Edema of the node
INFLUENCE OF THE BLOOD SUPPLY OF THE MOMOMATOUS NODE
Myoma of the uterus (MM) is a benign tumor,originating from muscle tissue. Necrosis is an irreversible cessation of the vital activity of tissues of a certain part of a living organism. MM, even in very small sizes, can deform the blood vessels that supply it with blood, and cause tissue necrosis. Previously, the term "malnutrition of the myoma node" was used.
D25 Leiomyoma of the uterus.
D25.0 Submucosal uterine leiomyoma.
D25.1 Intramural uterine leiomyoma.
D25.2 Suberous leiomyoma of the uterus.
Cystic degeneration and necrosis are detected in 60%removed myomatous nodes, they arise as a result of a violation of blood supply to the myoma. The frequency of necrosis of MM, according to free statistics, is about 7%. Nodules of a tumor are especially often necrotic during pregnancy, postpartum or postabortion periods.
Prevention of the violation of the blood supply to the myomatous node of the uterus consists in its timely diagnosis, rational treatment, detection of indications for surgical treatment in a planned manner.
Conduction of transvaginal ultrasound 2 times a year in women at high risk and once a year in practically healthy women.
In the conventional sense, there is no classification. Disruption of blood supply to the fibroids node may result from:
- torsion of the legs of the subserous myomatous node;
- ischemia of an interstitial node of large size, or its rapid growth.
Disruption of blood supply to the myoma node occursdue to torsion of the leg of the myomatous node, as well as as a result of ischemia, venous stasis and multiple thrombus formation in the interstitial nodes. MM, even in very small sizes, can deform the blood vessels that provide the blood supply to the endometrium and cause its necrosis. Sub-serous
nodes are usually associated with the body of the uterus with a widebase, but sometimes grow directly under the peritoneum, connecting with the uterus with a thin pedicle. Such nodes are very mobile and easily subject to twisting. Disturbance of blood supply in the myomatous nodes is due mainly to mechanical factors (torsion, bending, squeezing of the tumor). However, it is impossible not to take into account the peculiarities of hemodynamics during pregnancy. In patients with MM during pregnancy, a significant decrease in blood flow in the uterus is noted, especially in the intermuscular junction area, an increase in vascular tone, mainly in small-caliber vessels, severe venous outflow, reduced blood flow of the arterial and venous bed.
When the blood supply to the myoma node is compromised, various dystrophic processes occur: edema, necrosis, hemorrhage, hyaline degeneration, degeneration.
Particular importance is the formation of plotsnecrosis. Distinguish dry and wet types of necrosis MM. The so-called red necrosis of myoma is described. With dry tumor necrosis, there is a gradual wrinkling of areas of necrotic tissue, while creating a peculiar cavernous cavity with the remains of dead tissue. With wet necrosis, softening and moist necrosis of the tissue occurs, followed by the formation of cystic cavities.
Red necrosis is often affected by fibroids,located intramural. Usually this form of necrosis occurs during pregnancy and in the postpartum period. Macroscopically, tumor nodes are colored red or brown red, have a soft consistency, microscopically detect pronounced expansion of the veins and their thrombosis.
Aseptic necrosis is almost alwaysan infection that penetrates the site with hematogenous or lymphogenous pathway is attached. Infectious agents usually belong to the septic group of microbes (staphylococcus, streptococcus, E. coli). Infection of myomatous nodes presents a great danger due to the real possibility of diffuse peritonitis and generalized infection (sepsis).
Clinical manifestations of blood supply to the node depend on the degree of disturbance.
With acute development of the disease, it is noted:
- pain in the lower abdomen;
- subfebrile temperature;
- with a vaginal examination determine an enlarged and painful uterus.
Similar complications occur, as a rule, with large sizes of myomatous nodes.
When the legs of the subperitoneal myomatous node are twisted, the symptoms of an acute abdomen appear:
- pain in the lower abdomen;
- nausea, vomiting;
Necrosis of fibroids usually accompanies:
- acute pain in the abdomen;
- anterior abdominal wall tension;
- increased body temperature;
- nausea, vomiting;
- stool and urination disorder;
- with vaginal examination, the presence of myoma nodes in the uterus is determined, one of which is sharply painful on palpation.
Diagnosis is based on typical complaintspatients, anamnesis and objective examination, the results of laboratory and additional research methods. The patient's condition is satisfactory or of moderate severity. The skin is pale. Severe tachycardia. Blood pressure is within normal limits. The abdomen is strained, sharply painful, swollen, there are symptoms of irritation of the peritoneum with varying degrees of severity. In the blood, an increased number of leukocytes, a shift of the leukocyte formula to the left and an increase in ESR.
To additional methods of diagnosis include ultrasound of the pelvic organs and laparoscopy.
Ultrasound scanning together withdopplerography allows you to make an accurate diagnosis. In this case, the myomatous node contains cystic cavities, areas of different echogenicity, the blood flow inside the node and nearby sections of the myometrium is disturbed.
The most characteristic acoustic features include:
- increased uterine size, especially anteroposterior size;
- deformation of the contours of MM and the appearance in it of structures of round or oval shape, characterized by less echogenicity and sound conductivity.
With edema, the internal structure of the node becomesheteroechoic, the effect of "absorption" disappears and instead, as a rule, the effect of "amplification" appears. With such an echographic image, mistakes in the differentiation of uterine and adnexal structures often occur.
In the case of necrotic changes in the myomium, the echographic pattern changes even more significantly. Inside the tumor
certain echopositive and echo-negative areas, which are zones of necrosis, are determined.
The sound conductivity behind them increases.
Laparoscopy allows not only to clarify the diagnosis, but also to provide access to surgical treatment.
Myomatous nodes with degeneration of darker, bluish-colored color, with hemorrhages and white areas.
The peritoneum covering these nodes is dull.
Differential diagnosis is carried out withapoplexy of the ovary (painful form), ectopic pregnancy, acute appendicitis, with OVZPM, especially with complicated forms (purulent tubo-ovarian formations, pyosalpinx, pioovar).
Given the clinic of an acute abdomen, patients should be examined by a surgeon.
The purpose of the treatment: elimination of blood supply disorders of the MM node.
Indication for hospitalization in an emergency - a suspicion of a blood supply disorder of the myoma.
The main method of treatment is surgical. Non-pharmacological methods of treatment are not carried out.
Treatment is prompt, performed by a laparotomyor laparoscopic access. The choice of access is determined by the qualification of the surgeon and the technical support of the operating room. The amount of surgical intervention depends on many factors: the age of the patient, the implementation of reproductive function, size, localization, the number of myomatous nodes. Depending on the clinical situation and the age of the patient, the decision is made in favor of an organ-preserving operation.
With necrosis of the myomatous node, the conservativemyomectomy is not indicated; In the postoperative period serious complications can arise: divergence of sutures on the uterus, suppuration, peritonitis. Amputation or extirpation of the uterus with tubes is performed. Conservative myomectomy can be performed only in exceptional cases in young childless women under conditions of intensive antibiotic therapy.
Terms of incapacity for work depend on surgical access: after laparotomy - 14 days, after laparoscopy - 9 days.
After surgical treatment, patients need regular follow-up, according to medico-economic standards.
Annual preventive examination of the gynecologist with mandatory ultrasound of the pelvic organs.
If a MM is detected, follow-up with ultrasound 2 times a year.
According to the indications, surgical treatment is planned.
When there are pains in the lower abdomen, nausea, vomiting, fever, it is necessary to urgently consult a doctor.
With timely diagnosis and performing surgical treatment, the prognosis for life and health is favorable.
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Source: Gynecology - national guidelines, ed. IN AND. Kulakov, G.M. Savelieva, I.B. Manukhin 2009