nursing case study on uterine fibroids

Case report

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• Published: 13 July 2021

Massive uterine fibroid: a diagnostic dilemma: a case report and review of the literature

• Wiesener Viva 1 ,
• Dhanawat Juhi   ORCID: orcid.org/0000-0002-4273-1376 1 , 2 ,
• Andresen Kristin 1 ,
• Mathiak Micaela 3 ,
• Both Marcus 4 ,
• Alkatout Ibrahim 1 &
• Bauerschlag Dirk 1  

Journal of Medical Case Reports volume  15 , Article number:  344 ( 2021 ) Cite this article

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Fibroids of the uterus are the most common benign pelvic tumors in women worldwide. Their diagnosis is usually not missed because of the widespread and well-established use of ultrasound in gynecological clinics. Hence, the development of an unusually large myoma is a rare event, particularly in first-world countries such as Germany. It is even more uncommon that a myoma is misdiagnosed as a dietary failure.

Case presentation

Herein, we report the case of a Caucasian woman with a giant fibroid that reached a size of over 50 cm, growing slowly over the past 15 years, and was misdiagnosed as abdominal fat due to weight gain. We aim to discuss the factors that lead to the growth of such a huge tumoral mass, including misdiagnosis and treatment, and the psychological impact. Through this case, we intend to increase the awareness among general physicians and gynecologists. Although menstrual disorders incorporate several pathologies, adequate assessment remains the primary responsibility of health care providers. A literature review revealed approximately 60 cases of giant uterine fibroids.

The use of clinical and diagnostic devices, especially ultrasound, in this case, is indispensable. In conclusion, the growth of a giant fibroid can have disastrous effects on a woman’s health, including surgical trauma and psychological issues.

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Introduction

Leiomyomas or fibroids are the most common benign pelvic tumors in females that grow monoclonally from the smooth muscle cells of the uterus. Such tumors occur in nearly half of women over the age of 35 years, with increased prevalence during the reproductive phase due to hormone-stimulated growth [ 1 ]. At 50 years of age, 80% of African and almost 70% of Caucasian women have fibroids [ 2 ]. As the underlying pathogenesis of the development of these tumors remains unclear, several risk factors, such as positive family history, genetic alterations, and lifestyle factors (smoking, obesity, dyslipidemia, nutrition, exercise, and medical contraception), have been identified. Treatment of these lifestyle-associated risk factors with vitamin D supplementation, statin use, and dietary modification appears to be protective, along with parity [ 1 , 3 ]. Myomas may occur as a single lesion or as multiple lesions as reported in two-third of the cases, with variation in size from microscopic to large macroscopic extent [ 1 , 4 ]. As the majority of women with myomas remain asymptomatic [ 2 ], the number of undiagnosed uterine fibroids is high. Symptomatic women most likely suffer from abnormal uterine bleeding (meno- or metrorrhagia and polymenorrhea) as well as dysmenorrhea. Other frequent symptoms include dyspareunia or chronic acyclic pelvic pain [ 3 ]. Fibroids affect fertility [ 5 ] and can have a severe psychological impact on a woman’s life [ 3 ]. With continued growth, myomas can cause compression-related symptoms, such as dyspnea, frequent urination, or bowel complaints. The growth rate of myomas varies intra- and interindividually, thereby regressing or gradually increasing in size until the climacteric period is possible [ 1 ]. The identification of rapidly progressing growing fibroids requires close observational ultrasound examinations. Extremely large myomas can involve serious complications such as respiratory failure due to diaphragmatic compression [ 6 ] or incarcerated abdominal wall hernia [ 7 ].

In Germany, universal access to healthcare services is guaranteed by law [ 8 ]. The German ambulatory care sector is densely structured with accessibility of general physicians in less than 30 minutes in more than 90% of all cases [ 9 ]. Utilization of gynecological services in Germany usually begins between the ages of 15 and 16 years [ 10 ] and continues at age 20 with annual visits for prevention of cervical carcinoma [ 11 ], followed by recurrent examinations for breast cancer prevention [ 12 ]. The self-reported prevalence of myomas is high in German women (8.0%), with a mean age of 33.5 years at diagnosis. After the USA, Germany has the second-highest hysterectomy rate among women with uterine fibroids (29.1% versus 21.8%) [ 3 ]. Although diagnosis of a giant myoma is difficult with several possible differential diagnoses, the majority of uterine myomas are confidently diagnosed in the (pre-)clinical routine [ 1 ]. Herein, we present a rare case of a German woman whose uterine tumor was misdiagnosed and remained untreated for the past 15 years, growing into a giant fibroid (16.4 kg) with a size over 50 cm.

A nulligravid, 46-year-old German woman presented to the gynecology clinic because of abnormal uterine bleeding and a slowly increasing abdominal extent in the past 15 years. She had no bowel or bladder complaints. The patient reported two episodes of polymenorrhea and menorrhagia in the past years. Due to the patient’s general fear of physicians and absence of frequent symptoms, she consulted her gynecologist and general physician sporadically. The gynecologist did not use ultrasound to clarify the uterine pathology. The general physician attributed her progressive abdominal extent to weight gain and advised dietary change and physical exercise as management. Both primary health care providers did not perform a thorough physical examination, including imaging methods, leaving the fibroid undiagnosed and untreated.

In our clinic, a preliminary physical examination was performed, which indicated good general condition and no evidence of pallor or pedal edema. The patient’s preoperative body mass index (BMI) was 32.1 kg/m 2 . Her abdomen was enormously enlarged and pendulous with flank fullness on both sides. An irregular mass arose from the pelvis up to the xiphisternum and was not discernible owing to abdominal wall obesity. There were no hernias or abdominal varices. Renal angle fullness was not observed. Because of the patient’s anxiety, a vaginal examination could not be performed. Transabdominal ultrasound showed a huge intraabdominal mass. The right kidney showed impaired cirrhosis, while the left kidney showed compensatory enlargement. A small amount of ascites was observed. An urgent computed tomography (CT) scan was performed revealing a large tumor that occupied the abdominopelvic cavity completely. On the CT scan, the mass measured 32 × 27 × 34 cm (intralesion diameter) and could not be visibly separated from the uterine cavity, bladder, or liver (Fig. 1 ). The tissue of origin and extent of tumor invasion remained unclear. The mass appeared heterogeneous, containing cystic and necrotic areas along with solid components. It compressed the intestines, right kidney, and both ureters. The spleen was mildly enlarged. The hepatorenal recess (Morison’s pouch) showed minimal ascites. No lymph nodes were observed. Due to the slow growth of the tumor, few ascites, and negative lymph nodes, malignancy was highly unlikely.

CT reveals extensive abdominal enlargement in the scout view ( a ). Sagittal CT reconstruction depicts a giant tumor in contact with the liver (black arrow, b ) and with the urinary bladder (black arrowhead, b ). The mass contains necrotic components (white asterisk, c ), as well as small calcifications (black asterisk, d ). The preoperative situs shows compression of the right kidney (white arrow, c ) and ascites adjacent to the tumor (white arrowhead, d )

A midline longitudinal incision was made from the xiphisternum to the pubic symphysis, and the abdomen was opened. A large mass arising from the uterus up to the xiphisternum, firm in consistency with enlarged superficial veins, was seen. The mass extended laterally to both flanks and occupied the right and left hypochondrium. No adhesions to the intestinal organs were observed. The bilateral ovaries were enlarged to twice the normal size, with ovarian artery pulsation seen on both sides. Additionally, the bilateral fallopian tube round ligaments were thickened (Fig. 2 a and b). Due to the in situ findings, a total abdominal hysterectomy en bloc with bilateral salpingectomy was performed, and both ovaries were left intraabdominally. Postoperatively, bilateral ureteric peristalsis was confirmed. Intraoperative blood loss was 400 ml. The patient’s postoperative clinical course within 5 days of hospital stay remained complication-free with quick recovery. She was discharged after 5 days of surgery and had good overall health.

The tumor shows a dilated fallopian tube and an enlarged ovary ( a ). The fibroids appear macroscopically inhomogeneous with enlarged superficial vessels ( b )

Pathology confirmed a myomatous uterus measuring 52 × 37 ×  3 cm and weighing 16.4 kg. The tumor consisted of two separate myomas with diameters of more than 30 cm. Macroscopically, the shape was irregular, with overall consistency being firm with few soft areas. The tumor was pinkish-red in color, similar to (smooth) muscle cells. On the surface, enlarged aberrant blood vessels were observed. The cervix appeared normal, as well as bilateral fallopian tubes, although they were enlarged. For further histopathological examination, a cut section (total of 38 blocks) was performed, and tissue sections were stained with hematoxylin and eosin and examined under a light microscope. The cut sections revealed a heterogeneous phenotype with predominant white whirling structures. Microscopically, the tumoral mass consisted of smooth muscle cells and collagen bundles. Few areas had nuclear polyploidy, blood vessels, and enlarged glands with some superficial hemorrhagic areas. There was no evidence of malignancy.

Although uterine leiomyomas are frequent in women, fibroids > 50 cm in size, similar to the present case, with a weight of 11.6 kg (25 lb) and more being defined as giant , are exceedingly rare. The potential for benign tumors to outgrow quietly without causing specific symptoms is reasonable because of the large volume of the abdominal cavity, flexibility, and slow growth rate of the tumor [ 2 ]. The largest myoma ever reported weighed 63.3 kg and was discovered on autopsy [ 13 ]. Online search using the PubMed database showed approximately 60 cases of giant uterine myomas in the past 50 years worldwide [ 14 ]. Table 1 summarizes the global cases of giant uterine fibroids in the past 20 years.

Preoperative imaging studies are useful to define the extent of the tumor and to assess the likelihood of malignancy in cases of expansive or infiltrative growth. Ultrasonography is the preferred technique for the initial evaluation of gynecologic pathology because of its ubiquitous availability, noninvasiveness, and convenient cost–benefit ratio [ 15 ]. In the present case, preclinical ultrasound imaging would have been absolutely appropriate with regard to diagnosis, surveillance, and prevention of myoma-associated complications. As fibroids continue to grow, they outgrow their blood supply. Therefore, giant myomas often undergo degenerative changes, and dystrophic calcification can complicate the diagnosis [ 16 ]. Although a CT scan may not be the preferred method, many myomas are detected incidentally by CT imaging [ 15 ]. The widespread clinical use of a CT scan lies in its availability, time saving, and comfortable use. Lastly, magnetic resonance imaging (MRI) is recommended to define and measure uterine pathology confidently. As our patient was claustrophobic, MRI was not suitable for her. This imaging method is predominantly utilized in first-world countries in maximum-care hospitals because of its high cost. The atypical appearance of fibroids substantially limits the preoperative informative value of all techniques [ 15 , 16 ]. Hence, the underestimation of the presented fibroid was due to its histologic composition that did not allow precise separation from the intestinal organs.

Uterine leiomyomas have been misdiagnosed as adenomyosis, hematometra, uterine sarcoma, ovarian masses, and pregnancy [ 15 , 17 , 18 ]. Other common non-gynecological differential diagnoses include gastrointestinal tumors or inflammation [ 19 ]. Fibroids often occur with endometriosis and adenomyosis, with an overlap of symptoms [ 20 ], which significantly reduces diagnostic confidence. The position of the fibroid in relation to the uterus affects the patient’s symptoms and diagnostic specificity. Myomas occur within the muscular layer (70% of all cases; intramural), on the outside (20% of all cases; subserosal), or the inside (10% of all cases; submucosal) of the uterine cavity where they possibly have a connective stalk (pedunculation). Pedunculated subserosal myomas can be acutely symptomatic owing to torsion with obstruction of blood vessels, which requires immediate surgery. They often mimic the ovarian pathology. Another differential diagnosis is uterine cancer, with carcinomas being the most frequent and sarcomas and carcinosarcomas occurring rarely [ 2 ]. Malignant transformation of a leiomyoma to a leiomyosarcoma occurs in 0.2% of all cases [ 16 ]. It should be stressed that no imaging method can rule out malignancy so far, leaving the diagnosis of a giant uterine fibroid a challenge. Fibroids of an enormous extent cannot be treated with the most widely used minimally invasive surgery techniques: hysteroscopic myomectomy, vaginal hysterectomy, or total laparoscopic hysterectomy (TLH)/laparoscopic-assisted supracervical hysterectomy (LASH). Similar to the present case, the majority of giant fibroids are removed during total abdominal hysterectomy with additional bilateral salpingo-oophorectomy, depending on the patient’s age and affection of both adnexa. Intraoperatively, severe complications such as hemodynamic instability can occur because of extensive blood loss [ 2 , 21 ]. With regard to the amount of surgery, the general morbidity and mortality in patients who receive a laparotomy is remarkably higher. Postoperative complications include venous thrombosis and acute renal failure [ 22 ]. Generally, giant myomas are fatal for the patient; therefore, such patients have to be treated similarly to older multimorbid patients [ 2 ], with death being a possible outcome [ 23 ].

The prevention of giant fibroid development with close surveillance and early surgical therapy for women with progressive myomas is the clinical gold standard. In Germany, uterine fibroids indicate surgical hysterectomy in 60.7% of all cases [ 20 ]. This underlies the fact that uterine tumors are a relevant reason for hospitalization in women. The development of such a giant myoma in the present case is surprising despite the easy accessibility to professional care and high educational standard of the population in Germany. According to Stentzel et al. , the utilization of professional care depends on several personal factors rather than travel time. In particular, a high socioeconomic status was positively correlated with visits to gynecological care [ 9 ]. Data from the cross-sectional German Health Survey (GEDA) indicate that low social status correlates with less participation in medical check-ups [ 24 ]. This strengthens the role of education in the requirement of self-consciousness and awareness of health checks.

Given the patient’s unemployment for the last 3 years and her modest family background, her low socioeconomic status could have contributed to her worsening condition. Additionally, her general anxiety and previously diagnosed depressive state of mind could have led to the rejection of professional care. The misdiagnosis by her previous doctors could be explained by her lack of complaint regarding irregular menstruation. Women with fibroids of this size are expected to most likely suffer from menstrual disorders [ 1 ], but the patient presented with menstrual irregularities only twice in the past 15 years. This possibly did not prompt her attending physicians to further evaluate the uterus as a cause of the irregular increase in abdominal size. This case was challenging to us as fibroids of this enormous size are rare, and hence, the first diagnosis of fibroid uterus was not made. Instead, it was suspected to be an ovarian carcinoma. Surgical challenges of access, intraoperative determination of anatomy, and hemorrhage were anticipated. Such large masses with uncertain diagnoses pose challenges for young and experienced surgeons alike. The patient was relieved after her treatment and was extremely thankful that she was acknowledged and not merely told that her problems were due to weight gain.

Preclinical utilization of the services of gynecologists in northern Germany depends on personal factors, such as family background, educational level, and socioeconomic status. Menstrual disorders are diverse in diagnosis and have organic and nonorganic reasons that require diagnostic clarification. Therefore, liberal utilization of physical and ultrasound examinations by general physicians could help prevent a delay in diagnosis and therapy of treatable causes such as fibroids. Giant fibroids remain a diagnostic and surgical challenge, requiring expertise and interdisciplinary cooperation. Nevertheless, these gigantic benign tumors can be managed complication-free with proper diagnosis and surgical expertise.

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Abbreviations

Body mass index

Computed tomography

Magnetic resonance imaging

Total laparoscopic hysterectomy

Laparoscopic-Assisted supracervical hysterectomy

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Department of Gynecology and Obstetrics, University Medical Center UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105, Kiel, Germany

Wiesener Viva, Dhanawat Juhi, Andresen Kristin, Alkatout Ibrahim & Bauerschlag Dirk

Spectrum Clinic and Endoscopic Research Institute, 6A and 6B Neelamber building, Shakespeare Sarani, Kolkata, West Bengal, 700020, India

Dhanawat Juhi

Institute of Pathology, University Medical Center UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105, Kiel, Germany

Mathiak Micaela

Department of Radiology and Neuroradiology, University Medical Center UKSH, Campus Kiel, Arnold Heller Straße 3, Haus C, 24105, Kiel, Germany

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VW: manuscript writing; JD: manuscript writing; KA: data collection; MM: histology workup, provided immunohistochemical figures; MB: radiology workup, provided CT scan figures; IA: manuscript editing, surgery; DB: manuscript editing, surgery, provided figures. All authors read and approved the final manuscript.

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Correspondence to Dhanawat Juhi .

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Viva, W., Juhi, D., Kristin, A. et al. Massive uterine fibroid: a diagnostic dilemma: a case report and review of the literature. J Med Case Reports 15 , 344 (2021). https://doi.org/10.1186/s13256-021-02959-3

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DOI : https://doi.org/10.1186/s13256-021-02959-3

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• Uterine mass
• Giant fibroid
• Misdiagnosis
• Weight gain

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Two Case Reports of Fibroid Treatment with Ulipristal Acetate Before In Vitro Fertilization

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• Volume 3 , pages 2332–2338, ( 2021 )

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• Teresa Gastañaga-Holguera 1 ,
• Virginia González González   ORCID: orcid.org/0000-0002-4753-2384 1 ,
• Marta Calvo Urrutia 1 ,
• Isabel Campo Gesto 2 ,
• Marta Vidaurreta Lázaro 1 &
• Ignacio Cristóbal García 1  

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Uterine fibroids are common benign uterine neoplasms in women of reproductive age and pregnancy desire. Several surgical approaches for symptomatic fibroids are available, such as surgical or pharmacologic treatments. We report two cases of fibroids treatment with ulipristal acetate (UPA) in women with primary sterility. The first case reports a successful in vitro fertilization (IVF) after UPA as an alternative treatment to reduce the size of fibroids in a patient with two previous abdominal myomectomies, resulting in an evolutive pregnancy. The second patient is a clinical case of a successful IVF after UPA treatment in a patient with a submucous fibroid which induced myoma migration leading to its prolapse. Even though myomectomy appears to be the gold standard treatment for fibroids in women with reproductive desires, UPA treatment could be considered in those patients at high surgical risk, although more clinical series are needed to establish the safety of UPA as treatment in those women.

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Abbreviations.

controlled ovarian stimulation

European Medicines Agency

follicular-stimulating hormone

human chorionic gonadotropin

human menotropin hormone

international units

in vitro fertilization

magnetic resonance image

recombinant FSH

uterine artery embolization

ulipristal acetate

ultrasound scan

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Gastañaga-Holguera, T., González González, V., Calvo Urrutia, M. et al. Two Case Reports of Fibroid Treatment with Ulipristal Acetate Before In Vitro Fertilization. SN Compr. Clin. Med. 3 , 2332–2338 (2021). https://doi.org/10.1007/s42399-021-01003-1

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Comprehensive Review of Uterine Fibroids: Developmental Origin, Pathogenesis, and Treatment

Affiliations.

• 1 Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA.
• 2 Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, ul. Cegłowska 80, 01-809, Warsaw, Poland.
• 3 Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo 11566, Egypt.
• 4 Department of Anesthesiology, University of Illinois at Chicago, Chicago, IL 60612, USA.
• 5 Department of Pharmacology and Toxicology, Egyptian Drug Authority, formerly National Organization for Drug Control and Research, Cairo 35521, Egypt.
• 6 Department of Molecular Medicine, Institute of Biotechnology, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229-3900, USA.
• PMID: 34741454
• PMCID: PMC9277653
• DOI: 10.1210/endrev/bnab039

Uterine fibroids are benign monoclonal neoplasms of the myometrium, representing the most common tumors in women worldwide. To date, no long-term or noninvasive treatment option exists for hormone-dependent uterine fibroids, due to the limited knowledge about the molecular mechanisms underlying the initiation and development of uterine fibroids. This paper comprehensively summarizes the recent research advances on uterine fibroids, focusing on risk factors, development origin, pathogenetic mechanisms, and treatment options. Additionally, we describe the current treatment interventions for uterine fibroids. Finally, future perspectives on uterine fibroids studies are summarized. Deeper mechanistic insights into tumor etiology and the complexity of uterine fibroids can contribute to the progress of newer targeted therapies.

Keywords: developmental origin; epigenetics pathways; future directions; genetic instability; novel treatment; reprogramming; uterine fibroids.

© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society.

Publication types

• Research Support, N.I.H., Extramural
• Leiomyoma* / etiology
• Leiomyoma* / therapy
• Myometrium / pathology
• Risk Factors
• Uterine Neoplasms* / etiology
• Uterine Neoplasms* / pathology
• Uterine Neoplasms* / therapy

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• R01 ES028615/ES/NIEHS NIH HHS/United States
• R01 HD094380/HD/NICHD NIH HHS/United States
• U54 MD007602/MD/NIMHD NIH HHS/United States
• R01 HD087417/HD/NICHD NIH HHS/United States
• R01 HD106285/HD/NICHD NIH HHS/United States
• R01 HD094378/HD/NICHD NIH HHS/United States

The Nursing Management For Uterine Fibroids

The nursing management for uterine fibroids involves pain management, fluid replacement, bleeding control, and patient education. Uterine fibroids can lead to gynecologic complications. The conditions that can also affect pregnancy are fibroids, endometriosis, ovarian cysts, cervical dysplasia and more.

As a nurse, I had the honor to care for teens girls and adult women. I spent a few years working on a surgical unit with a section reserved for gynecology oncology service. Thus, I observed the patients with signs and symptoms of pain, dehydration and excessive bleeding.

Uterine fibroids necessitate the complex management of a highly trained team of gynecologists, oncologists, and surgeons. In addition, “Gynecologic oncologists also specialize in complex benign gynecologic surgery, including procedures for advanced-stage endometriosis , fibroids , ovarian and uterine masses, cervical dysplasia , ovarian cysts and risk-reducing surgery to prevent gynecologic cancers.” ( John Hopkins Medicine )

The patients often present with acute bleeding, unmanageable pain, and volume deficit. Therefore, the nursing care of uterine fibroids includes blood product transfusion to reverse blood loss. In addition, the pain regimen is very crucial because the patients often report severe pelvic pain. Lastly, nurses will maintain oral or intravenous hydration as recommended by the doctor.

I obtained clinical knowledge about uterine fibroids and gynecologic conditions that can affect pregnancy. I understand that nursing management can be complex but patient-focused. Thus, nursing implementations should be patient-specific.

Nursing Assessment Of Endometriosis

Many women suffer from endometriosis . This is a condition where tissues that belong in the uterus ( endometrium) grow outside the uterus. The tissues are often scattered over the ovaries, fallopian tubes or the intestines. The most common clinical manifestations are pain and irregular or abnormal menstruation.

Pain can be referred to as the lower back, rectum, and vagina. Women also report heavy & painful menstruation and spotting. Medical providers often order laboratory diagnostic testing and/or imaging to confirm their assessment findings. The condition can last for many years and can become chronic. There is no specific age group at risk for this condition.

Nursing Care For Endometriosis

The treatment plan is individualized and is aimed to manage and reverse associated symptoms. Besides, conservative recommendations ( heat pad, pain medication) often alleviate minor symptoms. Many surgical interventions can be performed, outpatient and inpatient. Cauterization -burning or freezing part of the body to remove affected tissue.

Ablation – laser removal of tissue and electrocoagulation where blood vessels are sealed using electric current in order to stop bleeding. Please advise patients to consult a gynecologist if they suffer constant pelvic pain and consistent menstrual irregularities. Can you tell a woman who suffers from endometriosis and uterine fibroids might have difficulty becoming pregnant or maintaining a successful pregnancy?

Clinical Manifestations OF Uterine Fibroids

Some women suffer from uterine fibroids which is a condition of abnormal growth in the uterus. It is most common during the childbearing years and affects mostly African American, obese women and early onset of puberty. The cause of uterine fibroids remain unknown, but successful treatment is available to eligible candidates.

Some of the symptoms include heavy menstrual bleeding, more extended periods, abdominal pain, lower back, and pelvic pain. Gynecologists validate diagnosis with laboratory testing and imaging.

Nursing Management For Uterine Fibroids

Treatment goals aim to minimize bleeding and prevent associated clinical symptoms – acute anemia, pain crisis, cardiac symptoms, dehydration and more. Nurses should anticipate cardiac monitoring and fluid volume replacement.

Pain regimen is also effective in some instances, and some Providers often recommend surgical procedures. In order to manage bleeding, some patients receive birth control prescription and hormone therapy to regulate periods. Some procedures include ablation, uterine artery embolization, removal of the uterus (hysterectomy) and uterine myomectomy ( non-cancerous removal of fibroids).

Some of the uterine fibroids size s can be as big as a twenty-four- week size baby. I have cared for college students in their twenties with uterine fibroids who passed out at school from syncope (sudden collapse) and transferred to the hospital urgently for treatment. The nursing management for uterine fibroids can be complex.

Cervical Dysplasia

This is a pre-cancerous condition that affects the cervix ( head of the uterus). The condition is due to abnormal cell growth and often diagnosed following a pap smear test and caused by the HPV ( human papillomavirus). It can lead to cervical cancer if untreated or diagnosed later. Women are asymptomatic (no associated symptoms) and rely on the gynecologic exam to detect the abnormalities.

When detected early, treatments include surgery or laser therapy. Please see a gynecologist if you are sexually active regardless of age. The American Cancer Society recommends HPV testing for all women between the age of 30-64 and cervical cancer screening every five years. Can you tell that many women might experience difficulty with pregnancy when diagnosed with this condition? I will cover other severe conditions in future posts.

Nursing Care For Uterine Fibroids

Nurses should educate themselves about the pathophysiology of uterine fibroids and other gynecologic conditions mentioned above in order to care for patients safely. It is highly recommended to be familiar with treatment plans, clinical expectations, and outcomes. Nurses should educate the patients about the prescribed treatment plan and advise the patients to seek medical assistance when they observe persistent symptoms.

In addition, the healthcare team should establish a therapeutic relationship with the patients and promote open communication. Nurses also need to provide emotional support to the patients. For instance, provide education about positive coping strategies to prevent depression in women and body image issues related to physical changes.

Education In Nursing Management For Uterine Fibroids

Patients should receive education to complete prescribed treatment in its entirety. Remember to identify patients’ support systems and involve health care partners with the patients’ approval. Patients might need social work referrals to manage psychosocial issues. For example, some culture does not accept women who experience reproductive challenges.

Lastly, the healthcare team can educate patients about alternatives to childbirth like surrogacy, adoption or cryopreservation – egg freezing. Please visit nursesophiedebtfree for additional nursing topics.

Uterine fibroids and other gynecologic conditions can affect pregnancy and can be detrimental to women and their significant others. People often offend others involuntarily and cause unintended emotional trauma. It is wiser to wait for expectant mothers to disclose their pregnancy status. There should be no assumptions based on physical body changes. A large or obese abdomen does not validate pregnancy and can be related to multiple medical conditions.

Nurses play a vital role in the management of patients with gynecologic conditions. They are also qualified to educate patients about symptoms, prescribed treatment plans, and outcomes. Women should visit primary care providers periodically in order to promote early screening and diagnosis.

Some gynecologic conditions are asymptomatic and are only detectable during a medical examination. Safe nursing management for uterine fibroids includes fluid replacement, pain management, bleeding control and patient education. Take charge of your health today and discuss all medical concerns with an independent provider.

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Nurse Sophie has been a registered nurse for over fifteen years. I have a Master's degree in nursing, and my clinical experiences include staff nurse, charge nurse, clinical nurse supervisor, nurse manager, and most recently, nurse consultant in Quality; Patient Safety and legal nursing. I was always passionate about system operations and practice standards. I have completed over 2000 hours of medical chart reviews. I am an expert in clinical investigations, and I also develop event timelines. I can assist the legal team with the Discovery process: Deposition, Interrogatories questionnaire, event timelines, locate expert witnesses, and more. I provide and formulate clinical opinions based on the investigative summary. I also provide nurse coaching services to nurses who experience burnout and looking for a career transition advice. I have been there! Done that! I used to feel overwhelmed when I was younger a bedside nurse and wanted to quit nursing until I changed my mindset and faced my fear of the unknown. After multiple failures, I successfully transitioned out of the direct care settings. It was the best decision that I have ever made. Please send me a request to receive 1:1 career coaching from Nurse Sophie. Nurse Sophie, MSN, RN, LNC Legal Nurse Consultant Patient Safety Specialist website: https://www.nursesophieconsulting.com Email: [email protected]

Nursing Interventions for Uterine Fibroids:

Educate the patient about uterine fibroids, their symptoms, and available treatment options.

Provide emotional support and counseling to address any concerns or anxieties related to the condition.

Administer prescribed medications and monitor their effectiveness and potential side effects.

Assist with minimally invasive procedures or surgical interventions, ensuring the patient's safety and comfort.

Teach the patient self-care measures, such as managing menstrual symptoms and maintaining a healthy lifestyle.

Collaborate with other healthcare professionals to ensure comprehensive care and follow-up.

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Naxlex comprehensive predictor exams.

Questions on Nursing Interventions for Uterine Fibroids:

A nurse is providing education to a group of women about uterine fibroids. Which statement by the nurse accurately describes a risk factor associated with uterine fibroids? A "Uterine fibroids are more common in women who have given birth.” B "African American women have a lower risk of developing uterine fibroids.” C "Genetic predisposition does not play a role in the development of uterine fibroids.” D "Excess body weight is not associated with an increased risk of uterine fibroids.” Click to see answer

Correct answer is b, explanation, a client with uterine fibroids asks the nurse about the causes of this condition. which response by the nurse is correct a "uterine fibroids are caused by a bacterial infection.” b "genetic predisposition and hormonal factors can contribute to the development of uterine fibroids.” c "uterine fibroids are primarily caused by high blood pressure.” d "the main cause of uterine fibroids is a lack of dietary fiber.” click to see answer, (select all that apply): a nurse is assessing a patient with uterine fibroids. which clinical presentations are commonly associated with uterine fibroids select all that apply. a heavy menstrual bleeding. b frequent urination. c severe abdominal pain. d pain during sexual intercourse. e low estrogen levels. click to see answer, correct answer is ["a","b","d"], a client is scheduled to undergo a surgical procedure for the removal of uterine fibroids. what pathophysiological process contributes to the growth of uterine fibroids a genetic mutations and hormonal imbalances. b a decrease in estrogen and progesterone levels. c smooth muscle cell atrophy in the uterus. d a decrease in blood pressure. click to see answer, correct answer is a, a nurse is discussing preventive measures for uterine fibroids with a group of women. what advice should the nurse provide to help reduce the risk of uterine fibroids a "consume a diet high in red meat and low in fruits and vegetables.” b "avoid pregnancy to decrease the risk of uterine fibroids.” c "maintain a healthy weight through regular exercise and a balanced diet.” d "increase estrogen and progesterone levels through hormone therapy.” click to see answer, correct answer is c, a nurse is assessing a patient with suspected uterine fibroids. which of the following symptoms is commonly associated with uterine fibroids a "i have been experiencing frequent urination lately.” b "i have a family history of uterine fibroids.” c "i have a history of recurrent miscarriages.” d "i had a pelvic examination, and the doctor found fibroids.” click to see answer, correct answer is d, a client with uterine fibroids is discussing treatment options with the nurse. the client asks about medications for managing fibroids. which statement by the client indicates an understanding of medication therapy for fibroids a "i should expect my fibroids to be completely removed with these medications.” b "these medications can help shrink my fibroids and relieve my symptoms.” c "i won't need any further treatments or procedures after taking these medications.” d "medications are only effective if my fibroids are small in size.” click to see answer, a nurse is assessing a patient with uterine fibroids. which nursing interventions are appropriate when evaluating this patient's condition select all that apply. a obtain a detailed medical history. b perform a physical examination, including pelvic examination. c order a chest x-ray to assess lung function. d evaluate the patient's psychosocial well-being. e assess the patient's dental health. click to see answer, a client is scheduled for a minimally invasive procedure to treat uterine fibroids. which of the following procedures is a minimally invasive option for fibroid treatment a myomectomy. b hysterectomy. c uterine artery embolization. d progestin therapy. click to see answer, a nurse is educating a patient about uterine fibroids and their potential impact on pregnancy. which statement by the nurse is accurate regarding uterine fibroids and pregnancy a "uterine fibroids have no effect on fertility or pregnancy outcomes.” b "fibroids may lead to recurrent miscarriages in some cases.” c "pregnant women with fibroids never experience complications.” d "surgical removal of fibroids is not recommended during pregnancy.” click to see answer, a nurse is providing education to a patient with uterine fibroids. which statement by the nurse is appropriate a "uterine fibroids are always cancerous, so surgery is the only option.” b "you don't need to worry about your diet or lifestyle; it won't affect your fibroids.” c "maintaining a healthy weight through regular exercise and a balanced diet can be beneficial.” d "uterine fibroids are more common in men than in women.” click to see answer, a client with uterine fibroids expresses concerns about infertility. what response by the nurse is accurate a "infertility is not a complication of uterine fibroids.” b "uterine fibroids can interfere with the implantation of a fertilized egg or cause complications during pregnancy.” c "uterine fibroids have no impact on reproductive health.” d "infertility only occurs in men, not women.” click to see answer, a nurse is discussing complications of uterine fibroids with a group of clients. which complications should the nurse include in the discussion a bowel obstruction. b hypertension. c urinary tract problems. d preterm labor and delivery. e anemia. click to see answer, a nurse is assisting a patient with uterine fibroids in managing her symptoms. what self-care measures should the nurse teach the patient a "you don't need to worry about managing your menstrual symptoms.” b "maintain a sedentary lifestyle to avoid aggravating your fibroids.” c "you can try over-the-counter pain relievers for your pelvic pain.” d "regular exercise and maintaining a healthy lifestyle can help manage symptoms.” click to see answer, a client is scheduled for minimally invasive procedures to treat uterine fibroids. what is the nurse's primary responsibility regarding these procedures a ensure the patient is sedated throughout the procedure. b monitor the patient's vital signs during the procedure. c discourage the patient from undergoing the procedure due to its risks. d administer antibiotics after the procedure to prevent infection. click to see answer, search here, related topics, more on nursing.

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• Case Report
• Open access
• Published: 27 April 2024

Minimally invasive treatment of uterine necrosis with favorable outcomes: an uncommon case presentation and literature review

• Tengge Yu 1  

BMC Women's Health volume  24 , Article number:  267 ( 2024 ) Cite this article

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Uterine necrosis is a rare condition and is considered a life-threatening complication. However, cases of uterine necrosis were rarely reported, particularly those caused by infection. In terms of treatment, no minimally invasive treatment for uterine necrosis has been reported, and total hysterectomy is mostly considered as the treatment option.

The article specifically focuses on minimally invasive treatments and provides a summary of recent cases of uterine necrosis.

Case presentation

We report the case of a 28-year-old patient gravid 1, para 0 underwent a cesarean section after unsuccessful induction due to fetal death. She presented with recurrent fever and vaginal discharge. The blood inflammation markers were elevated, and a CT scan revealed irregular lumps with low signal intensity in the uterine cavity. The gynecological examination revealed the presence of gray and white soft tissue, approximately 5 cm in length, exuding from the cervix. The secretions were found to contain Fusobacterium necrophorum, Escherichia coli, and Proteus upon culturing. Given the patient’s sepsis and uterine necrosis caused by infection, laparoscopic exploration uncovered white pus and necrotic tissue openings in the anterior wall of the uterus. The necrotic tissue was removed during the operation, and the uterus was repaired. Postoperative pathological findings revealed complete degeneration and necrosis of fusiform cell-like tissue. Severe uterine necrosis caused by a multi-drug resistant bacterial infection was considered after the operation. She was treated with antibiotics for three weeks and was discharged after the infection was brought under control. The patient expressed satisfaction with the treatment plan, which preserved her uterus, maintained reproductive function, and minimized the extent of surgery.

Based on the literature review of uterine necrosis, we found that it presents a potential risk of death, emphasizing the importance of managing the progression of the condition. Most treatment options involve a total hysterectomy. A partial hysterectomy reduces the extent of the operation, preserves fertility function, and can also yield positive outcomes in the treatment of uterine necrosis, serving as a complement to the overall treatment of this condition.

Peer Review reports

Uterine necrosis is a rare complication. Several cases of uterine necrosis have been reported following embolization of the uterine arteries for postpartum hemorrhage or uterine fibroids, or as a result of severe endometritis [ 1 ]. Symptoms of uterine necrosis caused by infection typically include lower abdominal pain, fever, and foul-smelling vaginal discharge. When the infection affects the tissue surrounding the uterus, the uterus becomes enlarged and tender, and the edema of the inflamed tissue holds the uterus in place. Some complications may occur infrequently, including peritonitis, pelvic vein thrombosis, pulmonary embolism, pelvic abscess, sepsis, kidney damage, and even death. Diagnosis is usually based on clinical symptoms and physical examination. Inflammatory markers, imaging studies, and secretion cultures can also assist in the diagnosis. Hysteronecrosis is typically treated with a total hysterectomy. Most patients recover, and only a small number of patients do not survive. We reported a case of uterine necrosis caused by infection. We removed part of the uterus instead of performing a total hysterectomy. The patient recovered well. Few cases of uterine necrosis have been reported, and no one has reported minimally invasive treatment for it. Given the rarity of the case and the lack of minimally invasive treatment options for uterine necrosis, this report was written in conjunction with a literature review summarizing similar cases of uterine necrosis.

We report the case of a 28-year-old patient who was gravid 1, para 0, with no significant medical history. The patient is Asian, from the Han ethnic group, China’s largest ethnic group. When she was 32 weeks pregnant, intrauterine fetal demise was confirmed by ultrasound. A cesarean section was performed due to the difficulty of vaginal trial labor following a lateral perineal incision, which was necessary because the fetus’s shoulder was exposed. After the operation, the patient continued to experience a high fever, with a maximum temperature of 39.5 degrees Celsius, and the fat around the abdominal incision has become liquefied. The number of patient’s pulses was 140, respiratory rate was 22 times per minute, and blood pressure was 131/87mmhg. After receiving treatment with medications such as Tienam and Piperacillin, the patient’s body temperature and inflammation returned to normal, and she was discharged from Municipal integrated traditional Chinese and Western medicine hospital. The type of antibiotic Tienam is Carbapenem antibiotics, and the dose is 500 mg by injection three times a day. The type of antibiotic Piperacillin is semi-synthetic penicillin antibiotics, and the dose is 1.5 g by injection three times a day. The disease subside after 7 days treatment.

A week later, she was admitted to Municipal integrated traditional Chinese and Western medicine hospital for the second time due to fever and pain in her lower left abdomen. The patient’s heart rate was normal, respiratory rate was 20 times per minute, and blood pressure was 121/80mmhg. The blood inflammation index was elevated, indicated by a C-reactive protein level of 52.01 mg/L. Brain CT and lung CT scans revealed no significant abnormalities. She was discharged after two weeks of treatment with medications such as Tienam and Piperacillin with the same dose as last time. The disease subside after 5 days treatment.

Five days later, she was admitted to our hospital for the third time due to a recurring fever, accompanied by vaginal purulent discharge and odor. The patient’s heart rate was 110 times per minute, respiratory rate was 23 times per minute, and blood pressure was 132/85mmhg. There was no increase in β-HCG, white cell count was 12.3 × 10^9 /L in the differential blood count, hemoglobin was 104 g/L, and procalcitonin was 0.12 ng/ml. She felt feverish and lethargic, with mild nausea. The patient was treated orally with Moxifloxacin by 1 tablet once a day for 3 days. A vaginal color ultrasound revealed a hypoechoic area in front of the uterus, indicating encapsulated effusion. The ultrasound also revealed an abnormal uterine echo, uneven uterine enlargement with abundant blood supply, trace effusion of the cervical canal, and pelvic effusion. The enhanced CT scan revealed swelling and adhesion of the anterior wall of the uterus and the adjacent anterior abdominal wall, along with changes in the surrounding exudate. Additionally, a lumpy, uneven low signal shadow was observed in the uterine cavity, along with visible pelvic fluid (Fig.  1 ). The histopathological analysis of intrauterine effluents revealed degenerative smooth muscle tissue accompanied by pus. Anaerobic culture of cervical secretions suggested the presence of Fusobacterium necrophorum. Biopsy of cervical and vaginal lesions revealed complete necrosis of fusiform cell-like tissue, with increased infiltration of inflammatory cells, and no identifiable endometrial tissue. Due to the presence of pus in the uterus, morinidazole was administered, and uterine drainage was performed. However, the result was not favorable. A gynecological examination revealed the presence of necrotic tissue in the vagina, extending approximately 5 cm from the cervical opening. The tissue appeared white and emitted a foul odor. It was recommended to undergo a laparoscopic surgery.

Sagittal computed tomography images. The uterus shows heterogeneous spongiform enlargement with multiple air locules, measuring 4 × 2.6 cm and extending over 5 cm. We have observed a difficulty in distinguishing between the myometrium and the endometrial cavity

Given that the patient had strong fertility requirements, the surgical procedure included laparoscopic necrotic tissue excision, uterine reconstruction, and the uterine drainage tube placement. During the laparoscopy, adhesion of the uterus to the anterior wall of the abdomen was observed. An opening with white pus and necrotic tissue was visible in the anterior wall of the uterus. The necrotic tissue in the cavity was removed during the operation (Fig.  2 Fig.  3 ). Cefoxitin (1.5 g tid ivgtt) and ornidazole (500 mg bid oral) were administered postoperatively to prevent infection for 2 days. After the surgery, the patient developed a fever with a peak body temperature of 39.3 degrees Celsius, which prompted a switch to cefoperazone-sulbactam sodium (2 g bid ivgtt) and ornidazole antibiotics (500 mg bid oral) for 7 days. After the body temperature returned to normal, the antibiotics were downgraded, the uterine drainage tube was removed, and oral antibiotics were continued after discharge. The results of the vaginal secretion culture indicated the presence of Escherichia coli and Proteus bacteria. The pathological results revealed extensively denatured necrotic tissue with calcification and heightened inflammatory cell infiltration.

The images seen during the surgery. The necrotic tissue of the uterus, attached to the anterior wall of the abdomen, is clearly visible in gray and white colors. It is situated in the anterior wall of the uterus and is connected to the uterine cavity

The gross specimen appeared gray in color, with an extremely soft texture, measuring about 5 cm in length, and accompanied by a foul odor

Uterine necrosis is a rare and serious complication. Cases of uterine necrosis have been reported in the literature as a complication of cesarean section, embolization for postpartum hemorrhage, or for a leiomyomatous uterus, as well as in cases of severe endometritis [ 2 , 3 , 4 , 5 , 6 , 7 ] (Table  1 ). Several authors have described cases of uterine necrosis associated with intrapartum or postpartum complications that increase the risk of infection. The literature reports cases of uterine necrosis resulting from the placement of B-Lynch compression sutures, uterine artery embolization, or surgical ligation techniques used to treat postpartum hemorrhage. These procedures may increase the risk of infection as the tissue becomes devascularized. A. Fouad et al. described a case similar to ours in which a patient underwent a cesarean section due to fetal death, followed by postoperative sepsis and purulent uterine necrosis. Despite undergoing a hysterectomy, the disease continued to progress and ultimately resulted in death due to septic shock and multiple organ failure.

The case we report has identified pathogenic bacteria in the culture, which is significant for diagnosing infection-induced uterine necrosis. Fusobacterium necrophorum is a pleomorphic, Gram-negative, non-spore-forming obligate anaerobic coccobacillus. It is associated with localized abscesses, throat infections, and life-threatening systemic diseases. It is a common resident of the oral cavity and the vagina. Of the two subspecies of Fusobacterium necrophorum, biovar B is the primary pathogen for humans. Potential virulence factors include cell wall endotoxin lipopolysaccharide, hemagglutinin, and hemolysin. Most reported cases related to gynaecology occurred in the postpartum or post-abortion period, in addition to a few reports associated with the use of intrauterine devices, tubo-ovarian abscesses, and gynecological Lemierre’s syndrome [ 8 , 9 , 10 ]. Although infected with the same pathogen, the case reported by T. Widelock et al. developed more severe symptoms, including lung abscesses and kidney failure, as a result of hematoplasm infection [ 11 , 12 , 13 ].

A pelvic ultrasound is the initial diagnostic test that can reveal signs of uterine necrosis. The uterine cavity is typically expanded and exhibits multiple echogenic foci with accompanying dirty acoustic shadowing. Little or no vascularity is observed [ 14 ]. The diagnosis requires further exploration through a CT scan or MRI, as these are the preferred methods of investigation. The CT scan is highly useful for diagnosis as it demonstrates the presence of gas in the myometrium, the lack of enhancement of the myometrium after contrast injection associated with uterine enlargement, and the presence of free fluid in the peritoneal space [ 15 , 16 ].

Since uterine necrosis is described as a life-threatening complication, it is suggested to manage it with hysterectomy and broad-spectrum antibiotic therapy [ 17 , 18 ]. But sometimes it’s a case-by-case situation.

Avoid the chances of associated infections by systematic vaginal sampling in the third trimester, and promote good asepsis during surgery and antibiotic coverage in case of doubt about any undiagnosed prepartum infection, which may potentiate hypoxia and the risk of necrosis. Uterine necrosis may be secondary to all these intertwined factors and could be potentiated by an environment of hypoxia, hypoperfusion, hypovolemia secondary to hemorrhage, massive transfusions with disadvantages in a patient who is immunocompromised by pregnancy, and possibly, by other vitamin and iron deficiencies.

Given the limited number of reported cases of uterine necrosis in the past, there is no standardized treatment protocol. However, due to the potential fatality of uterine necrosis, most treatment options involve total hysterectomy. In our case, only the necrotic tissue of the uterus was removed in young women who had not given birth, and the prognosis for the patient is good. This study also has limitations, including the short follow-up time and the small number of cases collected. It needs to be complemented by subsequent case reports related to uterine necrosis.

Data availability

No datasets were generated or analysed during the current study.

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Yu, T. Minimally invasive treatment of uterine necrosis with favorable outcomes: an uncommon case presentation and literature review. BMC Women's Health 24 , 267 (2024). https://doi.org/10.1186/s12905-024-03089-w

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Received : 21 December 2023

Accepted : 12 April 2024

Published : 27 April 2024

DOI : https://doi.org/10.1186/s12905-024-03089-w

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