MYOMA UTERI C E L I N E L Ö N N E R F O R S

Transkript

1 MYOMA UTERI C E L I N E L Ö N N E R F O R S

2 Jhonen Vasquez cartoon

3 Bakgrund 5-25% av fertila kvinnor 25% symptomatiska Menorraghia, trycksymptom, smärta, infertilitet, missfall Storlek och lokalisation Vanligaste orsaken till hysterektomi Assoscierad med stora kostnader Önskan om bevarad fertilitet hos äldre kvinnor och fördröjd baranfödande Heterogen åkomma Differential diagnoser, obs malignitet

4 Etiologi och patogenes Normal karyotyp Genmutationer (MED12) Stamceller som avviker från stamceller i myometriet Progesteron>östrogen MicroRNA Extracellulärt matrix TGF

5 Etiologi och patogenes OKLART

6 Risk/preventive factors Woman of reproductive age Ethnicity Pregnancy and childbirth Age at menarche and menopause Smoking Obesity Oral contraceptives Other: Retinoic acid, pirfenidone, components of green tea, and vitamin D3

7 Growth Growth pattern vary Usually slow (median 9% per year, range 89% to +138%) Related to ethnicity Rapid growth not related to the risk of sarcoma (0,23%)

8 Lifestyle factors Obesity Metabolic (serum triglycerides, blood glucose) Dietary Infection Uterine injury Stress Environmental factors Smoking

9 Gonadal steroids Development and growth Estrogen and progesterone receptors Oral contraceptives GnRH analogues and progesterone receptor modulators

10 Myomas and fertility Poorly understood Proximity to the endometrium, size Deformation of the uterine contour, tubal ostia, or cervix Changed contractility of the uterine muscle Altered blood flow and/or growth factor expression

11 Fibroids and IVF Decreased pregnancy and implantation rates Improved outcomes following myomectomy in women with myomas distorting the uterine cavity Decrease in the live birth- and clinical pregnancy rates in women with intramural myomas*

12 Pregnancy and childbirth Protective effect Prevalence 10% during pregnancy 60-80% do not grow during pregnancy Growth primarily during first trimester Proximity to the placenta Increased risk of spontaneous miscarriage, preterm labor, placental abruption, malpresentation, labor dystocia, caesarean delivery, retained placenta, intrauterine growth retardation and postpartum haemorrhage Postpartum shrinkage (80%)and remodeling

13 Behandling Medicinsk Interventionsradiologi Radiologisk Kirurgisk SYMPTOMSTYRD Fertilitetsönskan?

14 Medicinsk behandling Hemostatiska medikamenter (Cyklo-F) Smärtstillande Järnmedicinering Hormonspiral GnRH Selektiva progesteron receptor modulator (Esmya)

15 Interventionsradiologi Embolisering Fördelar: minimal invasiv metod OPERATÖRSBEROENDE Nackdelar: minskat ovarialreserv, påverkad endometrium, intrakavitära adherenser, risk för påverkan på andra organ, nekros, infektion, akut hysterektomi. OPERATÖRSBEROENDE RCT har visat bättre resultat med myomektomi

16 Radiological treatment Magnetic resonance guided focused ultrasound

17 Kirurgisk behandling Myomectomi; rekommenderad behandling vid fertilitetsbevarande kirurgi Submukösa= hysteroskopi/vaginal myomektomi Subserösa= tveksamt Intramurala= laparoskopi/lapartotomi Laparoskopi>laparotomi (minimal invasivt, mindre adherenser) Storlek, antal, lokalisation

18 da Vinci surgical robot

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22 Robotic myomectomy

23 Other surgical methods Laparoscopic occlusion of the uterine arteries

24 Vaginal myomectomy Large submucosal myomas not available for hystereoscopic resection

25 MRI

26 Postoperative ultrasound

27 Fertility after myomectomy Pregnancy rates 50-60% Heterogeneous group Mode of delivery- depending on depth of incision and size of lesion removed Uterine rupture, approximately 1% 3-6 month quaranteen Do not postpone pregnancy (80% recurrence rate after 10 years)