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Résidence - FM Learner > 102. Vaginal Bleeding (15%) > Flashcards

102. Vaginal Bleeding (15%) Flashcards

1
Q

Chez toute femme qui présente un saignement vaginal, éliminez quoi?

A

une grossesse.

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2
Q

Chez les femmes enceintes qui présentent un saignement vaginal,
Considérez certaines causes sérieuses.
Nommez en (3)

A
  • grossesse ectopique
  • décollement du placenta
  • avortement
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3
Q

N’oubliez pas de préciser le groupe sanguin et de procéder aux tests de dépistage. De plus, administrez le vaccin Winrho lorsqu’approprié.

A
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4
Q

Chez une femme non enceinte qui présente un saignement vaginal,
* a) Procédez à l’investigation et aux tests appropriés afin de diagnostiquer certaines causes sérieuses (p. ex. cancer), en utilisant une approche appropriée à l’âge.
* b) Diagnostiquez (et traitez) toute instabilité hémodynamique.
* c) Prenez en charge toute patiente hémodynamiquement stable, mais dont le saignement vaginal est important (p. ex. traitement médical ou chirurgical).

A
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5
Q

Lorsqu’une femme postménopausée présente un saignement vaginal, investiguez tout nouveau saignement ou tout changement vaginal.

Nommez des tests/investigations possibles

A
  • biopsie de l’endomètre
  • échographie pelvienne
  • tomodensitométrie
  • Pap test
  • sans oublier l’examen gynécologique
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6
Q

Differenciate menstruation regularity (3)

A
  • Normal variation is 2-20 days
  • Irregular (>20 day bleed-free intervals within 90 days)
  • Absent/amenorrhea (No bleed in 90 days)
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7
Q

Describe menstruation frequency (3)

A
  • Normal 24-38 days
  • Infrequent (>38d)
  • Frequent (<24d)
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8
Q

Describe normal/prolonged/shortened menstruations

A
  • Normal 3-8 days)
  • Prolonged (>8d)
  • Shortened (<3d)
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9
Q

Name outside reproductive age

A
  • Post-menopausal
  • Precocious (<9y)
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10
Q

Name DDX : Vaginal bleeding (6)

A
  • Pregnancy (Ectopic)
  • Trauma
  • Infection
  • Systemic (Hypothyroid, Hyperprolactinemia, Cushing’s, PCOS, Adrenal, Hypothalamic suppression - stress)
  • Iatrogenic / Medication (anticoagulants, hyperprolactinemia - antipsychotics, antidepressants)
  • AUB
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11
Q

Name categories of AUB

A
  • PALM (structural)
  • COEIN (nonstructural)
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12
Q

Name STRUCTURAL causes of AUB (4)

A

PALM

  • Polyp
  • Adénomyose
  • Léiomyome (Submucosal, Other)
  • Malignancy/hyperplasia
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13
Q

Name NON-STRUCTURAL causes of AUB (5)

A

COEIN

  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified
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14
Q

Describe history of vaginal bleeding (7)

A
  • Anemia (presyncope, SOBOE)
  • Sexual and reproductive history (pregnancy, STI, vaginal discharge, cervical screening)
  • Systemic (hypothyroidism, hyperprolactinemia, coagulation disorder, PCOS, adrenal/hypothalamic)
  • Pelvic pain/pressure
  • Impact on QOL
  • Fam Hx (coagulation, PCOS, endometrial/colon CA)
  • Comorbid (hormone tumours, thromboembolic disease, CVD) could impact treatment options
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15
Q

Describe physical exam of vaginal bleeding (7)

A

Potential sites of bleeding
* Vulva, vagina, cervix, urethra, anus, perineum

Pelvic examination, speculum
* Mass, laceration, friable area
* Cervical polyp
* Uterine enlargement (pregnancy, leiomyoma, adenomyosis, uterine malignancy)

General exam for systemic illness, thyroid, hyperandrogenism, acanthosis nigricans, galactorrhea

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16
Q

Name investigations for menstrual bleeding (10)

A
  • CBC (Hb)
  • B-hCG (Serum positive 9d post-conception, Urine positive 28d after LMP)
  • TSH, Prolactin
  • Blood type and screen
  • Coags, vWF, Fibrinogen (history of menorrhagia)
  • Iron studies
  • Gono/Chlam (cervicitis)
  • Cervical cancer screening (as per guidelines)
  • Endometrial sampling if …
  • Imaging if exam findings of structural lesion, symptoms persist
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17
Q

When to do endometrial sampling? (4)

A
  • > 40yo. Note: If postmenopausal on HRT <12mo can observe for one year before diagnosing AUB
  • Risk factor (Obesity, PCOS, nulliparity, diabetes, Hereditary nonpolyposis colorectal cancer (Lynch Syndrome 40-60% endometrial CA)
  • Failed management / persistent AUB
  • Consider if Infrequent AUB >3y (suggests anovulatory)
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18
Q

Name possible imaging for AUB (2)

A
  • Pelvic ultrasound (eg. ovulatory heavy bleeding)
  • Saline sonography for submucosal fibroids
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19
Q

Describe ACUTE management of non-pregnant vaginal bleeding (5)

A
  • Conjugated equine estrogen 25mg IV q4-6h x24h. Consider antiemetic due to side effects of nausea/vomiting
  • Combined OCP TID x7d
  • Medroxyprogesterone acetate 20mg TID x7d
  • Tranexamic acid 1g PO/IV TID x5d
  • Procedure (D&C, endometrial ablation, uterine artery embolization, hysterectomy)
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20
Q

Describe management : AUB-HMB (most leiomyomas or adenomyosis) (5)

A
  • Mirena IUD (LNg20)
  • Combined OCP
  • Progestin
  • Tranexamic, NSAIDs
  • Expectant if not anemic or does not desire treatment
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21
Q

Describe management : AUB-O (Ovulatory dysfunction) (3)

A
  • Mirena IUD (LNg20)
  • Combined OCP
  • Progestin
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22
Q

Describe management : Dysmenorrhea/pelvic pain

A
  • Gonadotropin-releasing hormone agonists (ex. Lupron)
  • Surgery (uterine fibroid embolization, myomectomy, and hysterectomy)
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23
Q

Name DDX First trimester bleeding

A
  • Saignement d’implantation
  • Grossesse anormale (extra-utérine/molaire)
  • Avortement (menacé, inévitable, incomplet, complet, manqué, septique)
  • Non obstétrical (pathologie utérine, cervicale et vaginale)
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24
Q

Name investigaitons for 1st trimester bleeding

A
  • CBC
  • Blood type
  • Serial b-hCG hCG (<35% over 48h suggest ectopic or abnormal IUP)
  • Abdominal Ultrasound
  • Transvaginal Ultrasound
25
Describe management if if excessive bleeding (3)
* Tranexamic acid IV over 10-20 mins * Misoprostol * Vasopressin injected on anterior lip of cervix (see paracervical block)
26
Describement management if incomplete abortion
* Consider dilation & aspiration * Prophylactic antibiotics (eg. Azithromycin/Doxycycline PO x1)
27
Name DDX : Second and Third Trimester (6)
* Expulsion du bouchon muqueux (début 72 h avant le travail, PPROM) * Placenta previa (20%) * Décollement placentaire (30%) * Rupture utérine (rare) * Vasa previa (rare) * Non-Obstetrical (Uterine, Cervical, Vaginal Pathology)
28
Desribe : Placenta previa
Touching/covering internal os (low-lying is within 2cm)
29
Describe : Placental abruption
* Painful contractions, hypertonus tender uterus, vaginal bleeding may be concealed * Clinical diagnosis, not well diagnosed on ultrasound * Kleihauer-Betke test (fetal cells in maternal blood)
30
Describe : Uterine rupture
* Suspect in shock, acute abdominal pain, change in station, abnormal FHR, vaginal bleeding * Risk: Uterine scar, hyperstimulation (IOL), multiparity
31
When to suspect Vasa previa ?
Suspect in painless bleeding with change in FHR
32
When to do cervical exam in 2nd and third trimester bleeding ?
Avoid digital cervical exam until placenta previa ruled out by ultrasound (also if possible prior to speculum)
33
Describe management : 2nd and 3rd trimester bleeding ?
* Get help, oxygen, IVF (LOTS!), foley * Massive transfusion protocol * Follow Hb and Coag
34
Name causes : Postcoital bleeding (7)
* Ectropion cervical (30 %) * Polypes cervicaux (20 %) * CIN (15 %) ou cancer (4 %) * Infection * Grossesse * Traumatisme * Atrophie
35
Describe tx : Ectropion cervical
Nitrate d'argent
36
Postcoital bleeding usually resolves by when ?
60% resolve by 6 months
37
Name blood tests for AUB (5)
* B-HCG * TSH (only if sx) * prolactin (if anovulatory) * Coagulation studies (if abnormal bleeding or family hx) * Androgens (if clinical hyperandrogenism : total testosterone, sex hormone binding globulin. If elevated, DHEEA-S, 17-OH.
38
Name other tests for AUB
* Endometrial bx * Transvaginal pelvic ultrasound * Pap * Colposcopy
39
Name indications for endometrial biopsy in AUB (4)
* Age >= 40 and anovulatory. (Irregular or infrequent cycles) * Age < 40 and risks * Failed medical tx * Significant inttermenstrual bleeding
40
Endometrial bx if age <40 and risks. Name risks (8)
* BMI > 30 kg/m2 * Chronic anovulation * DB * Infertility or nulliparity * Use of tamoxifen currently * Adolescents if obese and 2-3 years of AUB * POS * Hereditary non-polyposis colorectal cancer
41
Name HORMONAL management of AUB (3)
* Lévonorgestrel intra-utérin (Mirena, Kyleena) * OCP * Progestin
42
Name NONHORMONAL management of AUB (2)
* NSAID * Acide tranexamique
43
Name SRUGICAL management of AUB (4)
* Ablation * Hysterectomy * Polypectomy * Myomectomy
44
Describe manamgent SEVERE BLEEDING in AUB
* Stabilize patients : ABCs, MOVIES * R/O pregnancy * Hb * Pelvic ultrasound * endometrial bx if meets critera * Tx : Estrogen, tranexamic acide, high dose progestins
45
Name dx of PCOS
Need 2 of : 1. **Hyperandrogenism** (hirsutism/acbe/alopecia OR High free testosterone/SHBG) 2. **Ovulatory dysfunction** (alogo/anovulation) : Irregular cycles < 21 or > 35 days, or < 8 cycles per year OR regular cycles and low day 21 progesterone 3. **Polycystic ovaries on ultrasound**
46
Describe levels that are consistent with PCOS * FSH * LH * Estradiol * T, DHEA-S
* FSH : N * LH : High * Estradiol : Low * T, DHEA-S : Normal or slightly elevated
47
If high FSH and LSH, think of what?
Ovarian insufficiency
48
If low FSH and LSH, think of what?
Hypogonadisme
49
What other causes to R/O if hirsutism with normal androgens ?
* Medication * Cushing (Cortisol urinaire libre sur 24 heures, cortisol salivaire nocturne ou DST) * Idiopathique *
50
What other causes to R/O if markedly elevated androgens or DHEA-S ?
* Tumeur sécrétant des androgènes surrénaliens/ovariens R/O * Androstènedione, référence endocrino
51
Describe tx : PCOS (5)
* Tout contraceptif hormonal combiné (CHC) * Progestatifs (oraux, stérilet, intramusculaires ou implants) * Tx de l'hirsutisme : CHC, cire, laser, épilation, rasage, blanchiment, fil, électrolyse * Ajouter des antiandrogènes si les traitements ci-dessus sont inefficaces (spironolactone, finasteride) * Modification des facteurs de risque
52
When to start tx endometriosis ?
* Dx clinically to avoid tx delay * Don'T wait for laparoscopy
53
Name sx : Endometriosis
* Suspect if pelvic pain, infertility * Dysmenorrhea, dysuria, dyschezia, dyspareunia * Chronic, cyclic, climbing * Other sx : fatigue, low mood, lower uriary sx, poor sleep
54
Name risk factors : Endometriosis
* Low birth weight or BMI * Mullerian anomalies * Early menarche * Short menstrual cycles * Increased menstrual flow * Nulliparity
55
Name tests for endometriosis (5)
* Premier examen : échographie pelvienne transaginale * IRM pelvienne si profonde * Diagnostic clinique * Laparoscopie * Un examen normal n'exclut pas la possibilité
56
Describe 1st-line tx endometriosis
* Continuous hormonal contraceptive * Progestins (dienogest, levonorgestrel-releasing ius)
57
Who to investigate for post-menopausal bleeding?
EVERYONE WITH A UTERUS
58
Name investigations for post-menopausal bleeding
* Pelvic * Pap * Ultrasound OR endomaterial bx

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