CHAPTER IV

DISCUSSION
A female 45 years old was admitted to hospital because will undergo blood
transfusion for uterine myoma operation. Before admitted, patient was already
diagnosed with uterine myoma. After complete examination for the preparation of
the operation, it was found that her hemogloblin level was 3,6 and must be
admitted for blood transfusion. Patient undergo 6 packs of blood transfusion
before operation of uterine myoma.
Patient was diagnosed as uterine myoma and severe anemia based on history,
physical examination, laboratory examination and imaging. Based on history,
patient complain about abnormal bleeding and abdominal mass during
mestruation since 5 months.
Patient complains about abnormal bleeding and abdominal mass during
menstruation since 5 months. Menstruation become more painful than usual and
longer. In one month menstruation can occurs 3-4 times ranging 5 until 9 days.
Sometimes menstruation occurs continiously for one month. Bleeding is more
severe during the fourth until eightth day. In one day, more than ten softex was
used during menstruation.
A normal menstrual cycle is defined as 28 7 days, with menstrual flow
lasting 4 2 days, and an average blood loss of 20 to 60 mL. Based on history,
patient presented as menometrorrhagia. Menorrhagia is defined as prolonged or
heavy cyclic menstruation. Objectively, menses lasting longer than 7 days or
exceeding 80 mL of blood loss are determining values. Metrorrhagia describes
intermenstrual bleeding. Frequently women may complain of both patterns,
menometrorrhagia.
Abnormal uterine bleeding affacts 10-30% of reproductive-aged women and up
to 50 percent of perimenopausal women. Factors that impact the incidence most
greatly are age and reproductive status. The differential diagnosis of abnormal
bleeding is presented in table 4.1
Differential Diagnosis of Abnormal Bleeding
Dysfuctional uterine bleeding
Anovulatory
Perimenarcheal-immature hypothalamic-pituitary-ovarian axis
Perimenopausal-insensitive ovarian follicles
Endocrinopathies-systemic causes
Drugs-hypothalamic depressants, steroids
Ovulatory
Organic lesions
Pregnancy-associated causes-implantation spotting, abortion, ectopic
pregnancy, GTD, postabortal or postpartum infection
Anatomic uterine lesions
Neoplasm-leiomyoma, polyp, endometrial hyperplasia, cancer
Atrophic endometrium
Infection-sexually transmitted disease, tuberculosis
Mechanical causes-intrauterine device, perforation
Arteriovenous malformation
Partial outflow obstruction-congenital mullerian defect
Anatomic nonuterine lesions
Ovarian lesions-hormonally functional neoplasm
Fallopian tube lesions-salpingitis, cancer
Cervical and vaginal lesions-cancer, polyp, infection, trauma
Systemic abnormalities
Exogenous hormone administration- sex steroid, corticosteroids
Coagulopathies
Hepatic failure
Chronic renal failure
Endocrinopathies
Patient is 45 years old which in a perimenopausal period. Perimenstrual period
refer to the time period in the late reproductive years, usually late 40s to early 50s.
Abnormal uterine bleeding is a frequent clinical problem and accounting for 70%
of all gynecologic visits by peri and postmenopausal women. In perimenopausal
women the incidence of anoulatory uterine bleeding related to dysfunction of the
hypothalamic-pituitary-ovarian axis increases. Alternatively, the incidence of
bleeding related to pregnancy and sexually transmitted disease decreases. The
incidence of benign and malignant neoplastic growth as the cause of uterine
bleeding also increases with increasing age.
The diagnosis of tumor is very suggestive because of the presence of
abdominal mass. For 5 months patient also complain for intermittent abdominal
mass that only occurs during menstruation. It was located about three fingers
under the umbilicus. The size of the mass is about egg sized, no pain and is not
become larger. For the last 1 month, the mass is persistent. Weight loss is about 2
kg and sometimes complain about dizzy especially when changing position from
sitting to standing up. By ultrasonography, a mass was identifed from uterus and
the diagnosis of uterine myoma is suggestive.
On physical examination, blood pressure was 120/80 mmHg. Conjungtiva
looks pale and there was a palpable abdominal mass. Hemoglobin level was 3,6 at
April 17th 2014 and patients undergo blood transfusion. Six pack of whole blood
was transfused and patients hemoglobin level reached 10,2 at April 22nd 2014.
Patient also suffered a severe anemia. Anemia is not a diagnosis in itself but an
indication of one or more causes. Causes of anemia are presented in table 4.2
Table 4.2 Causes of Anemia
Increased loss of red blood cells
Acute blood loss
Chronic blood loss
Decreased production of normal red blood cells
Nutritional deficiencies
Viral infection
Bone marrow failure
Chronic renal failure
Chronic illness
Poisoning of bone marrow
Increased destruction of red blood cells (hemolysis)
Infection
Drugs
Autoimunne disorder
Inherited disorders
Increased physiological deman for red blood cells and iron
Pregnancy
Lactation
In chronic blood loss, there is a continuing loss of blood from the circulation
over a long period of time. Anaemia thus develops gradually. There is generally
no reduction in the circulating blood volume and normovolaemia is maintained.
The body can initially compensate for chronic red cell loss by increasing red
blood cell production. However, iron is lost with red cells and this eventually
depletes the bodys iron stores. Since iron is an essential component of
haemoglobin, its deficiency causes a reduction in the level of haemoglobin in the
red blood cells being produced. Chronic blood loss therefore typically gives rise
to an iron deficiency anaemia due to impaired production of haemoglobin. The
red cells are small (microcytic) and contain little iron (hypochromic). Since the
red cells contain less haemoglobin, the oxygen carrying-capacity of blood is
reduced.
In this patient, chronic blood loss is most likely as the cause of anemia based
on history and laboratory examination. Based on history, there was a prolonged
bleeding from reproductive tract. The laboratory examination reveals a
hypochromic mircrocytic anemia.
Patient undergo hysterectomy for the treatment of uterine myoma. Before
operation, patient need a correction for the anemia by 6 packs of whole blood.
The indication for surgery treatment in uterine myoma are:
i Abnormal uterine bleeding not responding to conservative treatments.
ii High level of suspicion of pelvic malignancy
iii Growth after menopause
iv Infertility when there is distortion of the endmetrial cavity or tubal
obstruction
v Recurrent pregnancy loss
vi Pain or pressure symptoms (that interfere with quality of life)
vii Urinary tract symptoms (frequency and/or obstruction)
viii Iron deficiency anemia secondary to chronic blood loss
The indication of surgical treatment in this patient is anemia secondary to
chronic blood loss and symptoms that are caused by the uterine myoma.
Hysterectomy is a definitive treatment for uterine myoma. There is no reccurence
after hysterectomy. However hysterectomy is not done it a woman whose still
desire a fertility. In this case, the patient was 45 years old and already have 4
children.