Uterine Fibroids
Presentation
R.B. is a 44 year old female who presents to the emergency room with severe menorrhagia that has worsened in the past four days. Reportedly over the past four days she has used 20 heavy flow menstrual pads per a day. Patient states that her last menstrual period was in June of this year. She also states that she has had lower abdominal discomfort and heavy menstrual flow since July. She was seen by a hematologist 2 weeks prior and was given IV iron, and was scheduled for a repeat myomectomy later this month. R.B. has a past medical history of chronic anemia, menorrhagia, and history of myomectomy 11 years ago. She is gravida 2, para 0, miscarriage 2.
Upon examination, R.B.’s abdomen is round and obese with large palpable uterine fibroids. Labs were drawn and reveal hemoglobin of 7 and hematocrit of 21. Patient is type and crossed for 2 units of PRBCs to be transfused.
Vital signs stable: HR 78, normal sinus rhythm, BP 132/76, Temperature 97.2 axillary, SpO2: 100% on room air
Diagnosis
Due to the patient’s clinical presentation and physical examination patient R.B. has uterine fibroids requiring surgery.
Treatment
Two units of blood were transfused in the ED with no reaction. Patient was admitted to the medical floor and was scheduled for surgery for the morning.
The following morning R.B. was taken to the OR and a laparoscopic-assisted abdominal myomectomy, bilateral uterine artery ligation, extensive, and repair of large bowel defect was performed under general anesthesia. She was found to have massive uterine fibroids localized involving the entire uterus measuring approximately 12-15 cm. The entire fibroid was resected. Estimated blood loss was 3.5L. During the case, she received 5L of lactated ringers, 8 units of PRBCs, 4 units of FFP, and 2 units of platelets. R.B. was tachycardic in 110s-120s throughout the case, remained intubated and was transferred to the SICU. Post operatively R.B. received one liter bolus of normal saline for marginal urine output that was initially 30-35 cc per hour. CBC was checked every six hours for twelve hours and remained stable. Overnight vital signs stabilized. R.B remained ventilated and sedated overnight and was extubated the following morning. Last hemoglobin and hematocrit at the end of twelve hours post operatively remained stable at hemoglobin 8.0 and hematocrit 27.1. Platelets stable at 130.
Outcome
R.B. was stable post operatively. Her only complaint was her frequent bloody vaginal discharge, which is normal post operatively for the type of surgery. Post extubation, R.B.’s oxygen was weaned down and now on room air. R.B. was able to ambulate to the chair with minimal assistance. R.B. was stable for transfer out of the SICU to the medical floor and was cleared for discharge on post op day 3.
Case created by Ronelia Balmoris, 2011.