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Copy of Copy of abnormal uterine bleeding
Transcript of Copy of Copy of abnormal uterine bleeding
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
1-prepubertal bleeding: <10y
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
-bleeding early pregnancy
3-COCs (accidental intake ot irregular)
pre pubertal bleeding
1- organic legion
cong. prolapse with trophic ulcer
vulvovaginitis of childern
post circumcision,FB,direct trauma
b-precocious puberty(most common)
c-accidental in take of COCs
post menopausal bleeding
post coital,fb,direct trauma
all except sarcoma botryoides
especially endometrial carcinoma(most serious)
abnormal uterine bleeding in absence of gross pelvic lesion
-10% of all gynecologic patients
-most common cause of abnormal
-common in the extremes of
1-1ry (disturbed axis)
(generalcauses ,IUD,hormonal contraception)
(dysfunctional polymenorrhea ,dysfuction menorrhagia)
(pseudomenstruation with COCs
1-estrogen withdrawal bleeding
2-estrogen breakthrough bleeding
3-progesterone withdrawal bleeding
4-progestrone breakthrough bleeding
1-irregular ripening of endometrium
2-irregular shedding of endometrium
irregular ripening of endometrium
irregular vaginal bleeding followed by menstruation
endometrium not controlled by progesteron-- lead to early shedding before menstruation
PMEB:mixed secretory and prolifrative but secretory dominant
progesteron 2nd half of cycle
irregular shedding of endometrium
menstruation followed by irregular bleeding
persistent CL lead to persistent progestrone --areaof endometrium still controlled by progesterone-- late shedding of these areas after menstruation
endometrial biopsy during bleeding mixed but prolifrative dominant
hormonal regulation of cycle
estrogen below the level it can maintain endometrium
clinico-pathologic syndrome characterizeed
-short period of amenorrhea followed by prolonged painless metrorrhgia
-symmetrical enlarged uterus
-bilateral cystic ovaries
- 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
chronic anovulatory condition lead to
estrogen ,endometrial hyperplasia till reaching level canot controlled by estrogen lead to shedding of endometrium
-causes of bleeding early pregnancy
2-non hormonal ttt
3-hormonal ttt (the main line of ttt)
ttt of choice because most cases are unovulatory
conversion of E2 E1
conversion of prolifrative
-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
-control acute bleeding to induced amenorrhea in chronically ill patient
1-D;C with or without hysteroscopy
refractory to medical ttt
medical refused or CI
3-alternative to hysterectomy
hysterectomy refused orCI
-endometrial ablation(laser thermal)
-bilateral uterine arteries embolization
2-office endometrial biopsy
(the most commonly use)
3-hystroscopic guided biopsy
Hydatidiform Molar 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
Color doppler ultrasound
Palpate vessels during vaginal examination
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
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.
Definition: any fetal loss from conception until the time of fetal viability at 24 weeks gestation.
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.
occurs without medical or mechanical means.
2. induced abortion
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
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
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
Advanced maternal age
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.
Localizations of ectopic pregnancy:
-Fallopian tube 95% (ampullary section 80%)
Types of abortion
Septic abortion: Any type of abortion, which is complicated by infection
Recurrent abortion: 3 or more successive spontaneous abortions
mild, often retroplacental clot identified at delivery
tense, tender abdomen and live fetus
with fetal demise
III A - without coagulopathy (2/3)
III B - with coagulopathy (1/3)
Sher’s Classification - Abruption
Bleeding from Abruption
Bloody amniotic fluid
“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
Uterine scar disruption
Cervicitis or cervical ectropion
Causes of Late Pregnancy Bleeding
-ultrasound - the most reliable method of verification of ectopic pregnancy
-levels of β-hCG - more often levels are lower than in normal pregnancy
-culdocentesis (a less commonly performed test that may be used to look for internal bleeding)
as inevitable abortion
- 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.
- 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.
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.
-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)
-previous ectopic pregnancy
Causes of early bleeding in pregnancy
- Wait 4 weeks for spontaneous expulsion
- evacuate if:
Spontaneous expulsion does not occur after 4 weeks.
- Manage according to size of uterus
- Uterus < 12 weeks : dilatation and evacuation.
- Uterus > 12 weeks : try Oxytocin or PGs
-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
1-Maha Elsayed Mahmoud Elsayed
2-Maha Gamal Mohamed Hamad
3-Maha Mahmoud Abd Elrazik
4-Mouhaned Ali Mouhamed
5-Mai Ibrahim Salama
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9-Mai Samir Elsaid