, there is a failure of normal decidua to form which causes the placenta to be directly anchored to the myometrium either partially or completely without any intervening decidua.

Placenta praevia in the present pregnancy is a risk factor for placenta accreta but previous placenta praevia is not a risk factor.



Q. 8

Hysteroscopic myomectomy scores over open omectoim in alb of the following except:

 A

Less recurrence

 B

Less post-operative pain

 C

Less bleeding

 D

Early ambulation

Q. 8

Hysteroscopic myomectomy scores over open omectoim in alb of the following except:

 A

Less recurrence

 B

Less post-operative pain

 C

Less bleeding

 D

Early ambulation

Ans. C

Explanation:

Ans. c. Less bleeding

Possible risk or complication of open myomectomy is excessive bleeding during the operation requiring blood transfusion, anemia due to blood loss during the operation and in post-operative period.

During hysteroscopic myomectomy, intraoperative bleeding is rare. Bleeding is unlikely unless vessels are lacerated or injured in the cervical canal or lower uterine segment during dilation or deep ablation or vaporization.

Hysteroscopic Myomectomy

  • Hysteroscpic myomectomy involves inserting a hysteroscope through the vagina and the cervix into the uterus.
  • Hysteroscopes are so thin that they can fit through the cervix with minimal or no dilation.
  • Because the instruments are inserted through the cervix, no abdominal incisions are needed.
  • A resectoscope, which is a hysteroscope fitted with a wire loop that uses high-frequency electrical current to cut or coagulate tissue, is then inserted to remove the fibroids.
  • The loop is placed around the fibroid, electrical energy passes through the loop, and the fibroid is cut loose.
  • The fibroid can then be removed through the vagina.

Advantages of Hysteroscpic Myomectomy:

  • This procedure is most often done on an “outpatient” basis under general anesthesia.
  • There is usually minimal discomfort during hysteroscopy.
  • It takes about 60 minutes to complete the procedure, which is followed by a few hours of recovery time.
  • Hysteroscopy can be used to remove fibroids on the inner wall of the uterus that have not grown deep into the uterine wall.
  • Complications occur less than 1% of the time with hysteroscopic myomectomy.
  • During hysteroscopic myomectomy, intraoperative bleeding is rare. Bleeding is unlikely unless vessels are lacerated or injured in the cervical canal or lower uterine segment during dilation or deep ablation or vaporization


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