QUESTIONS ON UTERINE FIBROID
1. Characteristics of dyspareunia (deep/superficial, interruption during SI)
2. DDX for dyspareunia + dysmenorrhea:
- Adenomyosis
- Endometriosis
- Dual gynae problem (fibroid + endometriosis)
- Severe fibroid (large enough to cause both symptoms)
3. Characteristic for fibroid:
- Number (single/ multiple)
- Size
- Types (submucosal/ subserosal/ intramural)
•A/w subfertility (not fertilization)...including cervical fibroid, intramural fibroid or submucosal fibroid obstructing tubal ostia
•Implantation (submucosal)
•Decidualization (Submucosa/ endometriosis)
*Subserosal* not a/w subfertility
Usually presented with pressure symptom, oedema, DVT (venous stasis), abdominal mass
*Submucosal* a/w heavy menstrual bleeding, recurrent muscarriage
4. Diagnosis of miscarriage
Biochemical (UPT)
Clinical (USG, presence of FHR)
When you ask about miscarriage, always ask
-first trimester/second trimester (because underlying causes are different)
-how pregnancy was diagnosed? UPT positive only, no evidence of pregnancy during USS. Subsequently UPT negative, that is biochemical pregnancy (60% of all miscarriages). If UPT positive, IUGS or fetal pole can be seen inside the uterus, it is clinical pregnancy (40% of all miscarriages). Then, you have ask about type of miscarriage (threatened/missed/inevitable/incomplete/septic) miscarriage in case of clinical pregnancy.
-treatment: conservative, medical, surgical
Ask for fetal gender in case of second trimester miscarriage.
Thoroughly ask about the underlying causes of miscarriages.
5. Types of miscarriage
•Threatened, missed, complete, incomplete, inevitable
6. Clerk pt with miscarriage:
• Ask details on family history (plot family genogram)
• Mode of removing product of conception (POC)
• Spontaneous, medical, surgical
7. Abdominal pain/discomfort
• Endometriosis: before and during menses
• Fibroid: during menses
(Assess the severity of pain: any analgesic taken?)
8. How severe is her obesity that she needed bariatric:
• any u/l comorbid
• any measure to reduce weight
• whats her indication for bariatric surgery
Downside of bariatric:
📌MOGTT cannot be done in bariatric surgery patient because of dumping syndrome
📌MOGTT cannot be given due to absorption of glucose depended on gastric acid secretion, reduce gastric acid, high chance for false negative
📌Blood sugar diary for one week to diagnose GDM
📌In pregnancy, increase physiological demand, pt at risk for malabsorption syndrome especially nutritional deficiency anemia
9. Phases for endometrial cycle:
Proliferative: 5-7mm
Secretory: up to 13mm
Menstrual: 1-5mm
(Normal endometrial thickness)
USG intrauterine fibroid interpretation:
Homogenous/ heterogenous
Anterior/ posterior
Cervical/ fundal/ body
Submucosal/ subserosal/ intramural
Pouch of Douglas (POD): suspected Endometrioma of ovary (it can reside in POD)
Surgery:
1. Hysteroscopic myomectomy
2. Laparoscopic myomectomy
3. Hysterectomy
•FIBROID MAPPING ON USG is enough to diagnose fibroid (no need MRI anymore)
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