- Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
- 1. Miscarriage and prematurity / / Manual for doctors and interns / Okhapkin M.B., Khitrov M.V., Ilyashenko I.N.-Yaroslavl 2002, p34 2. Obstetric bleeding / Guidelines.- Bishkek, 2000, C .13 3. Assistance in complicated pregnancy and childbirth. / A guide for midwives and doctors. Reproductive Health and Research, WHO, Geneva, 2002 4.Daylene L. Ripley MD. Atony, Invertion, and Rupture. Emergent Care Uterine Emergencies. Obstetrics and Gynecology Clinics, V.26, No. 3, Sept. 1999 5. Allan B MacLean, James Neilson. Maternal Morbility and Mortality. Report Of WHO, 2000 6. University of Iowa Family Practice Handbook, Fourth Edition, 2002 7. McDonald S, Prendiville WJ, Elbourne D Prophylactic syntometrine vs oxytocin in the third stage of labor (Cochrane Review) The Cochrane Library, 1998, 2, Update Software Oxford, Prendiville 1996 8. Prendiville WJ, The prevention of post partum haemorrhage: optimizing routine management of the third stage of labor Eur J Obstet Gynecol Reprod Biol, 1996, 69, 19-24 9. Khan GQ, John IS, Chan T, Wani S, Hughes AO, Stirrat GM Abu Dhabi third stage trial: oxytocin versus Syntometrine in the active management of the third stage of labor Eur J Obstet Gynaecol and Reprod Biol, 1995, 58, 147-51 A. Evans. Obstetrics/ Handbook of the University of California, 1999 11.Managing Complications in Pregnancy and Childbirth: a Guide for midwives and doctors. Department of Reproductive Health and Research Family and Community Health. World Health Organization, Geneva, 2003 12. Postpartum Haemorrage Module: Education Material for teachers of Midwifery. Maternal Health and Safe Motherhood Program. Family and Reproductive Health. World Health Organization, Geneva, 1996 13.Haemorrage: Intervention Group 6. Mother-Baby Package Spreadsheet. Family and Reproductive Health. World Health Organization, Geneva, 1999 14. Prendeville WD, Elbourne D, McDonald C. Active management of the third stage of labor versus expectant management (Cochrane Library Abstract, Issue 1, 2003). 15. Caroli G., Bergel E. Injections into the umbilical vein to eliminate the defect of the afterbirth / placental remnants (Cochrane Library Abstract, Issue 1, 2003). 16.15. Vorobyov A. Hematology in the struggle for human life 2005.-No. pp.2-5. 16. Eliasova L.G. Indicators of maternal mortality as criteria for the quality and level of organization of the work of obstetric institutions ..// St. Petersburg State Pediatric Medical Academy 10. 02.06.-p.1-3. 17. Barbara Shane. Outlok: special issue on maternal and neonatal health. //Issue 19, Number 3 18.Sara Mackenzie MD Obstetrics: late prenatal bleeding. //Management of Yowa University of Family Medicine. Ed. 4, chapter 14.
Information
Bazylbekova Z.O. MD Head of the Department of Pregnant Women with Obstetric Pathology and Extragenital Diseases of the Republican Research Center for Maternal and Child Health (RNITsOMiR).
Nauryzbayeva B.U. MD Department of Physiology and Pathology of Childbirth of the Republican Scientific Research Center for Maternal and Child Health (RNITsOMIR).
WFD of the mucous membrane of the cervical canal and the body of the uterus is both a diagnostic and therapeutic measure, i.e. It performs the functions of surgical hemostasis. After removal of the hyperplastic endometrium or bleeding polyp, bleeding stops. Further tactics depend on the pathomorphological study. Surgical treatment in the amount of panhysterectomy is indicated for the detection of uterine adenocarcinoma, atypical endometrial hyperplasia. With large or multiple uterine fibroids, nodular form of adenomyosis, a combination of fibromyoma and adenomyosis, surgical removal of the uterus is recommended: hysterectomy or supravaginal amputation of the uterus.
In other cases, with benign dyshormonal processes that caused uterine bleeding during menopause, a set of conservative measures is being developed. To prevent recurrence of menopausal bleeding, gestagens are prescribed that promote atrophic changes in the glandular epithelium and endometrial stroma. In addition, gestagen therapy alleviates other manifestations of menopause. In recent decades, antiestrogenic drugs (danazol, gestrinone) have been used to treat uterine bleeding in menopause. In addition to affecting the endometrium, antiestrogens help to reduce the size of uterine fibroids, reduce the manifestations of mastopathy. The use of androgens to suppress menstrual function is possible in women over 50 years of age. General contraindications for drugs of all groups are a history of thromboembolism, varicose veins, chronic cholecystitis and hepatitis with frequent exacerbations, arterial hypertension.
The use of hemostatic and antianemic drugs during uterine bleeding with menopause is auxiliary. If endocrine-metabolic disorders (obesity, hypothyroidism, hyperglycemia, hypertension) are detected, their medication and dietary correction is carried out under the supervision of an endocrinologist, diabetologist, cardiologist.
Recurrent uterine bleeding during menopause during or after treatment usually indicates undiagnosed organic diseases (submucosal myomatous nodes, polyps, endometriosis, ovarian tumors). Menopausal bleeding should always cause oncological alertness, since in 5-10% of patients at this age, endometrial cancer is the cause of bleeding. Women who have crossed the threshold of menopause should monitor their health no less carefully than at reproductive age, and in case of abnormal bleeding, immediately contact a specialist.
Dysfunctional uterine bleeding(DMK) - bleeding due to pathology of endocrine regulation, not associated with organic causes, most often occurring in connection with anovulatory cycles (90% of DMC). DMC refers to irregular menstrual cycles with heavy bleeding after a missed period. As a rule, DMK is accompanied by anemia. DMC in adolescence (juvenile) is most often caused by follicle atresia, i.e. they are hypoestrogenic, much less likely to be hyperestrogenic with persistence of follicles. Bleeding occurs after a delay in menstruation for different periods and is accompanied by anemia. Climacteric bleeding in most cases is also anovulatory, but in most cases they are due to the persistence of a mature follicle, i.e., it is hyperestrogenic. In anovulatory cycles, bleeding is preceded by a delay in menstruation of varying duration.
Code according to the international classification of diseases ICD-10:
- N92. 3- ovulatory bleeding
- N92. 4 - Heavy bleeding in the premenopausal period
- N93- Other abnormal bleeding from the uterus and vagina
- N95. 0 - Postmenopausal bleeding
Statistical data
14-18% of all gynecological diseases. In 50% of cases, the patient is older than 45 years (premenopausal and menopausal periods), in 20% - adolescence (menarche).Bleeding uterine dysfunctional: Causes
Etiology
Spotting in the middle of the cycle is a consequence of a decrease in estrogen production after ovulation. Frequent menstruation is a consequence of the shortening of the follicular phase, due to inadequate feedback from the hypothalamic-pituitary system. Shortening of the luteal phase - premenstrual spotting or polymenorrhea due to a premature decrease in progesterone secretion; the result of insufficiency of the functions of the corpus luteum. Prolonged activity of the corpus luteum is a consequence of the constant production of progesterone, which leads to a lengthening of the cycle or prolonged bleeding. Anovulation is an excess production of estrogens that is not associated with the menstrual cycle, not accompanied by cyclic production of LH or secretion of progesterone by the corpus luteum.Pathomorphology
Depends on the cause of DMC. Histopathological examination of endometrial preparations is mandatory.Dysfunctional uterine bleeding: Signs, Symptoms
Clinical picture
Royal bleeding, irregular, often painless, the volume of blood loss is variable. Characteristic absence: . manifestations of systemic diseases. violations of the functions of the urinary system and gastrointestinal tract. long-term use of acetylsalicylic acid or anticoagulants. the use of hormonal drugs. thyroid diseases. galactorrhea. pregnancy (especially ectopic). signs of malignant neoplasms of the genital organs.Dysfunctional uterine bleeding: Diagnosis
Laboratory research
Necessary in case of suspicion of other endocrine or hematological disorders, as well as in patients in the premenopausal period. They include assessment of thyroid function, KLA, determination of PT and PTT, HCG (to exclude pregnancy or hydatidiform mole), diagnosis of hirsutism, determination of prolactin concentration (in case of pituitary dysfunction), ultrasound, laparoscopy.Special Studies
Special tests to determine the presence of ovulation and its duration. Measurement of basal temperature to detect anovulation. Definition of the "pupil" phenomenon. Definition of the "fern" phenomenon. Symptom of cervical mucus tension. Pap smear. Ultrasound to look for ovarian cysts or uterine tumors. Transvaginal ultrasound - if pregnancy is suspected, anomalies in the development of the genital organs, polycystic ovaries. Biopsy of the endometrium. All patients over 35 years of age. With obesity. With SD. With arterial hypertension. Curettage of the uterine cavity - with a high risk of endometrial hyperplasia or carcinoma. If endometritis, atypical hyperplasia, and carcinoma are suspected, uterine cavity curettage is preferable to endometrial biopsy.Differential Diagnosis
Liver diseases. Hematological diseases (von Willebrand's disease, leukemia, thrombocytopenia). Iatrogenic causes (for example, trauma). Intrauterine spirals. Taking drugs (oral contraceptives, anabolic steroids, GCs, anticholinergics, digitalis drugs, anticoagulants). ectopic pregnancy. Spontaneous abortion. Diseases of the thyroid gland. Uterine cancer. Uterine leiomyoma, endometriosis. Bubble drift. Tumors of the ovaries.Dysfunctional uterine bleeding: Treatment methods
Treatment
Mode
Outpatient; hospitalization for severe bleeding and hemodynamic instability.Drug therapy
Drugs of choice. For emergencies ( bleeding severe degree; hemodynamic instability). Estrogens conjugated 25 mg IV every 4 hours, the maximum allowable is the introduction of 6 doses. After stopping bleeding - medroxyprogesterone 10 mg / day for 10-13 days or oral combined contraceptives containing 35 mg ethinylestradiol (ethinylestradiol + cyproterone). Correction of anemia - replacement therapy with iron preparations. For conditions that do not require emergency treatment. Estrogen hemostasis - ethinylestradiol 0.05-0.1 mg. Then the dose is gradually reduced over 5-7 days and continues to be administered for 10-15 days, and then 10 mg of progesterone is administered for 6-8 days. Progesterone hemostasis (contraindicated in moderate and severe anemia) - medroxyprogesterone 10 mg / day for 6-8 days or 20 mg / day for 3 days, norethisterone 1 tablet every 1-2 hours. Oral contraceptives - 1 tablet on the first day after 1-2 hours until the bleeding stops (no more than 6 tablets), then reduce daily by 1 tablet per day. Continue taking 1 tablet per day until 21 days, after which the reception is stopped, which provokes a menstrual-like reaction. alternative drug. progesterone instead of medroxyprogesterone. 100 mg of progesterone in / m - for an emergency stop of bleeding; not used in cyclic therapy. Do not use vaginal suppositories, since it is difficult to dose drugs in this case. Danazol - 200-400 mg / day. May cause masculinization; mainly used in patients with upcoming hysterectomy. Contraindications. Treatment is carried out only after the exclusion of other causes of uterine bleeding. Blind prescription of hormone therapy is not recommended.Surgery
Emergency conditions (profuse bleeding, severe hemodynamic disturbances). Curettage of the walls of the uterine cavity in DMC of the reproductive and menopausal periods. Removal of the uterus is indicated only in the presence of concomitant pathology. Conditions that do not require emergency care - curettage of the uterine cavity is indicated with the ineffectiveness of medical treatment.Patient observation. All women receiving estrogens for DUB should keep a diary to record abnormal bleeding and monitor the effectiveness of therapy.
Complications
Anemia. Adenocarcinoma of the uterus with prolonged unreasonable estrogen therapy.Course and forecast
Vary depending on the cause of DMC. In young women, effective drug treatment of DMK is possible without surgical intervention.Reduction
DMK - dysfunctional uterine bleeding.ICD-10. N92. 3 Ovulatory bleeding. N92. 4 Abundant bleeding in the premenopausal period. N93 Other abnormal bleeding from uterus and vagina. N95. 0 Postmenopausal bleeding.
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Click here to comment on: Bleeding uterine dysfunctional(Diseases, description, symptoms, folk recipes and treatment)
Juvenile (pubertal) uterine bleeding is dysfunctional bleeding in girls during puberty (from menarche to 18 years of age).
ICD-10: N92.2
general information
SUB is one of the most common and severe forms of reproductive system disorders during puberty, and their frequency in the structure of gynecological pathology of children and adolescents, according to various researchers, ranges from 8-10 to 25%. SUB is a risk factor for the development of menstrual and generative disorders, hormonally conditioned pathology in reproductive age. Among the reasons for hospitalization in the Ukrainian Center for Gynecology of Children and Adolescents "Ohmatdet" SMC occupy a leading position and account for 35% of all diseases.True UMC includes dysfunctional uterine bleeding that occurs during the period of the formation of menstrual function, i.e. bleeding, which are based on hormonal disorders, in which there are no initial organic diseases of the genital area (tumors, infantilism, malformations and systemic diseases). They occur, as a rule, two to three years after the formation of the menstrual function.
Etiology
In the development of dysfunctional SMC, the leading role belongs to the infectious-toxic effect on the structures of the pituitary gland and hypothalamus that have not reached functional maturity, which regulate ovarian function. Especially adverse effect of infection is observed in chronic tonsillitis. In addition, the predisposing causes of SMC include:
unfavorable course of the antenatal period;
chronic somatic diseases;
acute and chronic forms of stress;
unfavorable living conditions;
intoxication;
hypo- and beriberi;
pathological conditions of the endocrine glands (thyroid gland, adrenal glands), hypothalamic syndrome.
Pathogenesis
During puberty, JMC are, as a rule, acyclic bleeding, more often by the type of atresia of the follicles, less often by the type of persistence of the follicles. In both cases, there is hyperestrogenism (in the first - relative, in the second - absolute), which leads to endometrial hyperplasia with subsequent bleeding. Hyperplastic processes of the endometrium in this case can be expressed in glandular-cystic hyperplasia, endometrial polyp, adenomyosis.
Clinical picture
The main symptoms of JMC:prolonged (more than 7-8 days) spotting from the genital tract;
bleeding, the interval between which is less than 21 days;
blood loss more than 100-120 ml/day;
The severity of the disease is determined by:
the nature of blood loss (intensity, duration);
degree of secondary posthemorrhagic anemia.
Typical complaints in JMC are weakness, lack of appetite, fatigue, headache, pallor of the skin and mucous membranes, tachycardia. In addition, there are irregular, more or less heavy bleeding from the vagina, which can lead to the development of anemia, including severe. This is the main danger of juvenile bleeding.
Diagnostics
The diagnosis is based on a typical clinical picture. The examination is carried out in the presence of the mother or relative.Physical research methods
Questioning - the beginning, duration of bleeding and its features; menarche; features of menstrual function; preliminary treatment; features of the course of pregnancy and childbirth in the patient's mother.
General examination - anemia, the degree of development of secondary sexual characteristics (MF, armpit, pubic hair), the presence of hyperandrogenism.
Deep palpation of the abdomen - detection of tumors.
Examination of the external genital organs - the degree of development, the presence of anomalies, the nature of bleeding, the absence of injuries to the genital organs.
Recto-abdominal examination - to assess the condition of the internal genital organs.
Examination in the mirrors and bimanual gynecological examination (in sexually active girls) - determination of the condition of the internal genital organs.
Laboratory research methods
Mandatory:
determination of blood group and Rh factor;
complete blood count - the presence of signs of anemia;
general urine analysis;
biochemical parameters of blood - determination of the level of serum iron, bilirubin, liver enzymes;
expanded coagulogram.
If there are indications:
determination of the level of hormones in the blood and urine - FSH, LH, prolactin, estrogens, progesterone, cortisol, 17-KS - in daily urine;
hormonal colpocytology.
Instrumental research methods
Mandatory:
Ultrasound transabdominally, preferably transvaginally (in sexually active girls);
Vaginoscopy - in order to exclude the pathology of the vagina and cervix, their injuries.
If there are indications:
diagnostic curettage;
hysteroscopy;
X-ray of the skull with the projection of the Turkish saddle;
EEG;
CT scan for suspected pituitary tumor;
radiography of the hands (determination of bone age),
Ultrasound of the adrenal glands and thyroid gland;
MRI of the pelvic organs.
Expert advice
Mandatory:
pediatrician.
If there are indications:
oncogynecologist;
endocrinologist;
hematologist.
Differential diagnosis:
spontaneous abortion;
ectopic pregnancy;
hormone-producing ovarian tumors;
RE;
pathology of the vagina - trauma, foreign bodies, atrophic colpitis,
endometrial polyps,
adenomyosis,
cysts and tumors of the ovaries,
abnormalities of the uterine vessels - dysplasia and arteriovenous shunts,
diseases of the blood coagulation system.
Treatment
Treatment includes two stages.1. Stopping uterine bleeding - symptomatic hemostatic therapy (non-hormonal or hormonal hemostasis);
2. Prevention of recurrent bleeding.
Pharmacotherapy
The choice of hemostasis method is determined by the general condition of the patient and the degree of blood loss. Uterotonic, antianemic therapy and a general therapeutic effect are also necessarily carried out, contributing to an increase in the protective and adaptive forces of the body. However, it should be borne in mind that the symptomatic method of treatment does not always have the desired effect, which necessitates the appointment of hormone therapy. So, in the event of bleeding and severe anemization (hemoglobin 100 g / ml and below, hematocrit 25% and below), the presence of endometrial hyperplasia (M-echo more than 10 mm), hormonal hemostasis is performed, acting (unlike non-hormonal methods of stopping bleeding) quickly and quite efficiently. Stop bleeding with hormonal hemostasis occurs within 10-12 hours.
Currently, hormonal hemostasis in girls is carried out both with monophasic COCs and progestin preparations. Carrying out hormonal hemostasis with only estrogens in adolescence is undesirable, since the "withdrawal" bleeding is pronounced and leads to secondary anemia and inhibition of the central mechanisms of regulation of menstrual function. When prescribing combined progestogen-estrogenic drugs for the purpose of hemostasis, monophasic drugs containing a dose of ethinylestradiol from 30 to 50 μg (ethinylestradiol + gestogen, ethinylestradiol + levonorgestrel, ethinylestradiol + norethisterone) are used. Triphasic COCs for bleeding control are not recommended because they contain lower doses of progestins during the first two phases than monophasic drugs.
In order to prevent recurrence of bleeding, both combined monophasic and triphasic estrogen-gestagen preparations are prescribed. In this case, low-dose oral contraceptives (ethinylestradiol + gestodene, ethinylestradiol + levonorgestrel) are preferred. Taking into account the functional immaturity of the neuroendocrine system during puberty and the incomplete establishment of MC in patients, courses of hormone therapy should be administered at intervals of 1-3 months. During this period, general strengthening therapy, herbal medicine, cyclic vitamin therapy are carried out, homeopathic remedies are prescribed.
Hormonal drugs are prescribed to teenage girls with the consent of their parents.
For the purpose of hemostasis, non-hormonal drugs are also used:
non-steroidal anti-inflammatory drugs - reduce the synthesis and change the balance of prostaglandins in the endometrium, inhibit the binding of the PGE vasodilator to specific receptors, increase platelet aggregation and endometrial vasospasm. The drugs reduce menstrual blood loss, as well as dysmenorrhea, headache, diarrhea associated with menstruation;
phytopreparations - infusions of nettle, water pepper.
prophylactic hormone therapy(scheme No. 9) is carried out in combination with other methods of pathogenetic therapy, using:
sedatives;
iron preparations;
vitamins;
antioxidants;
homeopathic preparations;
psychotherapy;
physiotherapy (electrophoresis of the cervical sympathetic nodes with novocaine No. 10, endonasal electrophoresis with vitamin B 1 No. 100).
Surgery
Therapeutic and diagnostic curettage of the walls of the uterine cavity is carried out according to the following indications:
profuse uterine bleeding, posing a threat to the life of the patient;
severe secondary anemia (Hb 70 g/l and below, hematocrit below 25.0%);
suspicion of pathological changes in the structure of the endometrium (endometrial polyp according to ultrasound of the small pelvis).
Efficiency criteria:
normalization of the MC throughout the year;
absence of heavy and prolonged periods;
absence of pain during menstruation;
absence of pathological changes in the internal genital organs.