4'T's
1. Uterine aTony
2. Trauma - perineal damage
3. Tissue - retained placenta
4. Thrombin - coagulopathy
1. Uterine aTony
2. Trauma - perineal damage
3. Tissue - retained placenta
4. Thrombin - coagulopathy
4'T's
1. Uterine aTony 2. Trauma - perineal damage 3. Tissue - retained placenta 4. Thrombin - coagulopathy
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Adapted from William's Gynaecology (Schorge et al., 2008).
Absolute contraindications (Think: Where does estrogen act, how is it broken down) 1. Breast, endometrial, ovarian cancer 2. DVT / PE 4. CVD / Stroke 5. Hypersensitivity to estrogen 6. Liver dysfunction or disease (estrogen metabolised by liver) 7. Undiagnosed abnormal genital bleeding Relative contraindications (Think: Gallbladder, Liver, Heart, Kidney, Thyroid problems) 1. Prior endometriosis 2. Gallbladder disease 3. Hepatic hemangiomas 4. Prior cholestatic jaundice 5. Hypertriglyceridemia 6. Fluid retention + cardiac or renal dysfunction 7. Hypothyroidism 8. Severe hypocalcemia 9. Dementia Consider the hypothalamic-pituitary-ovarian axis + possible outflow obstruction. Too little or no FSH? Too high oestrogen? Too little or no estrogen? Outflow tract obstruction? Also think congenital vs acquired?
(Note: All conditions that can cause secondary amenorrhoea can also cause primary amenorrhoea. However there are some distinctive causes of primary amenorrhoea) Primary amenorrhoea - check height Short: 1. Growth hormone deficiency 2. Thyroid hormone deficiency 3. Genetic problems (eg Turner's) Normal height / Tall: 1. Gonadotropin-deficient either from hypothalamus or pituitary problems 2. Endocrine disorder 3. Premature menopause 4. Congenital absence of uterus / ovaries5. Outflow obstruction 6. Causes of secondary amenorrhoea (see below especially if normal breast development and uterus intact Secondary amenorrhoea 1. PCOS especially if normal FSH, normal or slightly elevated LH, high androgen levels, obesity, diabetic 2. Hyperprolactaemia 3. Polyglandular auto-antibodies 4. Outflow tract obstruction especially if Hx of prev surgery / instrumentation Primary amenorrhoea - if menstruation has not occurred by age 16
Secondary amenorrhoea - absence of menstruation for 6 months Definitive volume of blood loss >80ml per month during cyclic menses
However, difficult to quantify exactly. Reasonable signs of menorrhagia include: 1. Iron deficiency (not due to another cause) 2. Passing of clots during menstruation 3. Soaking of sanitary pads and tampons several times a day 1. Primary dysmenorrhoea
- uterine contractions resulting from production of prostaglandins by the endometrium - most women experience within 2 years after menarche. - less severe after first confinement 2. Secondary dysmenorrhoea - if dysmenorrhoea appears sometime later in life. It usually is due to pelvic pathology - endometriosis - adenomyosis - pelvic infection - fibromyomata - ovarian masses - tubal pathology - adhesions 1st degree: Graze (dermis layer affected, muscle layer unaffected)
2nd degree: +Mucosa and muscle layer affected 3rd degree: +External anal sphincter 3A <50% External anal sphincter thickness torn 3B >50% External anal sphincter thickness torn 3C External anal sphincter + Internal anal sphincter torn 4th degree: Rectal mucosa affected Repair: 1st degree tears rarely need suturing unless blood loss is marked. If 4th degree tear, repair rectal mucosa first, followed by vaginal mucosa. Always suture from above the tear's apex. One of the most commonly asked questions
1. Respiratory distress 2. Intraventricular haemorrhage 3. Necrotising enterocolitis 4. Retinopathy of prematurity 5. Jaundice 6. Problems with feeding 7. Problems with glucose control 8. Problems with temperature control Consider age of patient presenting:
In girls, (consider the causes for 'older women of reproductive age' but keep them lower down the list) 1. Dysfunctional uterine bleeding (60% of premenopausal women) a. Anovulatory (no ovulation, no corpus luteum and thus lack progesterone to stabilise endometrium - affects very young girls and perimenopausal women) b. Ovulatory (Prostaglandin metabolism problems) 2. Pregnancy-related causes a. Ectopic pregnancy b. Miscarriage 3. Systemic a. Coagulopathies b. Thrombocytopenia In older women of reproductive age, (also considering the above causes but further down the list) 1. Pelvic pathology a. Fibroids (Most common pelvic pathology as cause of menorrhagia) b. Polyps d. Adenomyosis e. Pelvic infection f. Endometrial carcinoma g. Atrophic vaginitis 2. Endocrine a. Hypothyroidism b. PCOS 3. Iatrogenic a. IUD b. PoP c. Anticoagulation 4. Dysfunctional uterine bleeding (60% of premenopausal women) a. Anovulatory (no ovulation, no corpus luteum and thus lack progesterone to stabilise endometrium - affects very young girls and perimenopausal women) b. Ovulatory (Prostaglandin metabolism problems) 5. Pregnancy-related causes a. Ectopic pregnancy b. Miscarriage 6. Systemic a. Coagulopathies b. Thrombocytopenia In post-menopausal women, 1. Exogenous hormones eg HRT/Mirena (30%) 2. Atrophic endometritis / vaginitis (30%) 3. Endometrial carcinoma (15%) / hyperplasia (5%) 4. Endometrial or cervical polyps (10%) |