Abnormal Bleeding Flashcards
What is “normal” menstruation?
Less than 80mls
Over 3-5days
At 28-30 day intervals
What is “abnormal” bleeding?
Increased/decreased bleeding - cyclical vs non-cyclical
Menorrhagia?
More volume, more days
Polymenorrhoea?
Short cycle with normal volume
Hypermenorrhoea?
Bleeds more days than normal (>5)
Classify organic causes of excessive uterine bleeding.
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
What is the most common cause of abnormal uterine bleeding in adolescents and how is it managed?
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)
What is cyclocapron and what is it used for?
Anti-fibrinolytic = used to reduce blood loss (CI in pts with previous thrombosis)
What is the most common cause and management of abnormal uterine bleeding in women of reproductive age?
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
What is the most common cause and management of abnormal uterine bleeding in perimenopausal women? (45-55ish)
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
What is the triad of signs found on ectopic pregnancy?
Lower abdo pain
PV bleeding
Ammenorrhoea
Define miscarriage/abortion
Premature termination of pregnancy by spontaneous or induced expulsion of a non-viable fetus from the uterus
Viability?
24weeks / 500g
What does recurrent abortion refer to?
3 consecutive abortions before a GA <20weeks
Classify abortions
1)Spontaneous
>incomplete
>complete
>missed
>inevitable
>threatened
2)Induced
>safe
>unsafe
What are the causes of spontaneous abortions in the first trimester?
> sporadic chromosomal abnormalities
developmental abnormalities
environmental factors - smoking, infections, toxins, drugs
poor placentation
ovary insufficiency
corpus luteum defect
autoimmune diseases
What are causes of spontaneous abortions on the second trimester?
> cervical incompetence
uterine abnormalities
poor placentation
infections - SYPHILUS NB, chlamydia, rubella
medical - hypothyroidism, diabetes mellitus
What are signs and symptoms of threatened abortion?
> lower abdominal pain
PV bleeding (NO clots)
os closed
intrauterine fetus with heart on u/s and + pregnancy test
What is your differential for a threatened miscarriage?
> implantation bleed
anovulatory bleed
ectopic pregnancy
anembryonic pregnancy
How do you manage a threatened abortion?
> counsel and reassure mother
bed rest
If uncertain diagnosis - repeat u/s in 2 weeks
What are the signs and symptoms of a inevitable abortion?
> PV bleeding (CLOTS)
lower abdominal pain with increasing severity
os open
products still inside
uterus may be tender
What can you mistake an inevitable abortion with and how do you differentiate the two?
Incompetent cervix
In an incompetent cervix, there will be no pain and no/minimal bleeding
How do you manage an inevitable abortion?
> resus if shocked
give oxytocin for uterine bleeding
first trimester = MVA
second trimester = oxytocin until fetus aborted followed by evac if retained products
What are the signs and symptoms of an incomplete abortion?
> 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
How do you manage an incomplete abortion?
> 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
What are the requirements for an MVA?
> GA <13weeks (height of fundus)
Hb>9
clinically and haemodynamically stable patient
What are the signs and symptoms of a complete abortion?
> abdominal pain that has subsided
PV bleeding that has stopped
os closed
Diagnosed only if you have seen and examined the expelled products yourself
How do you manage a complete abortion?
> 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
What are the signs and symptoms of a missed abortion?
> asymptomatic
ammenorrhoea
usually diagnosed on u/s checkup (accidental finding) = no fetal heartbeat
can present with PV bleeding
How do you manage a missed abortion?
> if <12weeks = MVA/dilation and evac in theatre
if >12weeks = induce labour with prostaglandins followed by evac
What types of septic abortion can you get?
Complete
Incomplete
How does a patient with a septic abortion present?
> 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
How do you manage a patient with a septic abortion?
> 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
How do you assess for organ dysfunction?
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
How do you treat a patient with septic abortion?
> resus (CAB)
antibiotics
evac/hysterectomy
repeat bloods post evac to monitor condition
careful monitoring and follow-up
When is a hysterectomy indicated for a patient with a septic abortion?
> multiple organ dysfunction
septic shock
necrotic cervix
pus in abdomen (acute abdomen, colpopuncture)
no improvement after evac
When is a evac indicated in a septic abortion patient?
Only if SIRS
Classify induced abortions/TOP
Safe (within law)
Unsafe (outside law)
How do you describe your findings on u/s writhing the ovary?
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
What models are used to assess an adnexal mass to predict if it’s benign or malignant?
Simple rules
Logistic regression 1
Logistic regression 2
IOTA Adnex model
What is the Rotterdam PCOS criteria?
1) >presence >12 follicles >2-9mm
OR
>ovarian volume >10cm^3 in one or both ovaries
2) oligo-anovulation
3) yperandrogenism
When will you be able to see the gestational sac on u/s?
6 weeks
What is the most accurate way to measure GA on u/s between 6-10 weeks?
Crown rump length (CRL) measurement
What are the most common causes of abnormal bleeding in prepubertal girls?
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
What is adenomyosis?
The growth of endometrial tissue into the myometrium
What causes adenomysosis?
Prolonged oestrogen exposure, local trauma and inflammation
What ultrasound criteria must be met to diagnose adenomyosis?
> asymmetrical myometrium thickening
increased vascularity in lesions
Hyperechoic islands
specific junctions zone irregularities/disruptions
What is a leiomyomata?
A benign Timor of Müllerian duct origin, composing of smooth muscle and fibrous strands (originates from muscle tissue)
Myomectomy?
Surgical removal of leiomyoma
In which circumstances of abnormal uterine bleeding is endometrial sampling ALWAYS indicated? ie independent of age
LYNCH syndrome
PCOS
Breast cancer oestrogen positive survivor
What are the risk factors for leiomyomatas?
> race (African Americans)
genetic factors
early menarche
obesity (more oestrogen)
nulliparety/low parity
How are uterine fibroids classified and what is the name of this classification?
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
