Diagnosis and Treatment of Submucous Myoma

of The Uterus with Interventional Ultrasound

BO LIANG, YANG-GUI XIE, XIAO-PING XU and CHUN-HONG HU

Presented by :
Kezia Nathania
1765050190

Facilitator :
Dr. Maruarar Panjaitan, Sp.OG

DEPARTEMENT OF OBSTETRICS AND GYNAECOLOGY

CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
2018
 Introduction
• Myoma of the uterus is one of the benign tumors of the reproductive. Incidence rate  50-60%
1) Intramural myoma (the highest incidence)
2) Submucous myoma (incidence rate  20-40%)
3) Subserous myoma
• Frequently occurs in women aged 30-50 years
• Submucous myoma of the uterus increase young trend
• Impact of myoma of the uterus :
 Infertility
 Anemia
 Threaten the life of severe cases
• The traditional treatment methods -> myomaenucleation and hysterectomy.
 Disadvantages : large trauma, serious postoperative adverse reactions, longer postoperative
recovery
• Interventional usg used to diagnosis and treatment of submucous myoma of the uterus.
• In the present study -> 25 patients diagnosed preliminarily as submucous myoma via
conventional usg -> investigate the value of interventional usg.
Patients and methods
• General materials -> 25 patients diagnosed preminarily as submucous myoma of the uterus via
conventional ultrasound examination. ( June 2014 – December 2016)
• Exclusion criteria :
i) Mentally-ill patients
ii) patients with malignant tumors
iii) patients with unclear consclouness or severe illness
iv) patients complicated with organic lessions
v) patients who refused to cooperate with the researchers.
• Research methods
• Research indexes : i) First, the conventional ultrasound examination
ii) The ultrasound-guided modified sonohysterography (modified SHG)
iii) Under the guidance of ultrasound, the best pucture path was confirmed
iv) Under the guidance of ultrasound, the tumors received the sclerotherapy
v) After operation, the conventional ultrasound, color Doppler and
ultrasonohysterography were performed, and Follow up patients
vi) Evaluation the patient’s life quality.
Figure 1. Diagnosis and treatment processes of interventional ultrasound. (A) Color Doppler image before intervention. (B)
Needle insertion map in SHG. (C) injection of normal saline in SHG. (D) Injection of hardening agent into the pedicle of tumors (E)
Uniform diffusion of hardening in the whole tumors; (F) Disappearnce of 3M tumor after injection.
• Criteria of submucous myoma of the uterus, (Netherlands International
Hysteroscopy Center)
 Type 0 : submucous myoma with pedicles, located in the uterine cavity without expantion
into the muscular
 Type I : submucous myoma without pedicles, <50% myoma expands to the muscular layer
 Type II : submucous myoma without pedicles, >50% myoma expands to the muscular layer

• Blood flow grading criteria, (Alder’s method)

 Grade 0 : No blood flow signal in myoma
 Grade I : A small amount of blood flow in myoma, showing no more than two thin-rod or
datted blood vessels
 Grade II : A medium amount of blood flowin myoma, showing one longer blood vessel into
the lesion or three-four dotted blood vessels
 Grade III : A large amount of blood flow in myoma, showing two longer blood vessels or no
more than five dotted blood vessels
• SF – 36 scoring criteria
The life quality patients -> using SF-36.
 Dimensions :
1. General healt status 5. Social function
2. Physical function 6. Live vitality
3. Physical pain 7. Emotional role
4. Somatic rolel 8. Mental health.

• Statistical analysis
 Analyzed using SSS 20.0 statical analysis software.
 Measurement data -> as mean ± standard deviation (mean ± SD)
 Enumeration data -. as percentage (%) and Chi-square test -> for comparison amoung group.
 P<0.05 indicate a statisticaly significant difference.

Results
• Pathological diagnosis of submucous myoma of the uterus
 Modified SHG + USG needle biopsy -> 24 out of 25 cases (96%) -> pathological as submucous myoma
of the uterus
o Type 0 : 6 cases - Type 0 : Complete disappeared (after treatment)
o Type I : 14 cases - Type I, II: 18 cases submucous myoma  intramural myoma (after treatment)
o Type II : 4 cases
Results
• Pathological diagnosis of submucous myoma of the uterus
 Significant differences of submucous myoma of the uterus before and after treatment (P<0.05)
(table I)

• Changes in clinical symtoms of patients with submucous myoma of the uterus

before and after treatment
 Before treatment, 10 cases -> Excessive menstruation
o 6 cases -> long menstrual period
o 4 cases -> anemia
 Before treatment hemachrome level  8.51±10.62 g/l
 116.32±12.21 g/l (after treatment)
 After treatment -> clinical symtoms significant improve compared before treatment (P<0.05).
(table II)
• The maximum diameter and volume of myoma of patients with submucous
myoma of the uterus before and after treatment.
 Diameter before treatment 3.25±0.47 cm  2.02±0.23 cm
 Volume before treatment 25.91±3.47 cmᶟ  18.15±2.39 cmᶟ (Table III)

• Blood flow grading of patient with submucous myoma of the uterus before and
after treatment
 Before treatment, After treatment
o Grade 0 -> 0 case  14 cases
o Grade I -> 3 case  6 cases
o Grade II -> 7 case  5 cases
o grade III -> 7 case  0 cases

• Comparisons of SF-36 scores of patients with submucous myoma of the uterus

before and after treatment
• The SF-36 scores of each dimension after treatment >>> before treatment (P<0.05). (Table V)
• Adverse reactions of patients with submucous myoma of the uterus after treatment.
 After treatment, (Table VI)
o Mild abdominal pain -> 8 cases Cold sweat -> 1 cases
o Increase secrection -> 7 cases Pale complexion -> 1 cases
o Slight vaginal bleeding -> 6 cases Dizziness -> 2 cases

Discussion
• Myoma uterus  long menstrual period, profuse menstruation, severe cases -> anemi and infertility
• Clinical treatment method of myoma the uterus : laparascopic fibroidectomy
 Disadvantage : General anesthesia and higher cost,
Uterine arteri embolization,
Postoperative adverse reaction.
• Patients receiving surgical treatment  longer recovery period after treatment.
• Patients receiving interventional ultrasaound-guided puncture injection of lauromacrogol :
 Short recovery
 Do not need hospitalized
• Clinical studies : ethyl alchol as the hardening agent in the treatment of myoma.
 Better clinical effect but adverse reaction after operation.
Disscusion
• Lauromacrogol -> a kind of ether compound.
 Endothelial cell in cystic wall > secretion function to produce aseptic inflammation.
 Cystic adhesions
 Closure and grandual absorption (used in slerotherapy of cysts in clinical practice in previous years)
• Incidence rate of myoma 5-10% it can cause more serious clinical symtoms :
 Excessive menstruation - Shortened menstrual cycle
 Prolonged menstrual period - Dysmenorea, anemia and fertility
• Modified SHG -> 18GTC puncture needle tip -> placed in the uterine cavity ->
 Slowl infused appropriate amount of normal saline -> No echo liquid dark area in the uterine cavity
 Forming a good acoustic window and contrast area -> Affective improve the display rate of lesion structure.
• SHG modified -> unique superiority in the typping of submucous myoma
 Avoid myoma surface bleeding and other complications due to blind curratage
 Asses percentage of tumor to the uterus cavity
 Help select the apropiate clinical resection mode of myoma
• Underwent ultrasound-guided sclerotherapy, SHG needed before treatment :
 Inject normal saline -> separate the uterine cavity and the source of myoma pedicle can be clear
 Protect the endometrium, -> prevent fluid infiltrate into the uterine
• After scleroteraphy :
 6 cases of type 0 submucous myoma shrunk -> blood supply was block
 18 cases of type I, II submucous myoma -> significant reduced
 Diameter submucous myoma before treatment : 3.25 ±0.47 -> 2.02 ±0.23 cm
 Volume before treatment: 25.91 ± 3.47cmᶟ -> 18.15±2.93 cmᶟ
 A total of 14 cases -> completely inactived
 4 cases -> partially inactivated
• After treatment :
 Menstrual period, anemia, hemachrome level, blood flow grading -> obivious improve (P<0.05)
 Efek mechanism of intratumor injection of lauromacrogol -> destruction
o Coagulation
o Degeneration of myoma capsule
o Vascular embolization
• Adverse reaction of patient renal cycst and liver cycst : sclerotherapy lauromacrogol > absolute ethyl
 After treatment : mild abdominal pain
 Slight vaginal bleeding, pale complexion
 Cold sweat, dizziness and other
Dissapeared for 1 week.
• Lauromacrogol -> lead to the denaturation
 Slight anesthetic,
 Alleviate postoperstive pain,
 Improve the patient tolerance.
• The score of each dimension -> after treatment significant > before treatment
• The score of SF-36 significant different before and after treatment (P<0.05)

Conclusion
• The interventional ultrasonography can effectively diagnose submucous myoma of the uterus.
• The treatment of submucous myoma :
 Effectively reduce of the tumor diameter and volume,
 Improve the blood flow in patients,
 Reduced the postoperative adverse reaction,
 Alleviate the patients’s pain.
• Invasive treatment method  worthy of clinical promotion and application.