By: ACLB/EDBS

Abortion and Vaginal bleedingDr. Helen albaño

Chadwik’s sign= bluish or pinkish discoloration of the cervixDifferential dx of Major gynecological problems:

-Vaginal bleeding-Pelvic pain-Pelvic Mass

These are categorized according to age.Differential DiagnosisThree most common:

1. Unusual vaginal bleeding2. Pelvic pain3. Pelvic/ abdominal mass

Vaginal bleedingAbnormal Vaginal bleeding:

1. Prepubertal bleeding2. Menorrhagia 3. Metrorrhagia 4. Postcoital 5. Postmenopausal6. Determine the Etiology.7. For pregnancy

-determine the age (15-45)-to rule in by doing serum pregnancy test

(+)= rule in (-)= does not rule out preg. Differential Dx of pregnancy with vaginal bleeding:

1. Implantation bleeding2. Threatened abortion3. Inevitable4. Complete5. Incomplete abortion6. Ectopic7. Molar pregnancy

Implantation bleeding-characteristic:

-minimal bleeding at time of the first menstrual period-lasts for a very short time-Present for 1-2 days w/a flow similar to the Normal menstrual period-oftentimes not perceptible to the px.*majority of abortions are due to chromosal defects

Molar pregnancy (trophoblastic ds.)-bleeding at 2nd to 3rd trimesterThreatened Abortion-Baby still alive-if bleeding comes from the cervix and it is closed-Size of the Uterus- consistent w/ the normal date of pregnancy. The uterus may or may not be contracting, and tender to touch.Examination:-Bimanual pelvic exam-Soft cervix-In threatened abortion- cervix is close if finger is inserted to the internal os.-Uterus should be compatible to age of gestation.-At 11th to 12th weeks- the abdomen should be at the level or above the symphysis pubis-At 20th week- level of umbilicus.

Inevitable Abortion-signs:AmenorrheaV. bleedingAbdominal painBag of water ruptureCervix dilatesThere are products of conception at the Internal os-bleeding is profuse.

*threatened abortion progresses to Inevitable abortion

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Complete Abortion-when the uterus has expelled its contents, the Int. os is closed. Bleeding is minimal-uterus returns near normal size

Incomplete abortionCommon at 6 weeks of gestation-pass out meaty tissues-a part of the products of conception are expelled but some remains in the uterus-cervix is dilated, there is bleeding and profuseUterus is smaller than the actual AOG-px experiences Crampy abdominal pain

*Symptoms of blood loss:-blurring of vision-dimming of vision-pulses are threading?-may lead to coma and death

Missed Abortion-Retention of the dead products-occur 3-4 weeks after fetal death-Uterus involutes so it is smaller than the expected date.-weight loss-bleeding is often minimal with dark red to brown blood.-(+) preg test remain for quite sometime-Cervix is round & soft

Ectopic pregnancy-implantation outside the endometrial cavity-may occur in the Cervix, fallopian tube, ovary, peritoneal cavity-can occur in distant organs like spleen but rare.

-Primary Ectopic preg. In a specific organ implies that preg was implanted directly within the organ.

-Secondary Ectopic preg Implies that the pregnancy ruptured from the fallopian tube & reimplanted.

Vaginal bleeding in Ectopic pregnancy:-due to the separation of the decidua from the endometrium as the implant dies. Direct bleeding from the site of the ectopic pregnancy, blood is transported to the uterus and through the cervix.

-triad of ectopic pregnancy>amenorrhea 90%>scanty to significant bleeding>Pelvic pain

Unilateral pain-limited to one site in case of fallopian tube pregnancy-pain is at left or right iliac regionGeneralized pain- in ruptured ectopic pregnancy. Pain is similar to PID.

*in AP, px will have low grade fever.

*PID- present as lower abdominal pain-2 fallopian tubes are the commonly affected organs.-presents vaginal dischargesPain at both sides- generalized abdominal pain-spiking temp., chills -ovaries are tender-cervix is soft

In ruptured fallopian tube- there is bleeding in the peritoneum causing generalized pain-there is acute blood loss

Get history to know the etiology!Because EP is the leading cause of death in the 1st trimester.

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In early ectopic pregnancy, 90 % presents vaginal bleeding, assoc. with abdominal pain. The uterus may be enlarged or normal.

Tubal or ovarian pregnancy-Adnexal mass may be noted (not uncommon)-common in normal pregnancies representing the corpus luteum of pregnancy .

-Adnexal tenderness.

Dx of Ectopic pregnancy:(+) serum pregnancy test-in normal preg and ectopic preg.

Transvaginal ultrasound-Intrauterine preg – pregnancy 6th weeks gestation; it is frequently possible to see a gestational sac w/in the uterine cavity.

-Ectopic pregnancy- Gestational may be seen outside the uterine cavity, i.e. in adnexa

-Ruptured Ectopic pregnancy

*Culdocentesis- aspiration of blood in the abdominal cavity through the posterior cul de sac (bulging in PID).

-the presence of clotted blood w/in the peritoneal cavity is evidence for intraperitoneal hemorrhage.-Unclotted blood – when blood vessel is hit-Pus –seen in PIDHemoperitoneum is secondary to ruptured ectopic pregnancy.

Intraperitoneal blood seen on Ultrasound is also suggestive of intraperitoneal bleeding.

Risk factors of Ectopic pregnancy (EP)1. Prior Ectopic pregnancy -40 to 50% recurrent

2. Previous PID- like salphingitis, vaginitis etc. can cause adhesion & scarring leading to obstruction on the expulsion of zygote.

3. Undergone tubal reparative procedures4. Smoking5. Women exposed in utero to Diethylstilbetrol (DES)- causes contraction of the fallopian tube and scarring6. Users of Itrauterine Device (IUD)- prevents uterine pregnancy but not uterine preg.7. Increasing Age8. Previous abortion

Procedure for Ectopic (tubal) Pregnancy-Tubal salphingectomy

Gestational Trophoblastic disease-causes vaginal bleedingHydatidiform mole (uray) –most common trophoblastic tumor occurring about 1/1000 gestations in non-asian women.

Clinical manisfestation of H. mole:>V. Bleeding>Enlargement of Uterus beyond the size of expected date of gestation.>Vaginal passage of grapelike structures (hydropic villi)> Hpn, edema, proteinuria causing pre ecclamptic toxemia.>HCG reaches 100,000 IU/L

Differential Dx of H. mole:-Normal Gestation (error in LMP)-Multiple gestation-Pregnancy w/ Uterine Myoma-Large fetus from diabetic mother-Polyhydramnios

-Ultrasound exam – in the late trimester or early second trim generally rules out H. mole.

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> H. mole shows Snow storm pattern appearance on Ultrasound.Amniotic fluid is manufactured by the fetus by urination which is balanced by fetal swallowing.

>Polyhydramnios is due to obstruction of the alimentary congenital tract.

Mean interval between menses:28 days (+/-7 days)Duration of flow:4-7 daysMean blood loss (MBL)35 ml (31-44)

Abnormal Uterine bleeding (AUB)-infrequent episodes, excessive, prolonged duration

Etiology of AUB:Organic cau se -due to systemic diseases-diseases of the Reproductive tractNon –organic cause-dysfunctional or endocrinologic

AUB may occur frequently in:1. Oligomenorrhea2. Polymenorrhea3. Menonorrhea4. Metrorrhagia5. Menometrorrhagia6. Hypomenorrhea7. Intermenstrual bleeding

Categories of AUB:Ovulatory AUB-Organic pathology: when AUB interspersed with what is otherwise regular cyclic ovulatory uterine bleeding -confirmed by BBT, plasma progesterone

Anovulatory AUB-Endocrinologic pathology: when AUB assoc w/ anovulation-rarely caused by other conditions-Dx is made by exclusion -seen in postpubertal period when HPO is still immature.

Etiology- complications of pregnancy:Most common:

1. Related to products of conception2. Incomplete abortion3. Ectopic pregnancy4. Endometrial lining degeneration

Dysfunctional Uterine Bleeding (DUB)-no ovulation, no ovum -endometrium is non secretory (do endo. Biopsy)

Management of DUB:Adolescent px mostly have normal clotting factor profile, so do:-Medical treatment 94%-Dilatation and curettage (D&C) 6%

DUB in menopause women-Irregular pattern-Scanty flow w/ prolonged spotting-Dx: Endometrial Biopsy-Generally sufficient to establish the appropriate diagnosis of non-secreting endometrium or hyperplasia.

DUB may be associated with:-Polycystic ovarian disease (Stein-levintal syndrome)-thyroid disease-Pituitary diseaseDUB may be secondary to;-stress-Excessive weight change-excessive exercise performance

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DUB in Reproductive years:-Manifestation?-Diagnosis: Endometrial biopsy-Women older than 35 yrs old with abnormal vaginal bleeding-In women at risk for endometrial hyperplasia or cancer, biopsy is necessary even in younger women. -complex endometrial hyperplasia= Pre-malignant lesion.

Procedure: -Measurement of menstrual blood-Serum ferritin, hemoglobin, serum iron, hCG-Endometrial curettage-Hysteroscopy-to visualize the endometrial cavity and measure the thickness of the lining endometrium-Sonography (ultrasound) - measure the depth of the lining-Hysterosonography

DUB treatmentMedical treatment-instead of surgical treatment-in absent organic cause-desires fertilityDefinitive tx is determined by Dx:-estrogens, progestins, NSAIDs, Antifibrinolytics, Danazol, GnRH

DUB is anovulatory-Progestin tx with Estrogen therapy-After bleeding stops, CE is continued and progestin ( Medroxyprogesterone acetate 1o mg) once a day is added-both hormones are given

Neoplastic causes of Vaginal bleeding

-Can be caused by a wide variety of neoplastic lesions-both benign and malignant affects the various organs of the female reproductive tract.

Cancers of the Vulva and Vagina-may present with vaginal bleeding-usually occur in women at postmenopausal period.-in reproductive years, bleeding is generally intermittent.-presents as metrorrhagia or postcoital bleeding rather than menses in normal menstrual cycle

Tumors of the Cervix-Squamous cell carcinomas-85%-Adenocarcinomas -15 %

-Other cervical lesions, endocervical polyps, may also cause metrorrhagia

Manifestations:-metrorrhagia-postcoital staining with larger lesions bleeding may quite profuse.

Uterine Lesions:Submucous myomas-the most common cause abnormal bleeding during reproductive yrs.-Benign lesion of the uterus.-Rarely causes bleeding in postmenopausal women.-May cause menorrhagia or meno-metrorrhagia-Generally assoc. with severe menorrhagia

Endometrial carcinoma is the most common gynecologic malignancy in Postmenopausal women, 90% of which presents postmenopausal bleeding.-Bleeding may be scanty or profuse

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-Women are most often exposed to continuous endogenous estrogen stimulation.

Fallopian tube cancer-Rare & generally occurs in the postmenopausal women.-Scant vaginal bleeding associated frequently with a; -watery discharge-Crampy pain-Occasional adnexal mass (physician should be alert)

Ovarian cancer-Vaginal bleeding often results when intraperitoneal blood enters the fallopian tube and through uterus & vagina.-Functioning ovarian tumors -Granulosa cell tumor or thecoma -Bleeding may be caused by:

Hyperplastic endometriumEndometrial cancer

Inflammatory conditions-bleeding is not a common symptom-severe inflammation in tissue leads to

Capillary oozingBlood vessel erosion

>Vulvitis, vaginitis, cervicitis & Endometritis-May all be associated with vaginal spotting-Generally w/o relationship with menstrual cycle

>Acute salphingitis or tuboovarian abscess may be also assoc. with vaginal bleeding.-secondary to endometrial inflammation or -abnormal uterine bleeding secondary to ovarian dysfunction.-the symptoms & signs of inflammation, including discharge, pain. Tenderness,

generalized signs & symptoms of infection will help in Differential diagnosis

Traumatic conditionsDirect trauma to the female external genitalia and internal reproductive tract may occur:>secondary to accidental injury>placement of foreign bodies w/in the vagina>traumatic coitus.> Coital lacerations

-bec. of rape or as part of normal sexual function.>Tears of the hymen or lacerations of the vagina when tissue is rigid may lead to severe vaginal bleed. >Conization of the Cervix>Bleeding of the vaginal cault after hysterectomy.

Systemic diseases-Clotting defects may be associated with the natural hx. Of the dse.

-Coagulopathies-blood dyscracia-Endocrinopathies

Postmenopausal Bleeding (PMB)-accounts for 5% of all gynecologic office visits.-mostly caused by pre-malignant or malignant-the most common premalignant and malignat causes are>Complex hyperplasia w/ atypia>Carcinoma of the endometriumOther causes of PMB:-Atrophic vaginitis-Cervical polyps-Leiomyomata uteri-Endometrial hyperplasia-Cervical erosion-Trichomoniasis

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-Hematuria-Trauma

Diagnostic Procedures for PMB:-Endometrial Biopsy-Vaginal Ultrasonography w/ endometrial thickness estimation-Sonohysterography-Hysteroscopy w/ directed biopsy & D&C.

Differential Diagnosis of Pelvic and Abdominal pain-Pain is defined as an unpleasant sensory & emotional experience assox. w/ actual or potential tissue damage or described in terms of such damage.

Acute AbdomenThe abdominal cavity is a continuum & overlap of signs is extremely common.-Disease w/ in a tubular viscus may cause crampy pain interspaced with no pain or periods of dull pain. (Bowel, fallopian tube, ureter)-Inflammatory conditions involving the ovary are frequently assoc. w/ continuous pain often described as sharp and throbbingManifestations:-sudden onset of abdominal pain-tenderness to palpation-rebound tendernessDiminished or absent bowel sounds

Etiology:may be caused by-infection-Hemorrhage-Infarction of tissue-obstruction of bowel

Differential Diagnosis of Acute abdomen:Preadolescent and adolescent girls

-Acute appendicitisOften presents initially as periumbilical pain that localizes to the right lower quadrant and is accompanied by anorexia or nausea and vomiting.

-Mesenteric lymphadenitis-Torsion of an adnexa-Salpingitis >tends to have a higher fever than Appendicitis >pain may be severe, they tend to be less ill than those w/ appendicitis

Acute abdomen in Older womenDifferential Dx:-Torsion or rupture of an adnexa-acute cholecystitis-Perforated ulcer-Acute diverticulitis

Pelvic inflammatory disease is less common in older women- acute exacerbations are rare in those who had tubal ligation.

Acute pelvic pain-Acute pain of gynecologic origin presents as both pelvic and lower abdominal pain.

Differential diagnosis includes diseases and dysfunction of the:-Genito-urinary tract-GIT-Masculoskeletal system

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By: ACLB/EDBS

Possible Causes of Acute Pelvic and Lower Abdominal painPregnancy-related:>Abortion>Ectopic preg.Disorders of the Uterus & Cervix:>Cervicitis>Endometritis>Degenerating myoma

Acute cervicitisSecondary to N. gonorrhoeae or C. trachomatis, may frequently assoc. w/ lower abdominal & pelvic pain.-pain is often Dull, aching nature-may radiate to the low back or the upper thighs.Clinical manifestation:-Cervical and vaginal discharge-Low grade fever-Slight leukocytosis-slight increase in ESR

Definitive Diagnosis is made by Culture of the organism.

Degenerating myoma-Presents w/ acute, sharp, or aching pain in the region of the myoma-The uterus is irregular & enlarged & tender to palpation.-There may be a mild leukocytosis but generally in laboratory parameters its normal.

Torsion of the Adnexa-with or without an ovarian cyst or tumor may lead to acute, crampy or continuous

pain w/c maybe unilateral but may progress to generalized lower abdominal pain.

Differential dx of Adnexal torsion:-appendicitis-PID

Acute Pelvico-abdominal painOvarian Tumors-Rupture of an ovarian cyst- may cause a sudden onset of pain-Leaking from a corpus luteum cyst generally occurs midcycle and, if it is on the right side, may be misdiagnosed as appendicitis-A hemorrhagic corpus luteum cyst may cause acute pain.

Musculoskeletal disorders-most pain that is limited to the lower back but not to the abdominal region-generally of musculoskeletal origin rather than from gynecologic dis.

Chronic and Recurrent pelvic pain-One of the major problems seen by the gynecologist-the most common examples of recurrent pelvic pain include:1. Dysmenorrhea2. Premenstrual syndrome3. Premenstrual Dysphoric disorder

Chronic pelvic pain is defined as noncyclic recurrence of pelvic pain for 6 or more months’ duration-incidence: prevalent in reproductive age women as high as 15-20%.

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Etiology of Chronic pelvic pain:-incomplete treated pelvic infections-recurrent pelvic infections-Endometriosis-postoperative pelvic adhesions-Diseases of the Urinary tract, bowel, neurologic systems

Pelvic congestion syndrome-Vascular engorgement of the uterus & the vessels of the broad ligament and lateral pelvic walls, which may lead to chronic pelvic pain.-May be cystic or solid and occur in any age group-may originate from the Cervix, uterus, or the Adnexa-other organs: GUT, Bowel, Musculoskeletal system, vascular-lymphatic system, nervous system

Pelvic & lower abdominal masses:May be cystic or solid and occur in any age group-may originate fromThe Cervix, uterus, or Adnexa-other organs: GUT, Bowel, Musculoskeletal system, vascular-lymphatic system, nervous system

REPRODUCTIVE AGE-majority of adnexal masses are follicle cysts

FOLLICLE CYSTS

-Functional, disappears in 1 to 3 mos.-size varies from few centimeters to as large as 8 to 10 cm in diameter.-Thin-walled and frequently rupture during pelvic examination

-No clinical significance.Diagnosis of Follicle cyst:Transvaginal ultrasound-establishes Dx and follow up the progression of cyst-it can be reassuring to the px and the doctor alike if a simple cyst is found.-it can help differentiate between a simple and a multiculated cyst and can rule out a solid tumor.

Corpus Luteum cyst-Physiologic cyst-Rarely become larger than 5 cm in diameter-Frequently tender to palpation-If bleeding, they may mimic an ectopic pregnancy.-Generally regress w/in a few weeks.

Hemorrhagic Corpus luteum -Also common during the reproductive yrs.-Rarely become larger than 5 cm in diameter-frequently tender to plapation-If blood leaks, it mimics an ectopic pregnancy-they generally regress w/in a few weeks.

Masses in Childhood Newborn with abdominal mass are generally Follicular cysts.(adnexal occasionally)-secondary to maternal hormone stimulation of fetal ovaries.-regress within the first few months of life.

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-thereafter, cysts and all tumors of the female pelvic organs are quite rare during childhood. -Abdominal masses found in the young child are more likely to be wilms’ tumors or neuroblastomas.-Tumors of the GIT, musculoskeletal system, or lymphatic system may also occur occasionally.-Solid or mixed solid and cystic adnexal masses are rare, but when they do occur are almost always

-dysgerminomas or-teratomas

-although benign and malignant teratomas have been reported in childhood, they are quite rare before the age of 10

Masses in Adolescence (Menarche to 19 Years)-Etiology:-once menses begins, obstruction of the lower reproductive tract,

-imperforate hymen,-agenesis of the vagina with intact cervix and uterus,-vaginal septum,

-may give rise to a hematocolpos or a hematometrium

Adnexal Masses in Childhood-Majority are non-neoplastic

-functional cysts and vary in size from 3 to 10 cm

-Neoplastic ovarian tumors-the most common is BENIGN CYSTIC TERATOMA of the ovary

-measures 5 and 10 cm in diameter-slow-growing,-frequently asymptomatic

Benign Cystic Teratomas-may cause adnexal abdomen

-May present as an acute abdomen-Rarely, the tumor may rupture, spilling oily, irritating contents into the peritoneal cavity and creating evidence of an acute abdomen

-the tumors frequently have a thickened capsule, and rupture is unusual

-Diagnosis:-may contain bone or teeth, abdominal roentgenograms or ultrasound may identify these.-transvaginal sonogram of a 4.0x3.6 cm dermoid cyst

Masses in Adolescence-Solid or solid and cystic adnexal tumors, although rare in adolescence, are almost always dysgerminomas or malignant teratomas.

Masses during the Reproductive Years-Masses seen at 20 to 44 y.o women may develop from

-the uterus and cervix,-The adnexa, and-other organ systems

-Intrauterine pregnancy, ectopic pregnancy, and trophoblastic disease

-should always be considered in women of reproductive years who develop such masses.

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-can often be ruled in or out by use of

-pregnancy test-ultrasound

-Leiomyomas of the-uterus, the cervix, the round ligament, or other pelvic organs are quite common in this age group-seen in 25% to 50% of women in the reproductive years-may develop myomas of the uterus and accessory organs-The majority are benign and vary in size from very small to large enough to fill the entire abdominal cavity.

Leiomyomas-are composed of smooth muscle cells in concentric whorls and are generally benign.-Leiomyosarcoma

-malignant degeneration of myoma-rare

-usually solid but with degeneration may give the impression of a cystic consistency.-Rarely may occur in the cervix or lower uterine segment

-may become quite large and may put pressure on the bladder neck, causing acute urinary retention

-Mymas tend to enlarge premenstrually and in pregnancy.

Adnexal masses in the reproductive Years-ovarian tumor,-cysts of mesonephric origin,-functional cysts of the ovary

-the most common adnexal masses found, and

-benign cystic teratomas-the most common neoplastic adnexal mass

-Endometrioma of the Ovary-endometriosis occurs, and ovarian endometriomas may develop-accompanied by the usual symptoms for endometriosis in association with a tender adnexal mass.

-Tumors emanating from other organ systems should also be considered in the differential diagnosis as in other age groups.-Diagnosis:

-An ultrasound or-IVP (intravenous pyelogram)

-should be useful in differentiating this entity from other pathologic conditions

Masses in the Perimenopausal and Postmenopausal Years(45 years old & older)

-consider masses originating from the uterus and cervix, from the adnexa, and from other organ systems.-myomas of the uterus regress postmenopausally.-a uterus that is growing in size should be investigated for the possibility of malignancy.-Adenocarcinoma of the endometrium,-Sarcomas, and-Mixed tumors of the uterus

-are all more common in the postmenopausal period, and many

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will be responsible for enlargement of uterine size, as well as PMB.

Adnexal masses occurring in postmenopausal women

-may still be benign, but the chance of malignancy increases with age,-the presence of ascites and the detection of the tumor bilaterally suggest malignancy

Malignant Adnexal Tumors(Perimenopausal Period)

-Epithelial Tumor-The majority of these malignant-Most were larger than 10 cm.

-the chance of malignancy increased with size of tumor and with age

Clinical Considerations to asses Differential Diagnosis

-Clinical findings associated with abdominal mass may help direct the physician to the appropriate diagnosis.-If ascites is present, by (PE or UTS) a malignant tumor, frequently of the ovary, is strongly suspected.-Benign fibromas of the ovary may also be associated with ascites and pleural effusion (Meig’s syndrome).-Defeminization or musculinization of the patient may suggest a rare musculinizing tumor of the ovary:

-Sertoli-Leydig tumor-preadloscent female, precocious puberty of a heterosexual type may be the presenting symptom

Sertoli-Leydig Ovarian tumor-Post-pubertal girl may manifest

-cassation of menses-early musculinization-may also be the presenting symptoms in women in the reproductive years

Feminizing ovarian tumors-Granulosal cell tumors-Thecomas, are more common.

-In the prepubertal girl-may present as precocious puberty-In menstruating women-may cause menometrorrhagia-In postmenopausal women-may present with PMB

-Brenner tumor,-may produce sex steroids and present in a similar fashion.

Brenner Tumor-It is composed of epithelial cells in clusters within a deep fibrous stroma.

-The cells closely match the cells that line the bladder

-In a Brenner tumor, you may see a “coffee bean nucleus” with a stripe down the middle.

General Diagnostic Considerations-Differential diagnosis of abdominal and pelvic masses is made by:

-abdominal and transvaginal ultrasound,-CT,-MRI scan,-special radiographic studies,

-such as intravenous pyelogram,-barium enema, and-upper GI series

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