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Obs And Gynae > Abnormal Bleeding > Flashcards

Abnormal Bleeding Flashcards

1
Q

What is “normal” menstruation?

A

Less than 80mls
Over 3-5days
At 28-30 day intervals

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2
Q

What is “abnormal” bleeding?

A

Increased/decreased bleeding - cyclical vs non-cyclical

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3
Q

Menorrhagia?

A

More volume, more days

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4
Q

Polymenorrhoea?

A

Short cycle with normal volume

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5
Q

Hypermenorrhoea?

A

Bleeds more days than normal (>5)

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6
Q

Classify organic causes of excessive uterine bleeding.

A

Gynaecological
>Polps
>Adenomyosis
>Leimyoma
>Malignancy
>Coagulation disorders
>Ovulatory disorders
>Endometrial
>Iatrogenic
>Not otherwise classified

Non-gynaecological
>Contraception - IUD, breakthrough bleeding
>Haematological - bleeding disorders
>Endocrine - hyper/hypothyroidism
>Medication - anticoagulants

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7
Q

What is the most common cause of abnormal uterine bleeding in adolescents and how is it managed?

A

Dysfunctional, Anovulatory >80%

= immature hypothalamic pituitary axis (produces oestrogen, not progesterone)

> clinical exam including PR
FBC, platelets, HIV

Treatment
>oral contraceptive pill (give progesterone if excess oestrogen)

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8
Q

What is cyclocapron and what is it used for?

A

Anti-fibrinolytic = used to reduce blood loss (CI in pts with previous thrombosis)

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9
Q

What is the most common cause and management of abnormal uterine bleeding in women of reproductive age?

A

Gynaecological = fibroids, adenomyomas, polyps, endometrial hyperplasia, endometriosis, PID, ovarian/uterine tumors, pregnancy, cx of miscarriages, molar/ectopic pregnancy

Non-gynae = bleeding disorders, thyroid disorders, medication

Management
>medical: document bleeding
1) IUD containing progestogen
2) cyclocapron
3) oralcontraception
4) NSAIDS
5) Treat the anaemia

> Surgical (Family completed/failed medication)
1) Hysterectomy
2) Endometrial ablation/resection

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10
Q

What is the most common cause and management of abnormal uterine bleeding in perimenopausal women? (45-55ish)

A

Exclude malignancy and pregnancy complications
Most common = anovulation

Management
> clinical exam
> tests = cervical smears, endometrial biopsies, endometrial ultrasound, pregnancy test
> medical = mirena, O+P pills, NSAIDS
> surgical = hysterectomy

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11
Q

What is the triad of signs found on ectopic pregnancy?

A

Lower abdo pain
PV bleeding
Ammenorrhoea

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12
Q

Define miscarriage/abortion

A

Premature termination of pregnancy by spontaneous or induced expulsion of a non-viable fetus from the uterus

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13
Q

Viability?

A

24weeks / 500g

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14
Q

What does recurrent abortion refer to?

A

3 consecutive abortions before a GA <20weeks

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15
Q

Classify abortions

A

1)Spontaneous
>incomplete
>complete
>missed
>inevitable
>threatened

2)Induced
>safe
>unsafe

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16
Q

What are the causes of spontaneous abortions in the first trimester?

A

> sporadic chromosomal abnormalities
developmental abnormalities
environmental factors - smoking, infections, toxins, drugs
poor placentation
ovary insufficiency
corpus luteum defect
autoimmune diseases

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17
Q

What are causes of spontaneous abortions on the second trimester?

A

> cervical incompetence
uterine abnormalities
poor placentation
infections - SYPHILUS NB, chlamydia, rubella
medical - hypothyroidism, diabetes mellitus

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18
Q

What are signs and symptoms of threatened abortion?

A

> lower abdominal pain
PV bleeding (NO clots)
os closed
intrauterine fetus with heart on u/s and + pregnancy test

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19
Q

What is your differential for a threatened miscarriage?

A

> implantation bleed
anovulatory bleed
ectopic pregnancy
anembryonic pregnancy

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20
Q

How do you manage a threatened abortion?

A

> counsel and reassure mother
bed rest

If uncertain diagnosis - repeat u/s in 2 weeks

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21
Q

What are the signs and symptoms of a inevitable abortion?

A

> PV bleeding (CLOTS)
lower abdominal pain with increasing severity
os open
products still inside
uterus may be tender

22
Q

What can you mistake an inevitable abortion with and how do you differentiate the two?

A

Incompetent cervix
In an incompetent cervix, there will be no pain and no/minimal bleeding

23
Q

How do you manage an inevitable abortion?

A

> resus if shocked
give oxytocin for uterine bleeding
first trimester = MVA
second trimester = oxytocin until fetus aborted followed by evac if retained products

24
Q

What are the signs and symptoms of an incomplete abortion?

A

> PV bleeding (CLOTS) - products of conception have been passed = amniotic fluid, fetus, placenta)0
lower abdominal pain (decreases after “passing something”)
os open
products of conception felt on os
uterine size smaller than period of amenorrhoea

25
Q

How do you manage an incomplete abortion?

A

> resus if in shock
1st trimester = misoprostil then MVA
2nd trimester = prostaglandins + evac/MVA after pregnancy expelled
rule out septic incomplete abortion

NB do not use misoprostil in a scarred uterus = it will rupture

26
Q

What are the requirements for an MVA?

A

> GA <13weeks (height of fundus)
Hb>9
clinically and haemodynamically stable patient

27
Q

What are the signs and symptoms of a complete abortion?

A

> abdominal pain that has subsided
PV bleeding that has stopped
os closed

Diagnosed only if you have seen and examined the expelled products yourself

28
Q

How do you manage a complete abortion?

A

> observe patient for bleeding
try and find a cause/diagnosis
- examine fetus for congenital abnormalities, chromosomal abn on fetal blood, intrauterine infection, cervical incompetence, syphilis
- placenta for chorioamnionitis

29
Q

What are the signs and symptoms of a missed abortion?

A

> asymptomatic
ammenorrhoea
usually diagnosed on u/s checkup (accidental finding) = no fetal heartbeat
can present with PV bleeding

30
Q

How do you manage a missed abortion?

A

> if <12weeks = MVA/dilation and evac in theatre
if >12weeks = induce labour with prostaglandins followed by evac

31
Q

What types of septic abortion can you get?

A

Complete
Incomplete

32
Q

How does a patient with a septic abortion present?

A

> fever
Hx of unsafe intervention
signs and sx of pelvic infection
-lower abdominal pain, peritonitis
-foul smelling/pussy discharge through os
-cervical excitation tenderness
-adnexal tenderness

33
Q

How do you manage a patient with a septic abortion?

A

> NB identify other organs involved by systemic evaluation
resus with colloids and crystalloids and blood!!!
antibiotics (aminoglycosides, metronidazole, cephalosporins)
remove source of sepsis
proper monitoring of disease process

34
Q

How do you assess for organ dysfunction?

A

CVS = pulse, BP
CNS = decreased GCS, confusion, meningeal signs
Resp = RR, saturation, CXR, ABG
GIT = liver enzymes
Renal = creatinine, UO
Haematological = Haematocrit, platelets, clotting profile
Immunological = WCC, CRP, temperature, VCT

35
Q

How do you treat a patient with septic abortion?

A

> resus (CAB)
antibiotics
evac/hysterectomy
repeat bloods post evac to monitor condition
careful monitoring and follow-up

36
Q

When is a hysterectomy indicated for a patient with a septic abortion?

A

> multiple organ dysfunction
septic shock
necrotic cervix
pus in abdomen (acute abdomen, colpopuncture)
no improvement after evac

37
Q

When is a evac indicated in a septic abortion patient?

A

Only if SIRS

38
Q

Classify induced abortions/TOP

A

Safe (within law)
Unsafe (outside law)

39
Q

How do you describe your findings on u/s writhing the ovary?

A

Using the IOTA (International ovarian tumor analysis) terminology to describe the appearance.
>unilocular (one incomplete septum)
>unilocular solid (
>multilocular (at least one complete septa)
>multilocular solid
>solid (at least 80% of mass is solid)

Anechoic
Hyperechoic
Low level echogenicity showing acoustic shadowing
Spider-web/lattice appearance = haemorrhage within cyst
Ground glass = endometrioma

40
Q

What models are used to assess an adnexal mass to predict if it’s benign or malignant?

A

Simple rules
Logistic regression 1
Logistic regression 2
IOTA Adnex model

41
Q

What is the Rotterdam PCOS criteria?

A

1) >presence >12 follicles >2-9mm
OR
>ovarian volume >10cm^3 in one or both ovaries

2) oligo-anovulation
3) yperandrogenism

42
Q

When will you be able to see the gestational sac on u/s?

A

6 weeks

43
Q

What is the most accurate way to measure GA on u/s between 6-10 weeks?

A

Crown rump length (CRL) measurement

44
Q

What are the most common causes of abnormal bleeding in prepubertal girls?

A

1) associated with secondary sexual characteristics
>precocious puberty

2) not associated with secondary sexual characteristics
>acute
-mass
=urethral prolapse
=perineal haematoma
=neoplasm
-no mass
=infective vulvovaginitis
=sexual abuse
=other injury

> chronic
-foreign body
-irritant vulvovaginitis
-dermatoses

45
Q

What is adenomyosis?

A

The growth of endometrial tissue into the myometrium

46
Q

What causes adenomysosis?

A

Prolonged oestrogen exposure, local trauma and inflammation

47
Q

What ultrasound criteria must be met to diagnose adenomyosis?

A

> asymmetrical myometrium thickening
increased vascularity in lesions
Hyperechoic islands
specific junctions zone irregularities/disruptions

48
Q

What is a leiomyomata?

A

A benign Timor of Müllerian duct origin, composing of smooth muscle and fibrous strands (originates from muscle tissue)

49
Q

Myomectomy?

A

Surgical removal of leiomyoma

50
Q

In which circumstances of abnormal uterine bleeding is endometrial sampling ALWAYS indicated? ie independent of age

A

LYNCH syndrome
PCOS
Breast cancer oestrogen positive survivor

51
Q

What are the risk factors for leiomyomatas?

A

> race (African Americans)
genetic factors
early menarche
obesity (more oestrogen)
nulliparety/low parity

52
Q

How are uterine fibroids classified and what is the name of this classification?

A

FIGO staging

0 = peduncuoated intracavitary
1 = submucosal <50% intramural
2 = submucosal >50%
3 = contact with endometrium 100% intramural
4 = intramural
5 = subserosal >50% intramural
6 = subserosal <50% intramural
7 = subserosal pedunculated
8 = other, for example, cervical, parasitic

Obs And Gynae (16 decks)

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