102. Vaginal Bleeding (15%) Flashcards
Chez toute femme qui présente un saignement vaginal, éliminez quoi?
une grossesse.
Chez les femmes enceintes qui présentent un saignement vaginal,
Considérez certaines causes sérieuses.
Nommez en (3)
- grossesse ectopique
- décollement du placenta
- avortement
N’oubliez pas de préciser le groupe sanguin et de procéder aux tests de dépistage. De plus, administrez le vaccin Winrho lorsqu’approprié.
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).
Lorsqu’une femme postménopausée présente un saignement vaginal, investiguez tout nouveau saignement ou tout changement vaginal.
Nommez des tests/investigations possibles
- biopsie de l’endomètre
- échographie pelvienne
- tomodensitométrie
- Pap test
- sans oublier l’examen gynécologique
Differenciate menstruation regularity (3)
- Normal variation is 2-20 days
- Irregular (>20 day bleed-free intervals within 90 days)
- Absent/amenorrhea (No bleed in 90 days)
Describe menstruation frequency (3)
- Normal 24-38 days
- Infrequent (>38d)
- Frequent (<24d)
Describe normal/prolonged/shortened menstruations
- Normal 3-8 days)
- Prolonged (>8d)
- Shortened (<3d)
Name outside reproductive age
- Post-menopausal
- Precocious (<9y)
Name DDX : Vaginal bleeding (6)
- Pregnancy (Ectopic)
- Trauma
- Infection
- Systemic (Hypothyroid, Hyperprolactinemia, Cushing’s, PCOS, Adrenal, Hypothalamic suppression - stress)
- Iatrogenic / Medication (anticoagulants, hyperprolactinemia - antipsychotics, antidepressants)
- AUB
Name categories of AUB
- PALM (structural)
- COEIN (nonstructural)
Name STRUCTURAL causes of AUB (4)
PALM
- Polyp
- Adénomyose
- Léiomyome (Submucosal, Other)
- Malignancy/hyperplasia
Name NON-STRUCTURAL causes of AUB (5)
COEIN
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
Describe history of vaginal bleeding (7)
- 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
Describe physical exam of vaginal bleeding (7)
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
Name investigations for menstrual bleeding (10)
- 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
When to do endometrial sampling? (4)
- > 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)
Name possible imaging for AUB (2)
- Pelvic ultrasound (eg. ovulatory heavy bleeding)
- Saline sonography for submucosal fibroids
Describe ACUTE management of non-pregnant vaginal bleeding (5)
- 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)
Describe management : AUB-HMB (most leiomyomas or adenomyosis) (5)
- Mirena IUD (LNg20)
- Combined OCP
- Progestin
- Tranexamic, NSAIDs
- Expectant if not anemic or does not desire treatment
Describe management : AUB-O (Ovulatory dysfunction) (3)
- Mirena IUD (LNg20)
- Combined OCP
- Progestin
Describe management : Dysmenorrhea/pelvic pain
- Gonadotropin-releasing hormone agonists (ex. Lupron)
- Surgery (uterine fibroid embolization, myomectomy, and hysterectomy)
Name DDX First trimester bleeding
- Saignement d’implantation
- Grossesse anormale (extra-utérine/molaire)
- Avortement (menacé, inévitable, incomplet, complet, manqué, septique)
- Non obstétrical (pathologie utérine, cervicale et vaginale)
Name investigaitons for 1st trimester bleeding
- CBC
- Blood type
- Serial b-hCG hCG (<35% over 48h suggest ectopic or abnormal IUP)
- Abdominal Ultrasound
- Transvaginal Ultrasound
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)
Describement management if incomplete abortion
- Consider dilation & aspiration
- Prophylactic antibiotics (eg. Azithromycin/Doxycycline PO x1)
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)
Desribe : Placenta previa
Touching/covering internal os (low-lying is within 2cm)
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)
Describe : Uterine rupture
- Suspect in shock, acute abdominal pain, change in station, abnormal FHR, vaginal bleeding
- Risk: Uterine scar, hyperstimulation (IOL), multiparity
When to suspect Vasa previa ?
Suspect in painless bleeding with change in FHR
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)
Describe management : 2nd and 3rd trimester bleeding ?
- Get help, oxygen, IVF (LOTS!), foley
- Massive transfusion protocol
- Follow Hb and Coag
Name causes : Postcoital bleeding (7)
- Ectropion cervical (30 %)
- Polypes cervicaux (20 %)
- CIN (15 %) ou cancer (4 %)
- Infection
- Grossesse
- Traumatisme
- Atrophie
Describe tx : Ectropion cervical
Nitrate d’argent
Postcoital bleeding usually resolves by when ?
60% resolve by 6 months
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.
Name other tests for AUB
- Endometrial bx
- Transvaginal pelvic ultrasound
- Pap
- Colposcopy
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
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
Name HORMONAL management of AUB (3)
- Lévonorgestrel intra-utérin (Mirena, Kyleena)
- OCP
- Progestin
Name NONHORMONAL management of AUB (2)
- NSAID
- Acide tranexamique
Name SRUGICAL management of AUB (4)
- Ablation
- Hysterectomy
- Polypectomy
- Myomectomy
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
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
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
If high FSH and LSH, think of what?
Ovarian insufficiency
If low FSH and LSH, think of what?
Hypogonadisme
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
*
What other causes to R/O if markedly elevated androgens or DHEA-S ?
- Tumeur sécrétant des androgènes surrénaliens/ovariens R/O
- Androstènedione, référence endocrino
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
When to start tx endometriosis ?
- Dx clinically to avoid tx delay
- Don’T wait for laparoscopy
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
Name risk factors : Endometriosis
- Low birth weight or BMI
- Mullerian anomalies
- Early menarche
- Short menstrual cycles
- Increased menstrual flow
- Nulliparity
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
Describe 1st-line tx endometriosis
- Continuous hormonal contraceptive
- Progestins (dienogest, levonorgestrel-releasing ius)
Who to investigate for post-menopausal bleeding?
EVERYONE WITH A UTERUS
Name investigations for post-menopausal bleeding
- Pelvic
- Pap
- Ultrasound OR endomaterial bx
