Objectives: To define myoma and its different types To describe its pathogenesis and correlate it with its clinical

findings To differentiate it from other abdominal masses To identify ancillary procedures for its definite diagnosis To identify its various complications To identify various treatment options Patient profile: HS, 35 G0, single from Paranaque City. Chief complaint: abdominal mass Past Medical History: (-) DM, HPN, TB, asthma, goiter, cancer, allergy, previous hospitalization or surgeries Family Medical History: (+) thyroid disease - sister (-) HPN, DM, asthma, allergies Personal/Social/Sexual History: nonsmoker, nonalcoholic beverage drinker, denies illicit drug use, vocational course graduate currently unemployed, coitarche at 30 years to a single nonpromiscuous sexual partner, (-) OCP, IUD, DMPA use Menstrual History: menarche at 15, regular monthly intervals, 4-5 days duration, 2 pads/day, (+) dysmenorrhea LMP: Oct 10, 2011 PMP: September 2011 Obstetric History: G0 History of Present Illness 2 years and 11 months PTA: During routine PE for employment abroad, an abdominal mass was noted by the attending physician. No visible abdominal enlargement, no abdominal pain, vaginal bleeding, vaginal discharge, menometorrhagia, weight loss/gain. Patient consulted at PGH where transvaginal UTZ done revealed multiple myoma uteri. She was advised operation but this was delayed due to insufficient funds. She was eventually lost to follow up. 2 months PTA: patient returned due to enlarging abdominal mass. She was scheduled for OR and eventually admitted at ward14B. (-) weight loss, anorexia, fever, cough, colds, dysphagia, dyspnea, chest pain, palpitations, profuse vaginal bleeding, pallor, easy fatiguability, weakness, edema, joint pains. Physical Examination: BP: 120/80 HR: 88. RR: 20. Temp: afebrile Awake, conscious, coherent, ambulatory, not in cardiorespiratory distress Anicteric sclerae, pink conjunctiva, (-) tonsillopharyngeal congestion, (-)neck vein engorgement Equal chest expansion, clear breath sounds, (-)crackles or wheezes Adynamic precordium, distinct heart sounds, normal rate regular rhythm (-) murmurs Flabby abdomen, normoactive bowel sounds (+) abdominal mass: 20x25 firm, nontender, movable with distinct borders IE: normal external genitalia, nulliparous vagina, cervix smooth firm and closed measuring 3 x 2.5cm (Lx W), corpus enlarged to 22-24 weeks size, (-)adnexal masses or tenderness DRE: good sphincteric tone, intact rectal vault, bilateral parametria smooth and pliable

Full and equal pulses, pink nailbeds, no cyanosis clubbing or edema Assessment: Multiple Myoma uteri, multiple G0 Diagnostics: Blood Type O+ Hemoglobin (g/dl) Hematocrit (%) RBCs ( x 106 /ml) RDW < 14.5 MCV 92 MCH 30 MCHC % 31 Platelet count 397 13 39 4.0 WBC 10.05 Neutrophils Band forms Basophils Eosinophils lymphocytes Monocytes 0.54 0.03 0.75 0.02 0.28 0.04

yellow, slightly hazy, Specific Gravity 1.015 pH 6.0, (-) Glucose, Ketones, Blood, Protein, Bilirubin, Nitrate, Leukocyte Normal Urobilinogen 0.1-1.0 Occasional casts, Rare RBCs Rare casts and WBCs Few Epithelial cells and Mucus threads Transvaginal UTZ The uterus is anteverted with irregular contour and heterogenous echopattern measuring 22.5x8.9x20.2cm (cervix measures 3.2x3.2x2.4). There are 3 well-circumscribed heterogenous masses seen (M1) 9.0x8.2x8.3cm, posteriormidcorpus, intramural with subserous component (M2) 9.8x10.1x10.8cm, posterior isthmic, intramural and (M3) 6.0x7.0x7.3cm, posterofundal intramural with subserous component. The endometrium is hyperechoic measuring 0.2cm and pushed anteriorly with intact subendometrial halo anteriorly. The right ovary measures 2.7x2.9x1.8cm The left ovary measures 2.3x2.8x2.3cm. No free fluid in the culdesac. Impression: Multiple myoma uteri Pelvic endometriosis with endometrial cysts Normal ovaries Plan: Explorative laparotomy, myomectomy chromotubation Possible total hysterectomy under regional anesthesia 1. 2. 3. 4. 5. 6. 7. Guide Questions What is myoma? Differentiate its types. How does it present, and correlate these with the patient. What other pathologies would you consider given the finding of an abdnominal mass? How do you establish its diagnosis? What are its complications? What are the various treatment options (medical and surgical)? How will you advise this patient?