Abnormal Vaginal Bleeding/Ectopic Pregnancy/Endometriosis

Question 1

Abnormal Vaginal Bleeding (4 types)

Answer 1

• aka uterine bleeding, common gynecological conern. Types of irregularities
  a) oligomenorrhea
  b) amenorrhea
  c) menorrhagia
  d) metrorrhagia

Question 2

Causes of abnormal vaginal/uterine bleeding

Answer 2

Causes may vary from anovulatory menstrual cycles to more serious causes such as ectopic pregnancy or endometrial cancer

Question 3

Menorrhagia
- common cause

Answer 3

• excessive bleeding characterized as an increased duration (>7 days), increased amount (>80ml) or both
• the most common cause -> anovulatory uterine bleeding
• For young women with excessive bleeding, clotting disorders must be considered

Question 4

Metrorrhagia
- possible causes (2)

Answer 4

• Also referred to as spotting, or breakthrough bleeding, is bleeding between menstrual periods
• For women of reproductive age, spontaneous abortion or ectopic pregnancy must be considred
• for women who are postmenopausal, endometrial cancer must be considered whenever spotting is experienced

Question 5

Amenorrhea
- primary vs secondary?

Answer 5

Aside from pregnancy - the most common cause for missing menses is anovulation
- Primary: failure of menstrual cycles to begin by 16 years (or 14 years with secondary sex characteristics)
- Secondary: cessation of menstrual cycle once established

Question 6

Oligomenorrhea

Answer 6

Refers to long intervals between menses, generally > 35 days
Oligomenorrhea owing to anovulation is common for women at the beginning and end of menstruation

Question 7

Nursing Management of Abnormal Vaginal Bleeding: Teaching

Answer 7

Teach them about characteristics of menstrual cycle:
- will assist to identify normal variation
- if menstrual cycle does not fall within the normal range, seek health care provider

Question 8

Nursing Management of Abnormal Vaginal Bleeding: Decrease risk of Toxic Shock Syndrome
- what is it? S&S?

Answer 8

• TSS is acute condition caused by staph aureus
• avoid prolonged use of superabsorbent tampons & pads
• initially flu-like symptoms - high fever, N/V, diarrhea, dizziness, fainting and disorientation

Question 9

Nursing Management of Abnormal Vaginal Bleeding (2)

Answer 9

• excessive amount of vaginal bleeding should be assessed accurately
• anemia & hypovolemia may be present - assess variations in BP, HR

Question 10

Surgical Therapy for Abnormal Vaginal Bleeding (3)

Answer 10

Surgery is indicated depending on underlying cause of abnormal vaginal bleeding
- D&C (dilation and curettage. used for miscarriage)
- Hysterectomy (if fibroids)
- Myomectomy (removal of fibroid without removing the uterus)

Question 11

Methods for performing surgeries (3)

Answer 11

• Laparotomy
• Laparoscopy
• Hysteroscopy (up through the vagina)

Question 12

Ectopic Pregnancy

Answer 12

• implantation of the fertilized ovum anywhere outside uterine cavity
• Result of fibrosis or damage to cilia in the tube following infection or inflammation of the Fallopian tube
• eventually the tube ruptures - peritoneal symptoms
• Is a life-threatening condition
• A women suspected of ectopic pregnancy should always be treated as an emergency

Question 13

Ectopic Pregnancy: Risk Factor

Answer 13

• history of pelvic inflammatory disease, prior ectopic pregnancy, progestin-releasing IUD, progestin-only birth control failure, and prior pelvic or tubal surgery

Question 14

Clinical manifestations of ectopic pregnancy
- if tube ruptures?

Answer 14

• Abdominal or pelvic pain - almost always present d/t distention of the fallopian tube
• missed menses
• irregular vaginal bleeding
• If tube ruptures, pain is intense -> risk for hemorrhage & hypovolemic shock. suspected rupture is treated as an emergency

Question 15

Diagnosis of Ectopic Pregnancy

Answer 15

• difficult d/t similarities to other pelvic and abdominal disorders
• a serum pregnancy test would be positive
  -KEY - serum BhCG level >1,500 and transvaginal U/S shows no intrauterine gestational sac.

Question 16

Symptoms of Tube rupture

Answer 16

sudden, severe pain, vaginal bleeding, shoulder pain while laying down, bleeding into peritoneal cavity: pallor, signs of shock and blood loss and a distended abdomen

Question 17

management of ectopic pregnancy

Answer 17

• surgery remains the primary approach and should be performed immediately
• for hemodynamically stable pt with the size of gestation <3cm, tx of IM injection of methotrexate is being used with increasing success.
• laparoscopy is preferable to laparotomy because of less blood loss, and decreased length of stay

Question 18

Laparoscopy: for ectopic pregnancy 2 types
- how do they choose which one?

Answer 18

1. Salpingotomy - the ectopic pregnancy is removed; tube is left to heal on its own
2. Salpingectomy - both ectopic pregnancy & the tube are removed

The choice depends on
- pts age
- tubes condition
- Serum bHCG levels
- pts future fertility desire

Question 19

Endometriosis

Answer 19

• presence of endometrial epithelial tissue (usually lines uterus) found outside the uterine cavity
• endometrial tissues undergoes a mini-menstrual cycle
• Blood collects in cyst-like nodules blue/black in color -> causes inflammation -> scarring & adhesions

Question 20

Endometriosis: most frequent sites

Answer 20

near ovaries, broad ligament, uterosacral ligaments, bowel, bladder

Question 21

Endometriosis and fertility

Answer 21

A common cause of infertility, increased risk for ovarian cancer.
Typically occurs in those who have never had a full-term pregnancy

Question 22

Clinical Manifestations of Endometriosis

Answer 22

symptoms and pain vary considerably and does not correlate with extent of endometriosis
most common manifestations: dysmenorrhea, infertility, pelvic pain, dyspareunia, and irregular bleeding

Question 23

Diagnosis and treatment of endometriosis

Answer 23

Laparoscopy for a definitive diagnosis
Treatment influenced by pts age, desire for pregnancy, symptom severity, and the extent and location of disease

Question 24

Conservative Surgery for Endometriosis

Answer 24

• to confirm diagnosis or to remove implants. lysing or excision of adhesion by laparoscopic laser surgery or laparotomy. For women wishing to get pregnant

Question 25

Definitive surgery for Endometriosis

Answer 25

Removal of uterus, fallopian tubes, ovaries, and as many endometrial implants as possible
- Postop care similar as abdominal hysterectomy

Question 26

Surgical Procedures for Female Reproductive System (7)

Answer 26

• Abdominal hysterectomy
• Vaginal hysterectomy
• Laparoscopic hysterectomy
• Robot-Assisted Surgery
• Vulvectomy
• Vaginectomy
• Pelvic Exenteration