Emergency department management of vaginal bleeding in the nonpregnant patient

Abnormal uterine bleeding is the most common reason women seek gynecologic care, and many of these women present to an emergency department for evaluation. It is essential that emergency clinicians have a thorough understanding of the underlying physiology of the menstrual cycle to appropriately manage a nonpregnant woman with abnormal bleeding. Evidence to guide the management of nonpregnant patients with abnormal bleeding is limited, and recommendations are based mostly on expert opinion. This issue reviews common causes of abnormal bleeding, including anovulatory, ovulatory, and structural causes in both stable and unstable patients. The approach to abnormal bleeding in the prepubertal girl is also discussed. Emergency clinicians are encouraged to initiate treatment to temporize an acute bleeding episode until timely follow-up with a gynecologist can be obtained.

Study of endometrial tissue in dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) is defined as heavy and or irregular menstruation in the absence of recognizable pelvic pathology, pregnancy or general bleeding disorder. Hyperplastic endometrium is abnormal histology finding found in DUB. Out of three type of hyperplasia, atypical type is associated with co-existent ca endometrium and the chance of progression to ca endometrium is very high. Thus this study was conducted to see the incidence of hyperplasia of endometrium in cases of DUB and to see the risk factors for endometrial hyperplasia. It was a prospective study carried out in span of two years (2010 JULY- 2013 Jan) in Nepal Medical College and Teaching Hospital. Hundred cases DUB who under went D&C or hysterectomy were included to study the age range, the relation of parity, patient symptom, contraceptive method and medical disease with the type of endometrial histology. It was found that DUB was common in perimenopusal age (49%) and the incidence increase with the increase of parity. Abnormal endometrial finding (hyperplasia) was found in 31% of the cases. Atypical and complex hyperplasia were associated with irregular menstruation and one third of the hyperplastic patient had hypertension (32.26%). Thus perimenopausal age, irregular menstruation and hypertension are risk factors for hyperplasia. So it is mandatory to do endometrial sampling in cases of perimenopausal age with irregular menstruation withor without hypertension.

[Efficiency of modern technology in obstetric practice]

Bleeding is one of the key components of critical states in obstetrics. The fight against obstetric hemorrhage related to the following aspects: the organization of care, qualifications of medical personnel, the availability and quality of the protocol. The introduction of modern technologies to reduce the frequency of massive postpartum hemorrhage and disability among women of reproductive age.

When to perform palliative surgery in the treatment of ovarian cancer: a brief review

The objective of this review was to address the main indications for palliative surgery in the treatment of ovarian cancer.

DESIGN

Articles from MEDLINE/PUBMED, EMBASE, and LILACS databases up to May 05, 2012 were included with no bars on foreign languages. The key words used were taken from the Medical Subject Headings and were as follows: ovarian cancer AND palliative surgery, ovarian cancer AND complications, and ovarian cancer AND intestinal obstruction. Subsequently, the references from the original articles were also analyzed.

RESULTS

Among the complications developing in the course of malignant neoplasia, intestinal obstruction stands out as the main indication for palliative surgery, which may also be indicated for rectovaginal and enterovaginal fistulas, as well as for genital and lower gastrointestinal hemorrhage.

CONCLUSION

Although incurable, the patients with complications due to ovarian cancer may have an extended survival and an improved quality of life with palliative surgery for the following reasons: a) improvement in the nutritional state after treatment for intestinal obstruction due to the possibility of oral nutrition; and b) improvement in clinical conditions, allowing for palliative chemotherapy.

Adenomyosis among samples from hysterectomy due to abnormal uterine bleeding

BACKGROUND

Adenomyosis is one of the most common, yet under diagnosed, underlying cause of abnormal uterine bleeding. We aimed to evaluate the presence of adenomyosis among the patients who presented with abnormal uterine bleeding.

METHODS

This was a retrospective study carried out on hysterectomy specimens of subjects who presented to the gynaecologist with the complaint of abnormal uterine bleeding not responding to conservative treatment. Excluded are the hysterectomies performed for malignant pelvic neoplasms and hysterectomy following labour for postpartum haemorrhage.

RESULTS

A total of 861 women underwent hysterectomy out of which 779 w\ere abdominal and 82 vaginal from Jan 2008 to Dec 2012. Adenomyosis was found in 296 of the 861 specimens studied. The most frequent combination of diagnosis was leiomyoma and adenomyosis. Pathologic conditions associated with adenomyosis were: leiomyomas 150 (50.6%), endometrial polyp 16 (5.4%), genital prolapse 12 (4.05%), chronic endometritis 10 (3.3%), endometrial hyperplasia 5 (1.6%), endocervical polyps 2 (0.6%).

CONCLUSION

Adenomyosis is a common pathologic finding significantly related to reproductive and menstrual characteristics of the patients.

Ruptured uterus and bowel injury from manual removal of placenta: a case report

BACKGROUND

Retained placenta is a significant cause of maternal mortality and morbidity throughout the developing world. 'Though, intestinal injury may arise as a complication of induced abortion following instrumentation through the genital tract, the involvement of the large bowel in complicated manual removal of placenta is a very rare occurrence

CASE REPORT

We present the case of a 28 year-old Para 3+0, 3 alive woman who had attempted manual removal of placenta in a basic emergency obstetric care facility that resulted in lower uterine segment rupture with evisceration of bowels through the laceration outside the introitus. She subsequently had right hemi- colectomy with ileo-transverse anastomosis and repair of uterine rupture with bilateral tubal ligation.

CONCLUSION

This case highlights the risk of exposing parturients to inexperienced attendants at delivery and emphasises the need for intensification of manpower training to attain the 5th MDG enunciated by the United Nations.

Hysterectomy for recurrent postmenopausal bleeding revisited: missed sclerosing stromal ovarian tumour

Sclerosing stromal tumour of the ovary is rare. Patients present with menstrual irregularities, pelvic pain, abdominal distension, and presence of a large pelvic mass during their twenties or thirties. We report a rare case of an ovarian sclerosing stromal tumour with an atypical presentation, in that it gave rise to recurrent postmenopausal bleeding.

[Severe bleeding one year after a cesarean section caused by placenta increta persistens]

Placenta accreta is a diagnosis, which will gynecologists have to face probably more often, than in previous years. The reason is the increasing number of cesarean sections, one of the most important risk factors. The following case shows, that a placenta accreta not treated primary by hysterectomy, can have consequences even after a longer period. This time the manifestation was a severe bleeding one year after the delivery per cesarean section, which had to be treated by an acute hysterectomy.

Endometriosis after laparoscopic supracervical hysterectomy with uterine morcellation: a case control study

STUDY OBJECTIVE

To compare the incidence of new-onset endometriosis after laparoscopic supracervical hysterectomy (LSH) with uterine morcellation to traditional routes.

DESIGN

Single center case-control study (Canadian Task Force classification II-2) of hysterectomies performed from January 2006 through December 2008.

PATIENTS

Two hundred seventy-seven laparoscopic supracervical hysterectomies with morcellation (cases) and 187 transvaginal or abdominal hysterectomies without morcellation (controls) were performed from January 2006 through December 2008.

INTERVENTIONS

A total of 464 women underwent hysterectomy, 277 cases via laparoscopic supracervical approach (LSH) with morcellation and 187 performed either transvaginally or abdominally without morcellation. Repeat operative procedures were performed for other benign indications on 16 of 464 (3.5%) patients who had undergone prior hysterectomy.

MEASUREMENTS AND MAIN RESULTS

One hundred two patients had endometriosis at the time of hysterectomy diagnosed by pathologic evaluation or gross visualization. In those without endometriosis, repeat operative procedures were performed for pain and bleeding in 3.3% (12/362). Sixty percent (3/5) of patients treated with LSH and 28.6% (2/7) of the control group were found to have newly diagnosed endometriosis, conferring a rate of 1.4% (3/217) in the LSH group and 1.4% (2/145) in the control subjects. In patients with endometriosis, repeat operative procedures for pain or bleeding occurred in 2.9% (3/102): 3/60 patients treated with LSH and none in the control group (0/42). Two of these 3 patients undergoing a second surgery had recurrent/continued endometriosis.

CONCLUSION

Newly diagnosed endometriosis was noted in 1.4% of patients after hysterectomy, with a similar incidence between the LSH and control groups. Reoperation for those with endometriosis at the time of LSH with morcellation was infrequent, but endometriosis was usually found. Further research is needed to delineate risk factors for development of de novo endometriosis after hysterectomy.

The Shakespearean principle revisited

Let every eye negotiate for itself and trust no agent. That line is from William Shakespeare's Much Ado About Nothing. To me, it is a fundamental doctrine of patient care, and I have named it the Shakespearean Principle. It stimulates skepticism, promotes doubt, improves communication, fosters proper decision-making, and protects against a malady that currently plagues our profession—herd mentality. This editorial shows what can happen when doctors violate the Shakespearean Principle. The story is real and tells of a woman whose doctor unintentionally killed her. To ensure anonymity, the time and place of the tragedy, as well as the players involved, have been changed.

Late-first-trimester cesarean section scar ectopic pregnancy with placenta increta: a case report

BACKGROUND

Cesarean section scar pregnancy is a rare ectopic pregnancy that is difficult to manage due to high risk of uterine rupture and maternal hemorrhage-a risk that increases with gestational age.

CASE

A 21-year-old, gravida 3 para 2 woman was diagnosed at 13.5 weeks' gestation by pelvic ultrasound and magnetic resonance imaging with a cesarean scar ectopic pregnancy and placenta increta. Surgical removal of the pregnancy via exploratory laparatomy with intraoperative use of vasopressin minimized initial blood loss. However, extraction of the placenta increta resulted in uncontrolled bleeding, requiring a supracervical hysterectomy.

CONCLUSION

This is the first case report, to our knowledge, of a late-first-trimester cesarean section scar ectopic pregnancy with placenta increta. Early identification of the ectopic pregnancy may allow for more conservative, nonsurgical management. However, with a more advanced gestational age and placenta increta, surgical management is most appropriate to minimize associated maternal risks. A transverse wedge resection of the implantation site, uterine artery embolization, uterine artery ligation, endovascular balloon catheters, or uterine artery tourniquet may help decrease bleeding during surgical extraction of the pregnancy and placenta increta, and also may prevent a hysterectomy.

[Global ablation of endometrium as a new uterus sparing operative method in uterine dysfunctional bleeding]

A new method of endometrial ablation has been presented. This is the method of bipolar tridimensional device "NOVA SURE". This innovative method enables to destruct the basal and functional layer of the uterus and thus leads to amenorrhea and hypomenorrhea.

[A woman with a vaginal tumor]

A 87-year-old woman presented with vaginal blood loss. A tumor protruded through the anterior vaginal wall. Biopsy revealed transitional epithelium without atypia. In 1975 the urethra was dilated because of ischuria after a midline cystocele repair resulted in trauma. A post-traumatic transvaginal diverticulum of the urethra was diagnosed and closed.

Comparison of level of pain between using manual vacuum aspiration and sharp curettage in management of abnormal uterine bleeding

OBJECTIVE

To compare the level of pain between using manual vacuum aspiration and sharp curettage in the patients who had abnormal uterine bleeding that underwent uterine curettage under paracervical block with analgesics.

DESIGN

Randomized controlled trial study.

MATERIAL AND METHOD

Between September 2009 to June 2010, 48 women with abnormal uterine bleeding who need to undergone uterine curettage were asked to join the present study and informed consents were signed. Twenty four women were randomly assigned into manual vacuum aspiration (MVA) group and other 24 women into sharp curettage group. The main outcome was the difference of the level of pain before, during and after procedure measured by using the visual analog scale and categorical pain scores. Fisher exact, Student t test and Mann-Whitney U test were used for statistical analysis.

RESULTS

The median visual analog score during MVA-procedure was significantly lower than the median visual analog score during in sharp curettage (median visual analog pain scores (interquartile range) 80 (30-100) vs. 45 (0-80); p < 0.01)). And the median score immediately after procedure in the MVA group was also significantly lower than in the sharp curettage group (median visual analog pain scores (interquartile range) 45 (0-80 vs. 25 (0-70); p = 0.02). The categorical pain score in the MVA group during procedure and immediately after procedure were also significantly lower than in the sharp curettage group. (No pain to mild pain vs. moderated to severe pain; p = 0.03, immediately after procedure: no pain to mild pain vs. moderated to severe pain; p = 0.01).

CONCLUSION

The level of pain in the patients who underwent uterine curettage by using MVA was lower than using sharp curettage. The using MVA may reduce pain compared to sharp curettage. However, more sample size research should be conducted to determine this significant.

[Management of cesarean scar pregnancy by hysteroscopy combined with uterine artery embolism]

OBJECTIVE

To investigate safety and efficacy of hysteroscopy in treatment of cesarean scar pregnancy (CSP).

METHODS

From Aug. 2003 to Dec. 2011, 33 cases with CSP treated by hysteroscopy guided by transabdominal ultrasound or laparoscopy were studied retrospectively in Women's Hospital, School of Medicine, Zhejiang University. The clinical characteristics including gestational age, myometrial thickness anterior to the CSP, β-hCG level before treatment, success rate, cure rate, operative time, blood loss, time of serum β-hCG resolution and CSP mass clearance, and complication were collected and analyzed.

RESULTS

Median gestational age was 54 days (range, 37 - 140 days). Median level of β-hCG before treatment was 15 000 U/L (range, 3.3 - 151 747 U/L). Mean thickness of anterior myometrium was 3.3 mm. Twenty-nine cases underwent uterine artery embolism (UAE) before hysteroscopy. Pouch in the anterior uterine isthmus with gestation masses implanted were observed in 30 cases (91%, 30/33). CSP masses progressed toward the pouch or uterine cavity in all cases was removed by cutting wire loop electrode combined with curettage. The mean operative time was (34 ± 10) minutes. Both success rate and cure rate were 94% (31/33). Salvage methotrexate (MTX) therapy was administrated in one case. Complication occurred in three cases (9%, 3/33). Both massive hemorrhage rate and hysterectomy rate were performed in two cases (6%, 2/33). No uterine perforation occurred. The mean time of hCG resolution was (22 ± 10) days. The mean time of CSP mass clearance was (21 ± 12) days. Four pregnancies were achieved in four cases: one term pregnancy and three abortions. No recurrent CSP occurred.

CONCLUSION

Management of CSP by hysteroscopy combined with UAE is safe and effective.

Two cases of vaginal bleeding in pet rats

Two unrelated rats were presented to the Western College of Veterinary Medicine emergency service for vaginal bleeding. Each was taken to surgery due to marked blood loss and suspicion of uterine pathology. Despite similar clinical presentation, gross and histopathologic examination revealed 2 different underlying disease processes, uterine dilatation with mild endometritis and vaginal polyp.

Effectiveness of paracervical block versus intravenous morphine during uterine curettage: a randomized controlled trial

BACKGROUND

Abnormal uterine bleeding is a common gynecologic problem. Fractional curettage, evacuation and curettage, and dilatation curettage are common gynecologic procedures for investigation and treatment of abnormal uterine bleeding. To perform all these procedures, anesthesia is needed but technique varies among hospitals. The standard procedure of uterine curettage was performed after paracervical block or intravenous morphine injection.

OBJECTIVE

To compare pain scores during and after uterine curettage using intravenous morphine versus paracervical block

MATERIAL AND METHOD

A randomized controlled trial study was performed. Sixty-four patients with abnormal uterine bleeding and indication for curettage were enrolled in the present study. Simple randomized procedure was used to distribute the patients into two groups. Intravenous morphine was carried out in 32 patients as the group A while paracervical block was used in the other 32 patients of the group B before uterine curettage. The main outcome measurement was pain score, which assessed by Numerical rating scale ranging from 0-10.

RESULTS

The median pain score during uterine curettage were 7.5 and 6 (p = 0.103), immediately after uterine curettage were 3 and 3 (p = 0.822) and 30 minutes after uterine curettage were 1 and 1 (p = 0.206) in the control and treatment group, respectively.

CONCLUSION

Pain scores in patients who received paracervical block were not statistically different from those who received intravenous morphine. Paracervical block could be used as another choice for pain relief during uterine curettage.

Ultrasound diagnosis and comprehensive surgical treatment of complete non-puerperal uterine inversion

INTRODUCTION

Ultrasonographic diagnosis of very rare case of complete non-puerperal uterine inversion secondary to a large sub-mucous fibroid.

CASE REPORT

A 50-year-old woman was admitted with heavy vaginal bleeding. Detailed vaginal and abdominal ultrasound, using color Doppler flow, raised the suspicion of complete uterine inversion. The distal ends of the fallopian tubes and part of the ovaries were demonstrated adherent to the uterine fundus. Laparoscopy showed there was no uterus inside the abdomen because of complete uterine inversion. Only a dimple with a constriction ring was found at the site of the uterus. A sub-mucous 6 cm fibroid was attached to the fundus, and vaginal myomectomy was performed to reduce uterine size in order to restore the uterus to its abdominal position. However, the uterus was impacted and only cutting longitudinally the anterior and posterior fornices helped to restore the uterus and facilitate an abdominal hysterectomy. Histological examination of the uterus and fibroid following hysterectomy confirmed their benign nature.

CONCLUSION

Ultrasonographic diagnosis of complete uterine inversion is feasible. However, high index of suspicion is necessary.

Spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin after chemotherapy

OBJECTIVE

To report an extremely rare case of spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin (β-hCG) post-chemotherapy.

CLINICAL PRESENTATION AND INTERVENTION

We present a 35-year-old choriocarcinoma patient whose serial serum β-hCG levels following a fifth course of chemotherapy had been within the normal range, but who developed spontaneous uterine perforation with intra-abdominal hemorrhage after eight courses of combined chemotherapy. The patient then underwent an emergency hysterectomy and survived.

CONCLUSION

Patients with persistent focus of disease in the uterus might experience uterine perforation even after adequate chemotherapy, and therefore, the follow-up for patients after chemotherapy is very important.

Alveolar soft part sarcoma of the uterine cervix in a woman presenting with postmenopausal bleeding: a case report and literature review

INTRODUCTION

Alveolar soft part sarcoma (ASPS) of the uterine cervix is a rare mesenchymal malignancy that occurs in adolescents and young adults.

CASE REPORT

A 52-year-old postmenopausal woman presented with profuse vaginal bleeding of one month's duration with severe anemia. The pelvic examination revealed a 3 cm mass on the posterior lip of the uterine cervix. On magnetic resonance imaging, the tumor had high signal intensity on T1- and T2-weighted images. A modified radical hysterectomy and bilateral salpingo-oophorectomy were performed. Immunohistochemical staining for TFE3 and electron microscopic examination revealed an ASPS of the uterine cervix.

DISCUSSION

The better prognosis of cervical ASPS, compared to the soft counterparts, may be related to early clinical detection, small size, resectability, and demarcation of the tumor.

Global endometrial ablation

Abnormal uterine bleeding (AUB) is a significant health problem for many women. Surgical treatment of AUB often follows failed attempts with first-line medical therapy. Hysterectomy, while being a definitive treatment, is a major surgical procedure with potential for significant complications and economic costs. Endometrial ablation was developed as an alternative to hysterectomy. The first-generation endometrial ablation devices required extensive training and experience to be performed effectively and safely. As a result, newer ablative devices were developed addressing the need for less technical knowledge and improved safety. Since 1997, the United States FDA has approved 5 global endometrial ablation devices for treatment of AUB attributable to benign causes. This review will focus on the technical aspects of these second- generation devices and their applications for treatment of AUB.

Communication of adenomyosis with the endometrial cavity: visualization with saline contrast sonohysterography

We report four cases of a finding of communication between the endometrial cavity and adenomyotic lesions observed during saline contrast sonohysterography. In each case there was a saline-filled defect extending from the endometrial cavity into the myometrium in the region of previously suspected adenomyosis. We believe this finding represents the sonohysterographic correlate of endometrium invading the myometrium, as has been described histologically.