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Management of abnormal uterine bleeding
JodySteinauer,MD,MASDept.Ob/Gyn&ReproductiveSciencesUniversityofCalifornia,SanFrancisco
Disclosures
July4,2017.Ihavenodisclosures.
The Questions
• Toomuch– abnormaluterinebleeding– Differentialandapproachtowork‐up
• Toomuch– fibroids
• Toofast:She’shemorrhaging—whatdoIdo?
• Sideeffect:duetohormonalcontraception
1:AUBand2:fibroids1:AUBand2:fibroids
4:Contraceptivesideeffects4:Contraceptivesideeffects 5:Bleedinginpregnancy5:Bleedinginpregnancy
3:Acutehemorrhage3:Acutehemorrhage
Case 1
A46year‐oldwomanreportsherperiodshavebecomeincreasinglyirregularandheavyoverthelast6‐8months.Sometimestheycome2timespermonthandsometimesthereare2monthsbetween.LMP2monthsago.Shebleeds10dayswithclotsandfrequentlybleedsthroughpadstoherclothes.Shealsohasdiabetesandisobese.
1. FSH2. Testosterone&DHEAS3. Urinehcg4. TSH5. Transvaginal Ultrasound(TVUS)6. EndometrialBiopsy(EMB)
Q1: Which is the first test should you order in this patient? Step 1: Pregnant?
Pregnant• Ectopic• SpontaneousAbortion• ThreatenedAbortion• MolarPregnancy• Trauma• Othercauses
NotPregnant• Anovulation***• Anatomic/structural**• Neoplastic*• Infectious• Iatrogenic• Non‐gynecologic
* = Most likely for this patient
Terminology: What is abnormal?
• Normal:Cycle=28days(21‐35);Length=2‐7days;heaviness=self‐defined
• Toolittlebleeding:amenorrheaoroligomenorrhea
• Toomuchbleeding:Menorrhagia(regulartimingbutheavy(accordingtopatientor>80cc)ORlongflow(>7days)
• Irregularbleeding:Metrorrhagia,intermenstrual orpost‐coitalbleeding
• IrregularandExcessive:Menometrorrhagia
• Preferredtermfornon‐pregnantheavyand/orirregularbleeding=AbnormalUterineBleeding(AUB)
Bradley, AJOG, 2016
Pathophysiology: Anovulatory Bleeding
Bricks&MortarEstrogen=Bricks,buildendometrium
Progesterone(P)=Mortar,stabilizes,onlyhavePifovulate
Normalmenses:WithdrawalofPcauseswalltofalldown,allatonce(orderlybleed)
Anovulation: NoPsowhenwallgrowstootall,itfalls.Itisheavywhenwallistall.Brickscanalsofallintermittently&incompletely–irregularly,irregular
Abnormal Uterine Bleeding Reference: AUB Differential
Uterus:Polyp,adenomyosis,leiomyoma,atrophy
Cervix:polyp,atrophy,trauma
Vagina:atrophy,trauma
Uterus:Polyp,adenomyosis,leiomyoma,atrophy
Cervix:polyp,atrophy,trauma
Vagina:atrophy,trauma
Uterus:Hyperplasia,malignancy
Cervix:Dysplasia,malignancy
Ovary:hormoneproducingtumor
Uterus:Hyperplasia,malignancy
Cervix:Dysplasia,malignancy
Ovary:hormoneproducingtumor
Uterus:Endometritis,PID
Cervix:Cervicitis
Vagina:Vaginitis(eg Trich)
Uterus:Endometritis,PID
Cervix:Cervicitis
Vagina:Vaginitis(eg Trich)
Coagulopathy(vWD),severerenalorliverdz,
GIorGUsource
Coagulopathy(vWD),severerenalorliverdz,
GIorGUsource
AnovulationAnovulation
NotPregnantNotPregnant
PALM-COEINPALM-COEIN
AnatomicAnatomic
NeoplasticNeoplastic
InfectiousInfectious
Non‐GynecologicNon‐Gynecologic
History and Physical Examination
• Hx:bleedingpattern,symptomsofanemia,sexual&reproductivehistory,chronicmedicalillness,medication
• Acutev.chronic
• PE:signsofhypovolemia andanemia,thyroidexamination,gynecologicexam,abdominalexamination,(screeningforcervicaldysplasiaandSTI)– Obesity:upto60%ofwomenwhodonotovulateareobese–increasedestradiol&testosterone;elevatedinsulindisorderedfolliculardevelopment
Initial Work‐up: Menometrorrhagia
• Always:Urinepregnancy
• Usually:TSH
• Maybe:Hct,r/ocoagulopathy
• Maybe:EMB(EndometrialBiopsy)
• Maybebutlater:Transvaginal Ultrasound
• Usuallynotnecessary:FSH,LH,Testosterone,Estradiol
A Rational Approach to EMB
Post‐Menopause:ALLwomenWITHANY BLEEDING(except4‐6monthsafterHT)
Recentonsetirregularbleeding: Considertreatingfirstandifbleedingnormalizes,noneedforEMB
>50: Allwomenwithrecurrent,irregular bleeding(considernotdoingifperiodslightandspacingout)
45‐50: Recurrentirregularbleedingplus>1riskfactorOR>6mosmenometrorrhagia (considernotdoingifperiodslightandspacingout)
<45:Longhx (>2yr?)ofuntreatedanovulatory bleedingorfailedmedicalmanagement
EMBisnotperfectlysensitivesofurtherevaluationmandatoryif:
1.PersistentAUBafternegativeEMB
2.PersistentAUBafter3‐6monthsofmedicaltherapy
Do all women with AUB need an ultrasound?
AlthoughTVUS isthebestimagingchoiceforpelvicpathology(ie betterthanMRI,CT)….• 80%withheavymenstrualbleedinghavenoanatomicpathology
• Incidentalfindingssuchasfunctionalovariancystsandsmallfibroids(~50%)areoftenfoundleadingtoanxietyandunnecessarytreatments
• SO….treatfirst,TVUSiftreatmentfails
What about U/S instead of EMB for post‐menopausal bleeding?
Transvaginal Ultrasound
• Measureendometrialstripe
• Abnormal=>4mm(or5)
• Non‐specific:myomas,polypsalsocausethickEM
• Operatorskillmandatory
• NOTUSEFULPRE‐MENOPAUSE
TVUS EMB
96% Sensitivity 94%
61% Specificity 99%
99% NPV 99%
40‐50% Furtherw/unecessary
?<5%
CanofferpatientchoiceaslongaseitherisquicklyavailableandpatientunderstandsshemayneedEMBafterU/S
CanofferpatientchoiceaslongaseitherisquicklyavailableandpatientunderstandsshemayneedEMBafterU/S
TVUS vs EMB to Detect Cancer (in post‐menopausal women)
Q2: You decide to do a urine pregnancy test and check her TSH – which is the most appropriate next test?
1. FSH2. Testosterone&DHEAS3. Serumbeta‐HCG4. Transvaginal Ultrasound5. EndometrialBiopsy
Q2: You decide to do a urine pregnancy test and check her TSH – which is the most appropriate next test?
1. FSH2. Testosterone&DHEAS3. Serumbeta‐HCG4. Transvaginal Ultrasound5. EndometrialBiopsy
A46year‐oldwomanreportsherperiodshavebecomeincreasinglyirregularandheavyoverthelast6‐8months.Sometimestheycome2timespermonthandsometimesthereare2monthsbetween.LMP2monthsago.Shebleeds10dayswithclotsandfrequentlybleedsthroughpadstoherclothes.Shealsohasdiabetesandisobese.
A46year‐oldwomanreportsherperiodshavebecomeincreasinglyirregularandheavyoverthelast6‐8months.Sometimestheycome2timespermonthandsometimesthereare2monthsbetween.LMP2monthsago.Shebleeds10dayswithclotsandfrequentlybleedsthroughpadstoherclothes.Shealsohasdiabetesandisobese.
EMB=“Disordered Proliferative” How do I stop the bleeding?
MedicalNSAID’sE+Ppill,patch,ringOralProgestinProgestinIUDIMProgestinGnRH agonistTranexamic Acid
SurgicalEndometrialablation
D&C/Hysteroscopy
Hysterectomy
Disorderedproliferative=Anovulation
Treatment of AUB: NSAIDs
• Suppressprostaglandinsynthesis,increaseplateletaggregation,andreducemenstrualbloodloss
• Reducesbloodlossby40%• Usealoneorwithothertreatments• Prescribe5daysATC
– Ibuprofen,mefenamic acid,naproxen
Treatment of AUB: CHC
• CHC– pill,patch,ring– improvecyclecontrol,decreasemenstrualbloodlossby40%whenusedtraditionallyorcontinuously– OneCOC(withestradiol)approvedbyFDAforheavymenstrualbleeding
– COCsoftenusedtotreatacuteandchronicAUB– Fewstudiessupportupto70%decreasedEBLwithCOCandonestudywithvaginalring
Bradley, AJOG, 2016
Treatment of AUB: Progestins
• Oralprogestin– IfovulatoryAUB=HMB:daily ordays5‐26“extendeduse”progestindecreasesbloodloss(MPA2.5‐10mgqd,norethindrone 2.5‐5mgqd,NETA5TID)
– Lowsatisfactionwithextendeduse– Ifanovulatory:cyclic progestin‐12‐14d/monthimprovesmensesinhalfofwomen
• Injectableprogestin– 50%amenorrheaafter1year,irreg.bleedinginfirstfewmonthsand50%atoneyear
• Intrauterineprogestin– Significantdecreaseinbloodloss,superiortootherprogestinsandCHCs
Bradley, AJOG, 2016; Heikinheimo, Best Practice & Research Clin Ob Gyn, 2017.
First Line Hormonal Treatments
• Firstchoice:Levonorgestrel IUD– >80%reductioninbloodloss,decreasedcramping,prevents/treatshyperplasia,highlyeffectivebirthcontrol
– Bloodlossandsatisfactioncomparabletoablation,satisfactioncomparabletohysterectomy
– Veryfewcontraindications
• 2nd choice:combinedcontraceptives(pill,patch,ring)ororalprogestin(cyclicv.daily)orprogestininjection– Decreasesirregularperimenopausal bleeding– Anytypeok,20mcgestrogenpreferredforwomen>40– Estrogencontraindications:smokers>35,HTN,complicatedDM,multipleRFforCAD,h/oDVT,migraineswithaura
Where do you find the US MEC and SPR?
Medical Condition
Birth Control Methods
MEC Category
Treatment of AUB: Tranexamic Acid
• ApprovedbyFDAfortreatmentofovulatory AUB• Preventsplasmaformation,fibrindegradation,andclotdegradation
• InRCT’s,moreeffectivethanplacebo,NSAID,cyclicprogestin
• Dose:1.0‐1.3gevery6‐8hoursx5days
• Risks:TheoreticriskofVTE– contraindicatedinhistoryoforriskfactorsforVTE– notwithCHC
• Sideeffects:Minimal
Surgical Treatments
• D&C,Hysteroscopy:– Notreallyatreatment– Temporaryreductioninbleeding– Curativeiffibroidorpolypremoved
• EndometrialAblation– Reducesbutdoesn’teliminatemenses– ~25%repeatablationorhysterectomyin5years– Mustruleoutcancerfirst– Can’tbedonein>12weekuteriorforwomenwhowantfertility
Perimenopausal/Anovulatory Bleeding: Summary
R/opregnancy,thyroiddz
EMBifmeetscriteria
Treatfirstasifanovulatory bleeding:– NSAIDs+– Hormones(Levo IUD,CHC,DMPA)
Ifpersists:– U/Stocheckforanatomiccauses(andEMBifnotalreadydone)
– Discusssurgicaloptionsforbleedingrefractorytomedicalmanagement.
Case 2: Is it the fibroids?
SamehistoryasCase1exceptshehasfibroids….Onexaminationheruterusis16weeks’size
• Verycommon 80%ofhysterectomyspecimens(doneforanyreason)and~75%haveonU/Satage50
• About50%areasymptomatic
• Growslowlyuntilmenopauseandthendecreaseby~50%(canstillcausebleedingpost‐menopause)
Fibroid Symptoms
• Bleeding– Usuallynormal ormenorrhagia(heavybutregular).Fibroidsstretchendometrium=morebleeding
– Occasionallymenometrorrhagia ifsubmucous orintracavitary(Fibroidsdistortendometriumsoitcan’tbestable)
• Pressure(notpain)• Dysmenorrhea
Heavy,irregularbleedingHeavy,irregularbleeding
NoeffectNoeffectHeavy,regularbleedingHeavy,regularbleeding
Is the bleeding due to the fibroids?
• Fibroidsarecommoninlater40s• Anovulationiscommoninlater40s• Theincreasedbleedingseentypicallyduetoincreasedvolumeordistortionoftheendometrium
• Therefore:Thintheendometriumbytreatingasanovulatory bleeding.
Treatment of AUB and Fibroids
• LNG‐IUD:approvedbyFDAforwomenwithfibroidsunlessdistorteduterinecavity
• Combinedhormonalcontraception• NSAIDS• Tranexamic acid• GnRHagonisttoshrinkfibroidsbeforesurgery,orbridgetomenopause
• (SPRMS– investigational)
AUB with Known Fibroids: Work‐up and Treatment
• R/ocancer(using“rationalemb algorithm”)andpregnancy(don’tblamefibroidsforthebleeding)
• NSAID’sandLNGIUD,CHC,tranexamicacid
• Ifnobetter,blamethefibroids!(LNGIUD>CHC)
• +/‐ Lupron‐‐asabridgetomenopauseorpre‐optoshrinktoobtainlessinvasiverouteofhysterectomy
• Othertx (hysteroscopic resectionif<3cm,myomectomy,MR‐guidedfocusedu/s,RFA,UAE,hysterectomy)
Case 3: Acute Hemorrhage
41yearoldwomanpresentswithdizzinessandheavyvaginalbleedingfor2weeksstraight.
Priortothis,occasionalirregularperiodsbutnothinglikethis!Hemoglobin=9
Acute AUB Treatment
ABC’sandStopthebleeding!• ConsiderEDfortransfusion
• Medicalmanagement– Estrogen– Rapidendometrialgrowth,vasospasmofarteries,plateletaggregation,increasingclottingsupportivefactors
• CEE25mgIVq4‐6hoursfor24hours,followedbyprogestinorCOCfor10‐14days
• COC:1tabTIDx7daysthentaper– Progestin:medroxyprogesteroneacetate20mgTIDx7days– Tranexamicacid1.3gTIDx5days
• Otheroptions:D&C,foley bulbtamponade,emergencyhysterectomy
Bradley, AJOG, 2016
COC Taper
• Don’twanttogive2‐4COC’sperdayandthenstopsuddenlyb/cwillhavelargewithdrawalbleed
• Taper:3x4days,2x4daysthen1 perdayfor1‐2months(60+pillsrequired).
• Instructnottotakeplacebosandgiveatleast3packsofpillsatonce.
• Givewithanti‐emetic,splitbid(i.e.2bidratherthan4allatonce)
Case 4: Because of her contraceptive…
• A32year‐oldwomanhasrecentlyinitiatedthebirthcontrolpill.
• Shehashadspottingfor30straightdays!Sheisannoyed.
Case 4: Because of the injection…
• A32year‐oldwomanhasrecentlyinitiatedthecontraceptiveinjection.
• Shehashadspottingfor30straightdays!Sheisannoyed.
Case 4: Because of the implant…
• A32year‐oldwomanhasrecentlyinitiatedthecontraceptiveimplant.
• Shehashadspottingfor30straightdays!Sheisannoyed.
Case 4: Because of the IUD…
• A32year‐oldwomanhasrecentlyinitiatedthelevonorgestrel IUD.
• Shehashadspottingfor30straightdays!Sheisannoyed.
Condom Pill InjectionLNGimplant
n=705 n=1637 n=579 n=66%Reportingthefollowingreasons
Tooexpensive 2.2 3.2 2.1 1
Toodifficultormessytouse 15.2 5.7 1.2 10.4Partnerunsatisfied 38.6 2.8 2.6 1.2Experiencedsideeffects 17.9 64.6 72.3 70.6Worriedaboutsideeffects 2 13.1 4.2 4.2
Didnotlikethechangesinmenstrualperiods 1.5 12.7 33.7 19.3
Experiencedcontraceptivefailure 7.5 10.4 5.7 8.3Worriedabouteffectiveness 13.2 3 2.2 0NoprotectionagainstSTIs 1.1 2.1 1.3 0Otherhealthproblems/doctor'sadvice 2.5 8.5 5.7 9.2Methoddecreasedsexualpleasure 37.9 4.1 8.2 1.1Toodifficulttoobtain 1.5 1.8 2 0Otherreason 15.4 10.6 8.1 10.2
Moreau C, Contraception, 2005.
Reasons for dissatisfaction leading to contraceptive discontinuation
Mechanism for Abnormal Bleeding with Hormonal Contraceptives
IrregularbleedingIrregularbleeding
Transitionfromthicktothinendometrium
Transitionfromthicktothinendometrium
Fragileandsuperficial
bloodvesselsinendometrium
Fragileandsuperficial
bloodvesselsinendometrium
Unstableendometrialstromaandglands
Unstableendometrialstromaandglands
Alteredendometrialremodeling
Alteredendometrialremodeling
COCs: Setting Expectations
• Unscheduledbleeding– 10‐30%inthefirstmonth– Lessthan10%bythethirdmonth
• Amenorrhea– Lessthan2%inthefirstyear– Upto5%after1year
Speroff L & Darney PD, Clinical Guide for Contraception 4th Ed, 2011
COCs: General Counseling
• Takepillatthesametimeeachday– Inconsistentpilluseassociatedwithincreasedriskofunscheduledbleeding1
• Stopsmoking!– Smokersmorelikelytoexperienceunscheduledbleeding/spotting1
– Amongsmokers,bleedingmorelikelytopersist
Rosenberg, Contraception, 1996.
CyclicUse ExtendedCycle
COCs: Regimens Treating Bleeding on Cyclic COCs
• Supplementalestrogen1– OralCEE1.25mgx7days– Oralestradiol2mgx7days
• IncreasedoseofestrogenifwomanusingCOCwith< 20mcgestrogen– SeveralCOCscontaining20mcgethinylestradiolresultedin:
• Higherratesofearlytrialdiscontinuation• Increasedriskofbleedingdisturbances2
• Switchtovaginalring
1. Speroff L & Darney PD, Clinical Guide for Contraception 4th Ed, 2011.2. Gallo MF, Cochrane, 2013.
Double or triple the birth control pill?
Treating Bleeding on Extended COCs
• DiscontinuetheCOCsfor3‐4consecutivedays1
– A3‐dayhormonefreeintervalwasassociatedwithgreaterresolutioninbreakthroughbleeding/spottingincomparisontocontinuingactivepills2
– Afterthefirst21days
1. Godfrey EM, Contraception, 2012; 2. Sulak PJ, AJOG, 2006.
DMPA: Setting Expectations
• Abnormalbleedingiscommoninthefirstyear• Ratesofunscheduledbleeding1
– Upto70%inthefirstyear– Approximately10%afterthefirstyear
• Amenorrheaismorelikelyovertime1
Within3months
After1year At5years
Rateofamenorrhea 12% 46% 80%
1. Speroff L & Darney PD, Clinical Guide for Contraception 4th Ed, 2011.
Summary: Injection Bleeding
EnhancedCounseling• Bleedingpatterns• Reassurance
EnhancedCounseling• Bleedingpatterns• Reassurance
ContinueDMPA• Moreinjections,lessbleeding
ContinueDMPA• Moreinjections,lessbleeding
TREAT• NSAIDsx5‐7days• Estrogen(COCsorsupplementalestrogenx10‐20d)
• Tranexamicacid
TREAT• NSAIDsx5‐7days• Estrogen(COCsorsupplementalestrogenx10‐20d)
• Tranexamicacid
DMPA
Etonogestrel Implant: Setting Expectations
• Mostwomenexperienceareductionofmenstrualbleeding1
• Bothersomebleedingreportedin25%ofpatients2
– 6.7%reportedfrequentbleeding– 17.7%prolongedbleeding
• Ratesofamenorrhea3
– Approximately20%infirstyear– 30‐40%after1year
1. Mansour D, Contraception, 2011. 2. Mansour D, Eur J Contracept Reprod Health Care, 2008 3. Speroff L & Darney PD, Clinical Guide for Contraception 4th Ed, 2011.
Contraceptive Implant: Bleeding Patterns
• Numberofunscheduledbleedingdays:
– IsHIGHESTinthefirst3months
– DECREASESoverthefirstyear
– PLATEAUSinthesecondandthirdyear
1. Flores JB, Int J Gynaecol Obstet, 2005.
Contraceptive Implant: Bleeding Patterns
• Moreunpredictablebleedingpattern1– Amenorrheamaynotbesustainedifachieved
– “Favorable”patterninthefirst3monthspredictsacontinuedfavorablepattern
– Forthosewithan“unfavorable”bleedingpattern,50%reportimprovementovertime
1. Mansour D, Eur J Contracept Reprod Health Care, 2008.
Treating Implant Bleeding
EXPECTANTMANAGEMENTfor6‐12months
EXPECTANTMANAGEMENTfor6‐12months
Supplementalestrogen
Supplementalestrogen
COCs10‐20daysCOCs
10‐20days
Oralestrogen‐1.25mgCEE2mgestradiol
Oralestrogen‐1.25mgCEE2mgestradiol
Transdermalestrogen0.1mg/day
Transdermalestrogen0.1mg/day
NSAIDsx5‐7days
NSAIDsx5‐7days
USSelectedPracticeRecommendationfor
ContraceptiveUse,2013
Where do you find the US MEC and SPR?
LNG‐IUS: Setting Expectations
• Unscheduledspottingorlightbleedingiscommon,especiallyduringthefirst3–6months
• ForLNG52/5,spottingwaspresentin25%oftheusersat6monthsanddecreasedovertime.1
1. Hidalgo M, Contraception, 2002.
IUD Comparison
Bedsider.org
4/5 years
“52/5”
“52/4”
“19.5/5”
“13.5/3”
LNG‐IUS: Setting Expectations
• LNG52/5andLNG52/4– 79‐97%reductioninbleeding– 33%oligo/amenorrheainfirst3months,70%2years– Amenorrheaat1yr:20%– Amenorrheaat3yrs:40%
• LNG19.5/5– Amenorrheaat1yr:12%– Amenorrheaat3yrs:20%
• LNG13.5/3– Amenorrheaat1yr:6%– Amenorrheaat3yrs:12%
Treating LNG IUD Bleeding
• Pre‐insertioncounseling– Discussbleeding/spottinginfirst3‐6months
– Discussamenorrhea
• Providereassuranceasbleedinglikelytoimprove
• CheckIUDlocation• NSAIDsATCq4wks mayhelp,noevidenceforestrogen
Irregular Bleeding by Contraceptive Ratesofirregularbleeding
COCs • 10‐30%infirstmonthofuse• <10%bythethirdmonthofuse
VaginalRing • Lesscommonin comparisontoCOCs• Upto6%infirstyear
Patch • SimilartoCOCs exceptslightlyhigherrateofspottinginfirst2cycles
Injectable • 70%in first year• 10% afterthefirstyear
Implant • Upto25% infirst2years
Cu‐IUD • Lessirregularbleedingcompared toLNG‐IUS
LNG‐IUS • Upto25% at6months• 8‐11%at18‐24months
Amenorrhea by Contraceptive
RATESOFAMENORRHEAWithin 1st year At1year Beyond
COCs <2% Upto5%
VaginalRing SimilartoCOCs
Patch SimilartoCOCs
Injectable 12% 46% 80%at5years
Implant 21% 30‐40%
Cu‐IUD 0% 0% 0%
LNG‐52/5&4 20% 40% at3years
LNG‐19.5/5 12% 20% at3years
LNG‐13.5/3 6% 12%at3years
US Selected Practice Recommendation for Contraceptive Use, 2016
US Selected Practice Recommendation for Contraceptive Use, 2016
Case : Early Pregnancy
• A35year‐oldwomanat8weeks’gestationpresentstoyourofficewithspotting.
Evaluation
• History– Riskfactorsforectopicpregnancy
• Physicalexam– Vitalsigns– Abdominalandpelvicexam
• Ultrasound– Transvaginal oftennecessary
• Lab– Rhfactor– HemoglobinorHematocrit– β‐hCG whenindicated
Isthepregnancydesired?Isthepregnancydesired?
Case 5: Bleeding in Early Pregnancy
• Keepthepatientinformed.– Providereassurancethatnotallvaginalbleeding&cramping= anabnormality,butavoidguaranteesthat“everythingwillbeallright”
– Assurethatyouareavailable
• Whatdoesthebleedingmean?– Upto20%chanceofectopicpregnancy– 50%ongoingpregnancywithclosedcervicalos– 85%ongoingpregnancywithviableIUPonsono– 30%ofnormalpregnancieshavevaginalbleeding
Ectopic Pregnancy
• 1‐2%ofallpregnancies• Upto20%ofsymptomaticpregnancies• ½ofectopicpatientshavenoriskfactors• Mortalityhasdeclined:0.5/100,000
– 6%ofpregnancy‐relateddeaths
• Earlydiagnosisimportant• Concernaboutmanagementerrors
Early Pregnancy Loss (EPL)
• 15‐20%ofclinicallyrecognizedpregnancies
• 1in4womenwillexperienceEPL
• Includesallnon‐viablepregnanciesinfirsttrimester=miscarriage
Pregnancy of Unknown Location
• Whenthepregnancytestispositiveandnosignsofintrauterineorextrauterine pregnancyonu/s– Wetrytofollowthesewomenuntiladiagnosisismade– Wehavetoweighriskofectopicpregnancy(EP)– Sometimesnofinaldiagnosis‐ bothEPLandEPmayresolvespontaneously
• Morecommonlyencounteredinsymptomaticearlypregnancy,butcanalsobeencounteredinasymptomaticwomen,especiallywhenu/searly
Simplified Workup of Bleeding &/or Pain
1. Whereisthepregnancy? U/S(sameday)2. Ifthepregnancyundesired? uterineaspiration3. Ifdesiredandwecan’ttellwhereitis:Isitnormal
orabnormal? quantitative(serial)Beta‐HCG– IfBhcg abovethreshold(>3,000)andnoIUP=Abnormal– MostlikelyanabnormalIUP
IUP=Intrauterine pregnancy
Simplified Workup of Bleeding &/or Pain
1. Whereisthepregnancy? U/S(sameday)2. Ifthepregnancyundesired? uterineaspiration3. Ifdesiredandwecan’ttellwhereitis:Isitnormal
orabnormal? quantitative(serial)Beta‐HCG– IfBhcg abovethreshold(>3,000)andnoIUP=Abnormal– SerialbetaHCGs:
• IfBhcg drops>50%in48hours=Abnormal• IfBhcg rises>50%in48hours=Mostlikelynormal(canbeEP)– Continuetofollowandrepeatu/s
• Ifbetween=Mostlikelyabnormal(stillcanbenormal)–Continuetofollowandrepeatu/s
4. Ifpregnancyclearlyabnormal,ifundesiredordesiresdefinitivedx uterineaspiration
IUP=Intrauterine pregnancy
Conclusions
• Diagnosis:thinkofpregnancy,thenanovulation• Work‐up:Alwaysruleoutpregnancy.Ifirregular:TSH,PLN.?HCT,?EMB,TVUSifinitialtx fails.
• Treatment:allbleedingtreatedsimilarly• NSAID’splushormones.Persistentabnormalbleedingrequirescontinuedwork‐upevenifEMBand/orultrasoundarenegative.
• Hormonalorcopperbirthcontrol:setexpectations
ThankstoRebeccaJacksonandSaraWhetstoneforsharingslides!ThankstoRebeccaJacksonandSaraWhetstoneforsharingslides!
• HCG2000‐ 3000– Non‐viablepregnancymostlikely,2Xectopic– Ectopicis19xmorelikelythanviablepregnancy– Foreachviablepregnancy:
• 19ectopicpregnancies• 38nonviablepregnancies
– 2%chanceofviablepregnancy
• HCG>3000– Ectopic70xmorelikelythanviablepregnancy
0.5%chanceviableIUP
In women with desired pregnancy consider beta hcg cut-off of >= 3000.
Society of Radiologists in Ultrasound: No Gestational Sac Slides for Reference Only