University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2018
Views:

116

Pages:

31
Author:

KillSteel

Heavy menstrual bleeding Abnormal uterine bleeding patterns • (HMB)Menorrhagia: prolonged or heavy cyclic menstruation. • Metrorrhagia(Intermenstrual bleeding IMB): bleeding between periods. • Polymenorrhea: abnormally frequent menses at intervals of ˂21 days. • Oligomenorrhea: cycle with intervals >35 days. • Hypomenorrhea: diminshed flow or or shortening of mense. • Postcoital bleeding. • PMB(postmenopausal bleeding). • BEO(bleeding of endometrial origin). HMB(Menorrhagia) • Definition: It is a complaint of heavy or prolonged cyclical blood loss (over several consecutive cycles) that has a major effect on a women quality of life. • In normal menstruation, one half to three quarters of the menstrual discharge is blood, the rest being fragments of endometrial tissue & mucous. • Menstrual blood loss not normally clot, Large amounts of fibrin degradation products are present as the endometrium releases fibrin lytic substances that are normally cause any blood clots to disintegrate. These substances are rapidly consumed, and if the blood loss is greater than the amount of lysine released, then clots may form. Classifications: Idiopathic: where no pathology can be found, is otherwise known as dysfunctional uterine bleeding (DUB), now is called- bleeding of endometrial origin(BEO) : is a diagnosis of exclusion-, the majority of women who present with HMB will have BEO. Exact mechanism is undefined.( disordered endometrial PG production ?). Secondary. Causes of HMB Complications of pregnancy(abortion, ectopic, GTD). Fibroids, endometrial/cervical polyps, endometriosis, adenomyosis, PID, endometrial hyperplasia, endometrialcervical/carcinoma, vagina cancer, fallopian tube cancer, ovary (sex cord stromal tumor), atrophic (vaginal, cervical, endometrial), STD, chronic endometritis, postpartum infection. Anovulation: immature HPO axis or aging ovarian failure, hypothyrpoidism, hyperprolactinemia, androgen excess. Systemic abnormalities: coagulopathies e.g. VWD, ITP, hepatic or chronic renal failure, hyperthyroidism. Causes of HMB(PALM-COEIN) P : POLYP. A : Adenomyosis. L : liomyoma. M : malignancy and hyperplasia. C: coagulopathy. O: ovulatory disorders. E: endometrial dysfunction . I : iatrogenic. N : not yet classified. Clinical evaluation • History: determine the impact that the bleeding is having on women quality of life (flooding, clots). • Dysmenorrhea: structural abnormalities, infection, pregnancy complications. • Intermenstrual , postcoital bleeding:( endometrial, cervical polyp, endometrial hyperplasia, carcinoma). • urinary pressure symptoms, may indicate : large fibroid. • Unusual vaginal discharge. PID. • History of bleeding since menarche, PPH, excessive postoperative bleeding, bleeding with dental extraction, bruising, family history of bleeding symptoms: coagulation disorders. • Smear history, Contraceptive history. • Weight change, fatigue: thyroid disease. Examination Sign of anemia. Evidence of systemic coagulopathy (bruising,petechiae). Goitre. Abdominal examination: pelvic mass(fibroid). Pelvic examination: • Speculum exam.:to assess vulva,vagina,cervix (this may reveal sources of bleeding,e.g. Tumor, discharge suggesting infection). A cervical smear should be performed if not done before. • Bimanual examination: uterine enlargement. Investigation 1. B HCG 2. Full blood count. all women with HMB. • If the history , examination strongly suggest cyclical HMB without the presence of pathology in women under 45year old, start first line medical treatment without further investigations. 3. (Wet prep) examination & cervical culture. 4. Cervical cytology or biopsy. 5. Endometrial biopsy : The aim is to exclude or diagnose endometrial cancer or hyperplasia. Indications: 1. > 45 years old. 2. < 45 yr. when medical treatment has failed, abnormal bleeding persist or with a history of unopposed estrogen exposure(obese, PCOS). Outpatient endometrial biopsy. • Pipelle endometrial sampler. • outpatient hysteroscopy, indication: 1. Pipelle biopsy attempt fails. 2. Pipelle biopsy sample is insufficient for histopathology assessment. 3. Patient poorly tolerate speculum examination. 4. There is an abnormality on US,e.g. Suggested endometrial polyp or submucosal fibroid. Indication for endometrial biopsy under general anasthesia: 1. If the patient fail to tolerate outpatient procedure. 2. Cervix needs to be dilated. Methods: Hysteroscopy. D&C. 6. Pelvic ultrasound indications. 1. When symptoms suggest endometrial polyp.e.g. Irregular or intermenstrual bleeding. 2. When pelvic mass palpated on examination (fibroid). 3. When drug therapy for HMB is unsuccessful. 7. Thyroid and coagulation study. management Medical treatment: The aim of therapy is to reduce the blood loss, reduce the risk of anemia & improve the quality of life. It is indicated when there is no obvious pelvic abnormality & the women wishes to retain fertility. The medical therapy can be divided two main groups: non-hormonal & hormonal treatment. Non- hormonal therapy: 1-non steroidal anti inflammatory drugs: As Mefenamic acid is PG synthetase inhibitor, it is believed to act by↑the ratio of the vasoconstrictor PGF2α to the vasodilator PGE2.↓MBl 20-25%. Common S/E of NSAID includes, GI irritation, inhibition of platelet aggregation . • C.I in duodenal ulcer , severe asthma. • Dose: 500mg p.o. Tds 2- Antifibrinolytics ( Tranexamic acid): reduce MBL by up to 50% by inhibiting endometrial fibrinolysis. Tranexamic acid 2-4 g/day for 4-7 days, its side effect limited to GI complaint. • Theoretical risk of venous thrombosis. • Non- hormonal treatment should be a first line in primary care using either mefenamic acid or tranexamic acid, both can be used together. Hormonal treatments Combined oral contraceptive pills. • Used cyclically or continuously. Progestogens The use of progestogens is based on the type of HMB(regular or irregular). a)oral administration: -in the luteal phase ( norethisterone 5mg twice daily). -Cyclical administration of norethisterone 5-10mg tid from day 6-26 is effective for treatment of ovulatory HMB. b)injected progestogens. c)Levonorgestrel intrauterine system (LNG-IUS, Mirena ) •is very effective which delivers 20mg of LNG over 24 hrs. •require changes every 5years. •It will reduce MBL 95% by one year after insertion due to endometrial atrophy(30% of women are amenorrhoeic by one). Benefits: 1. Alleviate the symptoms of dysmenorrhea. 2. Reduce the incidence of PID. 3. Provide very effective reversible contraception. 4. Used as an alternative to surgical treatment. 5. Progestogen side effects are much less than with oral form. Disadvantages:irregular mense and breakthrough bleeding for the first 3-9 months after insertion. Androgens Danazole: is isoxole derivative of 17 alpha-ethinyl testosterone which acts on hypothalamic pituitary axis as well as endometrium. Gestrinone is 19-testosterone derivative which has anti-progestogenic, anti-oestrogenic & androgenic activity. Danazol, gestrinone are no longer recommended for routine use in the treatment of HMB, owing to their unacceptable side effects: risk of musculinization. Weight gain, greasy skin, acne, alteration in lipid profiles or liver function. GnRH agonist Act by downregulating HPO axis, induce ovarian suppression, leading to amenorroea. Not used beyond 6 months because of its adverse effect on bone density (because of hypoestrogenic state), unless combined with hormone replacement therapy(HRT). Their use can be associated with flushing, sweating, irregular bleeding. Dose: • Goserelin(zoladex): 3.6 mg /month. Subcutaneous implant. • Decapeptyl(triptorelin): 3 mg/month or 11.25 mg every 3 months s.c or i.m. • Buserelin, 300 microg nasal spray tds. Summary: • First line treatment. Antifibrinolytic & PG synthetase inhibitors. • COCP effective • LNG-IUS is an excellent long-term alternative to surgery. Surgical treatment • Surgical Mx is only considered in women who have completed their family,with the exception of polypectomy and myomectomy where fertility can be retained. • Used in women whom medical treatment have failed. Endocervical polyps: can be removed in the outpatient setting. Endometrial polyp. Removed blindly under GA, or by hysteroscopy in outpatient or under GA. myomectomy Endometrial ablation • all organic and structural causes of HMB have been excluded. • Is the destruction of the endometrium to prevents regeneration. • 1st generation (TCRE with electrical diathermy loop or rollerball). • 2nd generation technique. • Novasure, Thermachoice (thermal uterine balloon therapy), Microsulis ( microwave ablation). Absolute contraindication for endometrial ablation: 1. 2. 3. 4. 5. 6. Genital tract malignancy. Women wishing to preserve fertility Pregnancy. Expectation of amenorrhea. Acute pelvic infection. Prior uterine surgery. Hysterectomy (Removal of the uterus). • Total abdominal hysterectomy(TAH). • Subtotal hysterectomy(STAH) • Bilateral salpingo-oopherectomy DUB(BEO) • Definition: abnormal uterine bleeding in women between menarche & menopause that can not be attributed to pregnancy, organic disease of genital tract, blood dyscrasias, systemic diseases, trauma, medications. The diagnosis of DUB is made by excluding other causes of AUB. • Almost always is caused by aberrations in the hypothalamic-pituitary-ovarian hormonal axis resulting in anovulation. Acute hemorrhage Hormonal 1. oral progestins: it halts endometrial growth and allow for organized sloughing with drug withdrawal. • For immediate control of bleeding, norethisterone, primolute N 20-30mg/day for 3 days or when bleeding stops, which ever come first, then 10mg/day for 21 days. • primoluteN 10mg/day , or medroxyprogesterone acetate 10 mg once daily, used in the 2nd half of the cycle for 10 days (15-25), to support anovulatory cycle. • Ovulatory DUB: norethisterone 5mg p.o. tid or medroxyprogesterone acetate 10 mg tid from day 5 to day 25 of each menstrual cycle have been shown effective 2. combined oral contraceptive pills. 3. estrogen: high dose estrogen therapy may be useful in controlling acute bleeding episodes because it promote rapid endometrial growth to cover denuded surfaces. - Conjugated equine estrogen(premarin)10mg orally in 4 divided doses ,or 25mg I.V of conjugated estrogen every 4hr for up to three doses, once the bleeding has slowed, patients can be given CCP.