Our Lady of Fatima University Valenzuela City

A Case Study of a Patient with Myoma in Preterm Labor

Partial Fulfillment of Related Learning Experience at Pasay City General Hospital, Pasay City Obstetric Ward

Kevin John Aguirre BSN 2Y2 10A

Mrs. Jennifer Carulla, RN, RM, MAN Clinical Instructor

I.

Introduction Myoma are the commonest benign uterine tumors and itis estimated that they occur in 2040% of women during their reproductive years. They can cause a wide rangeof clinical symptoms such as heavy menstrual periods, pressure symptoms to surrounding organs and fertilityproblems. As a result, surgery for uterine broids iscommon, and in both the UK and USA broids are the primary indication for hysterectomy. However, inmany women uterine broids are found incidentally on routine gynecological examination or on pelvic imagingperformed for unrelated symptoms. Whether myoma are symptomatic or not depends primarily on their size and on their position in relation to the uterine cavity Although the denitive management of gynecological symptoms attributable to uterine broids is surgical removal, many women decline surgery or prefer to pursue medical management. The natural history of broids is poorly understood, which makes it difcult to advise asymptomatic women with broids on the risk of developing clinical symptoms in the future. It is well known, however, that broids are sensitive to circulating estrogens, which will either cause them to grow or to maintain their size. It is less clear whether the growth of broids is affected by factors other than ovarian steroid hormones. The aim of this retrospective study was to describe the natural history of uterine broids in premenopausal women and to identify demographic and morphological features that may inuence their growth rate. Uterine fibroids, also called fibroid tumors, fibromyomas, myoma or leiomyomas, are non-cancerous tumors that develop in a womans uterus. This condition affects approximately 1 in 4 women. However, many women with uterine fibroids do not experience any symptoms. In the period of Hippocrates in 460-375 B.C., this lesion was known as the uterine stone1. Galen called this finding scleromas during the second century of the Christian period1. The term fibroid was coined and introduced in 1860 by Rokitansky and in the 1863 by Klob1. In 1854, a German pathologist named Virchow demonstrated that these neoplasms (fibroids) were composed from smooth muscle cells2. It was Virchow who introduced the word myoma. In 1809, Danville, USA, the first laparotomy was performed consequent to an indication of myoma3. Mrs. Jane Todd Crawford, President Abraham Lincolns cousin, was 56 years old when she had an abdominal distention and appeared as if she was pregnant with twins. Laxatives, enemas and phytotherapy were first given as treatments to relieve the distention and volume in the abdomen1. A surgeon named Ephraim Mcdowell performed a laparotomy to remove the ovarian cyst containing complex content and when it was analyzed. It was known to be a pediculate leimyoma4.

The first successful operation of uterine fibroids through myomectomy was performed in 1840 by Jean Zulma Amussat of Paris5. In 1842, Amussat reported two submucous fibromyoma cases in which vaginal myomectomies were performed5. Later, Dr. Washington Atlee from Pennsylvania was recognized as the first who performed a successful abdominal

myomectomy operation that appeared in the American Journal of Medical Science in 18456. In 1853 Gilman Kimball of Massachusetts conducted the first deliberate myomectomy after diagnosing his patient with uterine fibroids5. He is also the first doctor to successfully perform a hysterectomy for the purpose of removing uterine fibroids 7. Myomectomy was abandoned until 1922 when British surgeon Victor Bonney, invented the Clamp for myomectomy in an attempt to decrease intra-operatory bleeding1. By 1930, Victor reported 403 myomectomy cases with minimal fatalities1. As medical knowledge evolved so did the treatment methods for uterine fibroids.

General Objective The researcher of this case had decided to put a major look or study regarding the existence of myoma to a patient whose in preterm labor due to Urinary Tract Infection. This aims to know what are the possible factors that give way to this previa tumor and what are the complications that this disease can be brought to the patient.

Specific Objective To be able to: Conduct a study regarding a tumor that probably exist due to the clients present condition in connection to her pregnancy and Urinary Tract Infection. Identify the disease itself and the present condition of the patient. Identify factors that leads to its existence. Assess clients knowledge regarding her condition. Input necessary information to the client regarding her health status. Characterize the disease by the way the client identifies it. Recognize the behavior that is correlated to the disease. Put up interventions based on gathered informations from the study.

II.

Patients Profile a. Biographical Data Name: Address: Sex: Age: Birthday: Birthplace: Nationality: Religion: Civil Status: Quinlog, Arlene Fontanilla Sampaguita B, NAIA. Baltao, Pasay City Female 39 years old July 9, 1972 Dipolog Filipino Roman Catholic Married

b. Admission

Date and Time of Admission:

February 17, 2012 9:00 pm

Chief Complaint:

Hypogastric Pain

Admission Diagnosis:

PU 30 weeks AOG at LMP Transverse PRETERM Labor G0P2

Principal Diagnosis:

Tumor Previa Urinary Tract Infection

History of Present Illness 2 years prior to admission patient experienced miscarriage at first three months of pregnancy with several mild epigastric pain on pre pregnancy with mild naussea.

Obstetric History

Pregnancy: G2P0 Pregnancy Order Gravida 1 2009 Year Pregnancy Outcome 3 months s/p complication curettage

Gravida 2

Present pregnancy

Still on labor

a.Physical Assessment Actual Vital Signs RR 20 bpm PR - 93 BP 100/70 Normal Values 12-20 bpm 60 100 bpm 120/80 mmHg Interpretation Normal Normal Hypotension

General Status: Chest Heart Lung Breast Uterus Essentially Stable Essentially Stable Essentially Stable Engorged Glomelular

Abdomen

24 cm

(Fundic Height)

Floating

Cervix: Dilatation:1 cm Color: Pinkish Presentation: Midline Station: Floating

GORDONS 11 FUNCTIONAL HEALTH PATTERN Health Perception and Management Questions pertains to those asked by the nurse to provide an overview of the individuals health status and health practices that are used to reach the current level of health or wellness. *The client under this condition perceived that what she had felt is a normal hypogastric pain she got used to experience after miscarriage. But during her 7th month of current pregnancy, the patient was alarmed about the present pain and went for her check up to ensure the safety of the current pregnancy. During the chueck up, the patient was diagnosed to have Urinary Tract Infection and eventually sent on Pasay General Hospital and further discovered Myoma that may possibly put the baby at risk of Preterm delivery.

Nutritional Metabolic This pattern describes nutrient intake relative to metabolic need. *the Client was order to have Diet as Tolerated * Take medications as prescribed by the Physician. * Clients appetite increased because meals in the hospital were being delivered three times a day. Elimination Describes the function of the bowel, bladder and skin. Through this pattern, the nurse is able to determine regularity, quality and quantity of stool and urine. Diets bowel movement is once a day and stool formation is formed. Clients urine output is cloudy and she has this movement for about 6 to 7 times a day.

Activity Exercise - This pattern centers on activity level, exercise program and leisure activities. * Except from the clients self care ability such as moving body parts and sitting, the client fail to didnt have any ways of activity or exercise because of complete bedrest order.

Sleep Pattern Because of complete bed rest order, the client was able to get 12 to 14 hours of sleep a day during the first week of admission but during this past few days, her sleep pattern changed from 12 to 14 hours of sleep to 6 to 7 hours of sleep a day because of the environments thermal condition. Cognitive-perceptual Assesses the ability of the individual to understand and follow directions, retain information, make decisions and solve problems. Also assesses the five senses. The client was able to follow directions being given by the physician and is not having a hard time retaining informations because her cognitive functions were not affected by her condition. Clients five senses are also in good condition.

Self perceptions/ Self Concept Overall, the client considers herself in perfect condition even though she was ordered for complete bed rest that reduces the use of her individual function but overall, the patient feels good about herself.

Role Relationship The patient is married with no child and considers herself as a wife as of the moment and hoping to be a mother soon.

Sexuality Reproductive The patient verbalize that she and her husband is trying to have their child after the experience of miscarriage on first pregnancy thats why their sex life is active during unpregnant state.

Coping-Stress Tolerance The patient cope stress by watching television, sleeping and eating most of the time. She thinks that this is the best way of coping stress instead of using vices as her medium.

Value- Belief pattern The patient is Roman catholic thats why she maintains her faith in spite of the experience of miscarriage during her first pregnancy.

III.

Background Knowledge * Uterine leiomyomas, commonly known as fibroids, are well-circumscribed, noncancerous tumors arising from the myometrium (smooth muscle layer) of the uterus. In addition to smooth muscle, leiomyomas are also composed of extracellular matrix (i.e., collagen, proteoglycan, fibronectin). Other names for these tumors include fibromyomas, fibromas, myofibromas, and myomas. Leiomyomas are the most common solid pelvic tumor in women, causing symptoms in approximately 25% of reproductive age women. However, with careful pathologic inspection of the uterus, the overall prevalence of leiomyomas increases to over 70%, because leiomyomas can be present but not symptomatic in many women. The average affected uterus has six to seven fibroids. Leiomyomas are usually detected in women in their 30's and 40's and will shrink after menopause in the absence of post-menopausal estrogen replacement therapy. They are two to five times more prevalent in black women than white women. Risk for developing leiomyomas is also higher in women who are heavy for their height and is lower in women who are smokers and in women who have given birth. Although the high estrogen levels in oral contraceptive pills has led some clinicians to advise women with leiomyomas to avoid using them, there is good epidemiologic evidence to suggest that oral contraceptive use decreases the risk of leiomyomas. Leiomyomas are classified by their location in the uterus. Subserosal leiomyomas are located just under the uterine serosa and may be pedunculated (attached to the corpus by a narrow stalk) or sessile (broad-based). Intramuralleiomyomas are found predominantly within the thick myometrium but may distort the uterine cavity or cause an irregular external uterine contour.Submucous leiomyomas are located just under the uterine mucosa (endometrium) and, like subserosal leiomyomas, may be either pedunculated or sessile. Tumors in subserosal and intramural locations comprise the majority (95%) of all leiomyomas; submucous leiomyomas make up the remaining 5%.

IV.

Anatomy and Physiology

The human uterus is a pear-shaped organ composed of two distinct anatomic regions: the cervix and the corpus. The corpus is further divided into the lower uterine segment and the fundus. The cervix is a narrow cylindrical passage which connects at its lower end with the vagina. At its upper end, the cervix widens to form the lower uterine segment (isthmus); the lower uterine segment in turn widens into the uterine fundus. The corpus is the body of the uterus which grows during pregnancy to carry a fetus. Extending from the top of the uterus on either side are the fallopian tubes (oviducts); these tubes are continuous with the uterine cavity and allow the passage of an ova (egg) from the ovaries to the uterus where the egg may implant if fertilized.

The thick wall of the uterus is formed of three layers: endometrium, myometrium, and serosa. The endometrium (uterine mucosa) is the innermost layer that lines the cavity of the uterus. Throughout the menstrual cycle, the endometrium grows progressively thicker with a rich blood supply to prepare the uterus for potential implantation of an embryo. In the absence of implantation, a portion of this layer is shed during menstruation. The myometrium is the middle and thickest layer of the uterus and is composed of smooth (involuntary) muscle. The myometrium contracts during menstruation to help expel the sloughed endometrial lining and during childbirth to propel the fetus out of the uterus. The outermost layer, or serosa, is a thin fibrous layer contiguous with extrauterine connective tissue structures such as ligaments that give mechanical support to the uterus within the pelvic cavity. Non-pregnant uterine size varies with age and number of pregnancies, but is approximately three and a half inches long and weighs about one sixth of a pound.

I.

Pathophysiology

II.

Laboratory Procedures and Interpretation

Hematology Result ( 2-21-12 ) Result Hemoglobin Hematocrit (2-12-12) Hemoglobin Hematocrit RBC WBC Differential Count Neutrophils Lymphocytes Eosinophils Platelet Count Blood Type O Adequate 150-400x109/l .83 0.17 0.25-0.35 130 0.40 4.2 13.9 4.2-5.4x1012/l 5-10x109/l 128 0.38 Normal 120-160 g/l 0.36-0.47

Urinalysis ( 2-22-2012) Color Character Reaction/Ph Specific Gravity Sugar Yellow Cloudy 6.5 1.010 (-)

Protein Blood Leucocytes Nitrite Microscopic Pus Cells RBC OBSTETRIC ULTRASOUND Fetal Number: Single

(-) (-) (-) (-)

0-2/hpf 0-2/hpf

Fetal Lie Presentation: Transverse Placental Location: Grade III Amniotic Fluid: Adequate Fetal Movement: Active Cardiac Activity: 153 bpm

VII.Course in the Ward

III.

Discharge Plan Home Medication: Drugs: Cefuroxine Mefenamic Acid FeSo4 Dosage 500 mg 500 mg Frequency TID X 7 Days PRN OD

Home Care:

Daily Perineal Hygiene Encourage Breastfeeding May Go Home