Red degeneration of fibroid

Ans. is c I.e. Red degeneration of fibroid

Friends, the answer is quite obvious but let’s see how other options can be ruled out. Option “a-Preterm labour

Points in favour                                                                          Points against

Patient has fibroid (Though no mention has                • Torsion is not associated with fever

been made whether it is pedunculated                          and leucocytosis.

or not, Remember torsion is seen in

subserous pedunculated Myomas)°

• Patient is complaining of acute

pain in abdomen.

Option “d”        Infection of fibroid

Points in favour                                          Points against

• Presence of fibroid                   • Acute pain in abdomen

(Remember : Infection is common        (Infection of fibroid will not cause acute pain in abdomen).

in submucous fibroids)°                      • Infection of fibroid occurs following abortion or labour

• Fever                                       (Here patient is pregnant but there is no history of

Option “c”    Red degeneration of fibroid

Red degeneration of fibroid : also called as Cameous degeneration.

• It is seen mostly during pregnancy mid pregnancy° (But can occur at other times as well and in non

pregnant females also).°

• It is an aseptic condition.°
• The myoma suddenly becomes acutely painful°, enlarged° and tender°.

• Patient presents with :                  Acute abdominal pain° Vomitting°

Malaise°

–                              Slight fever°

Lab investigations :                          – Moderate leucocytosis°
Raised esr°

Pathological changes in the tumour :

• Fibroid becomes soft. necrotic or homogenous especially in its centre.
• It is stained Salmon pink°, or red (due to Diffusion of blood pigments from the thrombosed vessels).
• It has fishy odour° (due to secondary infection with coliform organisms)
• Histologically : There is evidence of thrombosis in some vessels.°
• Pathogenesis : There is subacute necrosis of the myoma caused by an interference in blood supply (aseptic infarction).°

Management :

• Conservative management°
• Patient is advised rest°
• Analgesics are given to relieve the pain.°
• The acute symptoms subside in 3-10 days° and pregnancy proceeds uneventfully.

Diagnosis is by ultrasound.

D/D

• Appendicitis°, Twisted ovarian cyst°, Pyelitis° and Accidental haemorrhage°.
• So amongst above options – Red degeneration is the correct answer.

Ans. is a i.e. Second trimester 

Friends, answer to this question was quite obvious as each one of us have mugged it up; but finding an appropriate reference was a difficult task.

Read for yourself whatDutta Obs. 6/e, p 309 has to say‑

“Red Degeneration; It predominantly occurs in a large fibroid durin^g the second half of pregnancy or puerperium.”

From the above statement answer could be second trimester, third trimester or puerperium.

“Red degeneration; manifests typically about midpregnancy when the leiomyoma suddenly become acutely painful, enlarged and tender.”

This clears the doubts and confirms our answer i.e Red degeneration is most common during second trimester (midpregnancy).

Friends you should also keep in mind the following important points regarding – Fibroids and pregnancy.

Effects of Fibroid on pregnancy :

• Infertility

– Leiomyomas are a sole cause of infertility in less than 3⁰/0 of cases.°

–  It causes infertility by :

1. Hindering the ascent of the spermatozoa by distorting the uterus and tubes.
2. By disturbances in ovulation and
3. By interfering with implantation of the fertilized ovum.

–  Pregnancy rate following myomectomy = 40%°

• Abortion°, Placental abruption° and Premature labour°.

Occurs when fibroid interferes with enlargement of uterus, initiates abnormal uterine contractions or prevents efficient placentation,

• Ma!position° and Malpresentation° of Fetus : occur as fibroid can prevent engagement of head.
• Obstructed labour : It can be caused by cervical° and broad ligament tumours° which are fixed in the pelvis and by pedunculated subserous leiomyomas which become trapped in the pouch of Douglas.
• During labour

– If fibroid is situated above the presenting part – uneventful vaginal delivery.

– If fibroid is situated below the presenting part spontaneous vaginal delivery may occur; otherwise caesarean section is done. Thus chances of cesarean section are increased.°

• Post Partum Hemorrhage° /Delayed Involution° can occur if placenta is implanted° over the leiomyoma.

Uterine inertia – Inertia due to fibroid is not supported

Management of Red degeneration of fibroid.

• Patient is managed conservatively.°
• Patient is put to bed rest and given analgesics° (to relieve the pain), sedatives° and if required antibiotics.°
• If because of mistaken diagnosis iaparotomy is done, abdomen is closed without doing anything.
• Myomectomy should never be contemplated during caesarean section as vascularity of fibroid is increased
  during pregnancy (due to increased estrogen) leading to increased blood loss during cesarean section.°

For more information about Red degeneration, refer answer 8

Ans. is d i.e. Red degeneration       

From the given options the answer is quite obvious as red degeneration of fibroid is managed conservatively not by any surgery.

But here I would like to discuss in detail the surgical management of fibroid and its indications, especially myomectomy (which is being done more frequently these days).

Indications of surgical management of fibroid :

• Fibroid causing symptoms : – Menorrhagia°

–  Chronic / Acute, Pelvic pain°

–  Pressure symptoms like urinary retention.°

• Fibroid like cornual fibroid causing infertility.°
• Sub mucous fibroid causing infertility (Other causes of infertility should be ruled out before surgery).°

Surgical options can be :

•  Myomectomy
• Hysterectomy

Indication of myomectomy : Myomectomy is specifically indicated in an infertile woman or woman desirous of bearing child and wishing to retain the uterus. Indications being the same as for surgery.°

Some specific indications for Hysterectomy :

• In patients > 40 years of age.°
• Multiparous women.°
• If fibroid is associated with malignancy.°
• During myomectomy if their is uncontrolled hemorrhage or other surgical difficulty.°
• If the size of uterus is < 12 weeks vaginal hysterectomy can be done.°

• Myomectomy is the enucleation of myomata from the uterus leaving behind a potentially functioning organ capable of future reproduction.°
• Prerequisites : Anemia should be corrected.°

–  All other causes of infertility should be excluded.°

– Male factor infertility should be ruled out.°

– Diagnostic D and C should be performed in case of irregular cycles, to detect any polyp and to rule out endometrial cancer.°

– Hysteroscopy or HSG : To detect a fibroid encroaching the uterine cavity or a polyp or tubal block.°

• Myomectomy is specifically indicated in an infertile woman or woman desirous of bearing child and wishing to retain the uterus.°

Time of myomectomy :

• It should be performed in preovulatory menstrual phase to reduce blood loss during surgery.°
• It should not be performed during pregnancy and at the time of cesarean section.°

Contraindications :

• Big broad ligament fibroid : (as many large vessels are present which can cause uncontrollable bleeding and thus the need to abandon myomectomy and do hysterectomy.°
• Multiple tiny fibroids scattered through the uterine wall.°

Instrument used to decrease blood loss during myomectomy : bonney’s myomectomy clamp.°

• Myomectomy operation should always be followed by shortening of round ligament to prevent retroversion.°
• Bonney’s hood technique : is done in interstitial fibroid on the fundal posterior wall.°

Results (Important) :

• Pregnancy rate following myomectomy : 40%°
• Abortion rates if woman conceive : 25%°

Myomectomy :

• Low grade postoperative pyrexia is a rule and should not be treated by antibiotics (pyrexia is d/t slight extravasation of blood in uterine wall or peritoneal cavity and settles spontaneously in 7-14 days).
• Recurrence rate : 5-10%°
• Persisting menorrhagia 1-5%°
• Reason for persisting menorrhagia is either myoma was not responsible for the complain or an intrauterine polyp or fibroid was overlooked during surgery.
• 20 – 25% women subjected to myomectomy : ultimately come for hysterectomy.

Thrombosis of the veins

Is aseptic infarcation

• Hyaline change: It is present in two third of the fibroids and is very rarely symptomatic.
• Cystic change
• Oedema
• Red degeneration
• Calcification
• Fatty change

Red degeneration is a complication of uterine myoma, though it mostly occurs in pregnancy it is not a rare cause of painful myomas in woman over the age of 40. Sarcomatous change in myoma is extremely rare and is yellow – gray in colour with haemorrhages to the naked eye.

In a pregnant female with red degeneration of fibroid, management is essentially conservative treatment with analgesia and rest.

Ans. b. Sarcomatous change .

• The risk of sarcoma developing in a fibroid uterus is approximately 0.5% (Least common secondary change).

Secondary Changes in Fibroid

• Hyaline degeneration:
• MC change, more common in central portion^Q
• Cystic degeneration (after menopause)
• Fatty degeneration (after menopause)
• Calcareous degeneration (after menopause)
• Atrophy° (after menopause)
• Red degeneration° (2′ half of pregnancy)
• Sarcomatous change:
• Least common change^Q
• Incidence 0.5% of all fibroids
• More common in intramural and submucous fibroids