All of the following are the indications for myomectomy in a case of fibroid uterus except :
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 : - Menorrhagiadeg - Chronic / Acute, Pelvic paindeg - Pressure symptoms like urinary retention.deg Fibroid like cornual fibroid causing infeility.deg Sub mucous fibroid causing infeility (Other causes of infeility should be ruled out before surgery).deg Surgical options can be : Myomectomy Hysterectomy Indication of myomectomy : Myomectomy is specifically indicated in an infeile woman or woman desirous of bearing child and wishing to retain the uterus. Indications being the same as for surgery.deg Some specific indications for Hysterectomy : In patients > 40 years of age.deg Multiparous women.deg If fibroid is associated with malignancy.deg During myomectomy if their is uncontrolled hemorrhage or other surgical difficulty.deg If the size of uterus is < 12 weeks vaginal hysterectomy can be done.deg Myomectomy is the enucleation of myomata from the uterus leaving behind a potentially functioning organ capable of future reproduction.deg Prerequisites : Anemia should be corrected.deg - All other causes of infeility should be excluded.deg - Male factor infeility should be ruled out.deg - Diagnostic D and C should be performed in case of irregular cycles, to detect any polyp and to rule out endometrial cancer.deg - Hysteroscopy or HSG : To detect a fibroid encroaching the uterine cavity or a polyp or tubal block.deg Myomectomy is specifically indicated in an infeile woman or woman desirous of bearing child and wishing to retain the uterus.deg Time of myomectomy : It should be performed in preovulatory menstrual phase to reduce blood loss during surgery.deg It should not be performed during pregnancy and at the time of cesarean section.deg 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.deg Multiple tiny fibroids scattered through the uterine wall.deg Instrument used to decrease blood loss during myomectomy : bonney's myomectomy clamp.deg Myomectomy operation should always be followed by shoening of round ligament to prevent retroversion.deg Bonney's hood technique : is done in interstitial fibroid on the fundal posterior wall.deg Results (Impoant) : Pregnancy rate following myomectomy : 40%deg Aboion rates if woman conceive : 25%deg 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%deg Persisting menorrhagia 1-5%deg 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. Routes of myomectomy Abdominal Vaginal myomectomy Myomectomy Done in case of submucosal pedunculated fibroid Hysteroscopic myomectomy Submucosal fibroiddeg which cannot be removed by simple vaginal route can be removed with the help of hysteroscope Laparoscopic Myomectomy Indicated for pedunculated Subserosal fibroids (<10cms in size) Intramural fibroids can also be removed by laparoscope but it is very time consuming Myolysis or myoma coagulation using laser In this procedure lasers are used to drill holes into the substance of intramural myoma
Associated infeility
Recurrent pregnancy loss
Pressure symptoms
Red degeneration