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Copy of Copy of abnormal uterine bleeding

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mai eldahan

on 23 April 2014

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Transcript of Copy of Copy of abnormal uterine bleeding

abnormal uterine bleeding
def
bleeding from female genital tract other than normal uterine bleeding

normal uterine bleeding
1-menstruation 2-bleeding during 3rd stage labor
3-bleeding during puerperium 4- birth crisis
classification
1-clinical classification
2-etiological classification
3-age classification
clinical classification
a-regular
1-oligomenorrhea
2-polymenorrhea
3-hypomenorrhea
4-menorrhagia
5-menostaxis
6-hypermenorrhea
7-polymenorrhagia
b-irregular
metrorrhagia



etiological classification
age classification
1-prepubertal bleeding: <10y
2-pubertal bleeding:10-16y
3-child bearing period:16-40y
4-premenopausal bleeding:from 40y till 5y before menopause
5-perimenopausal bleeding:5y before and after menopause
6-postmenopausal bleeding:after menopause till death
eatiological classification
1-organic legion
a-general cause
1-hypertention
2-heart failure
3-hyperthyrodism
4-hemorrhagc fever
5-hemorrhagic drug
6-hemorrhagic bl.diseases
b-local causes
1-obstetric cause
-bleeding early pregnancy
-antepartum hemorrhage
-postpartum hemorrhage
2-gynecologic cause
-congenital
-inflammatory
-traumatic
-neoplastic
2-hormonal
1-DUB
2-HRT
3-COCs (accidental intake ot irregular)
4-birth crisis
5-precocious puberty





pre pubertal bleeding
1- organic legion
a-general cause
ITP,leukemia,purpura
b-local causes
-cogenital
cong. prolapse with trophic ulcer
-inflammatory
vulvovaginitis of childern
-traumatic
post circumcision,FB,direct trauma
-neoplastic
sarcoma botryoides
2-hormonal
a-birth crisis
b-precocious puberty(most common)
c-accidental in take of COCs




e
post menopausal bleeding
1-organic legion
a-general cause
b-local cause
-inflammatory
senile vaginitis
-tramatic
post coital,fb,direct trauma
-neoplastic
all except sarcoma botryoides
especially endometrial carcinoma(most serious)
2- hormonal
HRT


لاتa-history
-personal history
-past history
-present history
b-examination
-general examination
-abdominal examination
-local examination
c-investigation
-US
-endometrial sampling

اا
1-fraction D,C
(the classic)

DUB
def:
abnormal uterine bleeding in absence of gross pelvic lesion


incidence:
-10% of all gynecologic patients
-most common cause of abnormal
uterine bleeding
-common in the extremes of
reproductive age
clssification:
a-etiological classification
1-1ry (disturbed axis)
2-2ry
(generalcauses ,IUD,hormonal contraception)
b-clinical classification
1-regular
-ovular
(dysfunctional polymenorrhea ,dysfuction menorrhagia)
-anovular
(pseudomenstruation with COCs
2-irregular
withdrawal bleeding
metropathia heamorrhagica





c-hormonal classification
1-estrogen withdrawal bleeding
2-estrogen breakthrough bleeding
3-progesterone withdrawal bleeding
4-progestrone breakthrough bleeding
dysfunctional menorrhagia
1-irregular ripening of endometrium
2-irregular shedding of endometrium
irregular ripening of endometrium
cause
LPD
c/p
irregular vaginal bleeding followed by menstruation
mech.
progesteron--area of
endometrium not controlled by progesteron-- lead to early shedding before menstruation
pathology
PMEB:mixed secretory and prolifrative but secretory dominant
TTT
progesteron 2nd half of cycle
irregular shedding of endometrium
cause
persistent CL
c/p
menstruation followed by irregular bleeding
mech.
persistent CL lead to persistent progestrone --areaof endometrium still controlled by progesterone-- late shedding of these areas after menstruation
pathology
endometrial biopsy during bleeding mixed but prolifrative dominant
TTT
hormonal regulation of cycle




threshold bleeding
estrogen below the level it can maintain endometrium
-birth crisis
-ovulation spotting

metropathia hemorrhagica
def
clinico-pathologic syndrome characterizeed
-cliinical;
-short period of amenorrhea followed by prolonged painless metrorrhgia
-symmetrical enlarged uterus
-bilateral cystic ovaries
-pathologically:
- endometrial hyperplasia
-follicular cystic ovaries
any postmenopausal bleeding considered malignant untill proved otherwise,not because it is the most common but because it is most serious

diagnosis
pathogenesis:
chronic anovulatory condition lead to
estrogen ,endometrial hyperplasia till reaching level canot controlled by estrogen lead to shedding of endometrium
DD;
-causes of bleeding early pregnancy
-endometrial carcinoma
TTT
1-general ttt
2-non hormonal ttt
3-hormonal ttt (the main line of ttt)
4-surgical ttt
hormonal ttt
1-gestagen
-indication
ttt of choice because most cases are unovulatory
-mech
(anti estrogen)
antimitotic effect
antigrowth effect
conversion of E2 E1
conversion of prolifrative
secretory
-dose
-norethisterone(tab=5mg)
-to arrest bleeding 10-30 mg/
dayfor 10 day
-metropathia 1*2*3w then rest for 1 week for cycle
-CL insufficiency 1*2*10 d 2nd half of cycle


2-COCs
sever bleeding
3-estrogen
progestron breakthrough
4-GnRH agonists
-control acute bleeding to induced amenorrhea in chronically ill patient
-preoperative
5-danazole
surgical ttt
1-D;C with or without hysteroscopy
refractory to medical ttt
2-hysterectomy
medical refused or CI
3-alternative to hysterectomy
hysterectomy refused orCI
-endometrial ablation(laser thermal)
-bilateral uterine arteries embolization

thanks
2-office endometrial biopsy
(the most commonly use)
3-hystroscopic guided biopsy
(the best)
Hydatidiform Molar Pregnancy


Ectopic pregnancy

bleeding in early pregnancy

Immediate cesarean delivery if fetal heart rate is non-reassuring
Administer normal saline 10 – 20 cc/kg bolus to newborn, if found to be in shock after delivery


Management – Vasa Previa

Rarest cause of hemorrhage
Onset with membrane rupture
Blood loss is fetal, with 50% mortality
Seen with low-lying placenta, velamentous insertion of the cord or succenturiate lobe
Antepartum diagnosis
Amnioscopy
Color doppler ultrasound
Palpate vessels during vaginal examination


Vasa Previa

Assess mother for hemodynamic and coagulation status
Vigorous replacement of fluid and blood products
Vaginal delivery preferred, unless severe hemorrhage


Treatment – Grade III Abruption

Assess fetal and maternal stability
Amniotomy
IUPC to detect elevated uterine tone
Expeditious operative or vaginal delivery
Maintain urine output > 30 cc/hr and hematocrit > 30%
Prepare for neonatal resuscitation


Treatment – Grade II Abruption

A d & c is done to evacuate the mole
Follow-up care is very important
Tends to be carcinogenic—choriocarcinoma
Recommend no future pregnancies for at least a year
Evaluate HCG levels closely
Chest x-rays at interverals


Treatment and nursing care with Molar Pregnancy


Defined as proliferation and degeneration of the chorion
A benign neoplasm of the chorion
The embryo fails to develop in most cases
Occurs in 1 of 2000 pregnancies
More often in low socioeconomic groups with low protein diets
More often is the younger or older mother


- expulsion of all products of conception.
- Cessation of bleeding and abdominal pain.
- P.V.: closed cervix.
- US: empty uterus.


Complete abortion

Definition: any fetal loss from conception until the time of fetal viability at 24 weeks gestation.
OR:
Expulsion of a fetus or an embryo weighing 500 gm or less
Incidence: 15 - 20% of pregnancies total reproductive losses are much higher if one considers losses that occur prior to clinical recognition.
Classification:
1. spontaneous:
occurs without medical or mechanical means.
2. induced abortion

Abortion/Miscarriage

Apt test – based on colorimetric response of fetal hemoglobin
Wright stain of vaginal blood – for nucleated RBCs
Kleihauer-Betke test – 2 hours delay prohibits its use


Diagnostic Tests – Vasa Previa

Risk Factors – Uterine Rupture

Occult dehiscence vs. symptomatic rupture
0.03 – 0.08% of all women
0.3 – 1.7% of women with uterine scar
Previous cesarean incision most common reason for scar disruption
Other causes: previous uterine curettage or perforation,
inappropriate oxytocin usage, trauma
Uterine Rupture

Can occur with blunt abdominal trauma and rapid deceleration without direct trauma
Complications include prematurity, growth restriction, stillbirth
Fetal evaluation after trauma
Increased use of FHR monitoring may decrease mortality


Abruption and Trauma

With no active bleeding
Expectant management
No intercourse, digital exams
With late pregnancy bleeding
Assess overall status, circulatory stability
Full dose Rhogam if Rh-
Consider maternal transfer if premature
May need corticosteroids, tocolysis, amniocentesis


Treatment – Placenta Previa

Occurs in 1/200 pregnancies that reach 3rd trimester
Low-lying placenta seen in 50% of ultrasound scans at 16-20 weeks
90% will have normal implantation when scan repeated at >30 weeks
No proven benefit to routine screening ultrasound for this diagnosis


Risk Factors for Placenta Previa

Previous cesarean delivery
Previous uterine instrumentation
High parity
Advanced maternal age
Smoking
Multiple gestation


Prevalence of Placenta Previa

Uterus expands faster and reaches landmarks earlier
More morning sickness
Earlier signs of PIH
Vaginal bleeding in the 4th month
Discharge with grape-like vesicles


Symptoms of a Molar Pregnancy


Ectopic pregnancy – complication of pregnancy where fertilized ovum implants outside the uterine cavity.

Most of ectopic pregnancies are not viable.

Heterotopic pregnancy

Localizations of ectopic pregnancy:
-Fallopian tube 95% (ampullary section 80%)
-cervix
-ovaries
-abdomen
….

Types of abortion

Threatened abortion.
Inevitable abortion.
Incomplete abortion.
Complete abortion.
Missed abortion
Septic abortion: Any type of abortion, which is complicated by infection
Recurrent abortion: 3 or more successive spontaneous abortions


Bleeding in
obstetrics

Grade I
mild, often retroplacental clot identified at delivery
Grade II
tense, tender abdomen and live fetus
Grade III
with fetal demise
III A - without coagulopathy (2/3)
III B - with coagulopathy (1/3)


Sher’s Classification - Abruption

Bleeding from Abruption

Externalized hemorrhage
Bloody amniotic fluid
Retroplacental clot
20% occult
“uteroplacental apoplexy” or “Couvelaire” uterus
Look for consumptive coagulopathy


Premature separation of placenta from uterine wall
Partial or complete
“Marginal sinus separation” or “marginal sinus rupture”
Bleeding, but abnormal implantation or abruption never established


Placental Abruption

Placenta Previa
Abruption
Uterine scar disruption
Cervical polyp
Bloody show
Cervicitis or cervical ectropion
Vaginal trauma
Cervical cancer

Causes of Late Pregnancy Bleeding

Diagnosis:
-ultrasound - the most reliable method of verification of ectopic pregnancy
-levels of β-hCG - more often levels are lower than in normal pregnancy
-laparascopy
-laparatomy
-culdocentesis (a less commonly performed test that may be used to look for internal bleeding)

Missed abortion

Treatment
as inevitable abortion



Clinical feature:
- Partial expulsion of products
- Bleeding and colicky pain continue.
- P.V.: opened cervix… retained products may be felt through it.
- US: retained products of conception.

Incomplete abortion

Threatened abortion:
- Short period of amenorrhea.
- Corresponding to the duration.
- Mild bleeding (spotting).
- Mild pain.
- P.V.: closed cervical os.
- Pregnancy test (hCG): + ve.
- US: viable intra uterine fetus.
Management
reassurance.
Rest.
Repeated U/S




Clinical features/management

Haemorrhage into the decidua basalis.
Necrotic changes in the tissue adjacent to the bleeding.
Detachment of the conceptus.
The above will stimulate uterine contractions resulting in expulsion.

Pathology

Treatment:
-metotrexate (if the mass is less then 3.5 cm in diametar)
-laparascopy, laparatomy (if the mass is greater than 3.5 cm in diametar, internal bleeding, cardiovascular colapse)

SALPINGOSTOMY SALPINGECTOMY

Risk factors:
-IUD
-PID
-previous ectopic pregnancy
-endometriosis
-tubal ligation
-tubal surgery
-smoking
-Kartagener sy.(PCD)


Hydatidiform mole

Ectopic pregnancy

Abortion

Causes of early bleeding in pregnancy

Treatment
- Wait 4 weeks for spontaneous expulsion
- evacuate if:
Spontaneous expulsion does not occur after 4 weeks.
Infection.
DIC.
- Manage according to size of uterus
- Uterus < 12 weeks : dilatation and evacuation.
- Uterus > 12 weeks : try Oxytocin or PGs
feature:
-gradual disappearance of pregnancy symptoms signs
-brownish vaginal discharge
-pregnancy test-ve but may be +ve for 3,4 weeks after death of fetus
-us absent fetal heart pulsation
complication:
-septic abortion
-DIC
supervised by
Prof.Dr.
Ahmed Badawy
done by
1-Maha Elsayed Mahmoud Elsayed
2-Maha Gamal Mohamed Hamad
3-Maha Mahmoud Abd Elrazik
4-Mouhaned Ali Mouhamed
5-Mai Ibrahim Salama
6-Mai Ibrahim Abd Elfatah
7-Mai Esayed Ashour
8-Mai khaled Eldahan
9-Mai Samir Elsaid
Full transcript