Gynaecological Emergencies




(1)
Royal Free NHS Foundation Trust, London, UK

 



Secondary dysmenorrhea is associated with underlying pelvic pathology and can lead to ED attendance.


Causes of secondary dysmenorrhoea

Lower genital tract:

Painful cryptomenorrhoea:



  • Imperforate hymen


  • Transverse vaginal septum


  • Congenital absence of cervix

Acquired cervical stenosis

Uterus:



  • Congenital uterine abnormalities: non-communicating horn


  • Adenomyosis


  • Pedunculatedsubmucous fibroid


  • Endometrial polp


  • Intrauterine adhesions


  • Intrauterine device use

Pelvis:



  • Endometriosis (may be associated with dysmenorrhoea, dyschezia, chronic pelvic pain, infertility, haematuria, and rectal bleeding)


  • Chronic pelvic inflammatory disease


  • Pelvic adhesions


Key historical features in secondary dysmenorrhoea





  • Typically, the onset is after several years of painless periods


  • The pain may not respond to non-steroidal anti-inflammatory agents or oral contraception


  • Gynaecological symptoms: dyspareunia; abnormal vaginal discharge; menorrhagia; inter-menstrual or post-coital bleeding


  • Gastrointestinal symptoms: rectal pain and bleeding (endometriosis)


Causes of abnormal vaginal bleeding

Abnormal menstrual bleeding:



  • Excessive


  • Reduced


  • Inappropriate (by age)

Non-menstrual bleeding:



  • Post-coital


  • Intermenstrual


  • Postmenopausal


Categories of excessive vaginal bleeding





  • Menorrhagia: excessive menses (>80 ml monthly menstrual loss, ie >90th centile for menstrual blood loss) but normal cycle (>7 days with one or more days of excessive loss)


  • Short cycle (<21/7) but normal menses (polymenorrhoea)


  • Short cycle + excess bleeding (polymenorrhagia)


  • Excessive menses at long intervals


  • Metrorrhagia: irregular intervals with excessive menses


Causes of abnormal genital tract bleeding in the reproductive age group

Pregnancy –related

Early pregnancy



  • Implantation bleeding


  • Pregnancy failure: miscarriage (haemodynamic status; state of internal os; products of conception)


  • Ectopic pregnancy


  • Gestational trophoblastic disease (molar pregnancy)

Later pregnancy (antepartum haemorrhage-from 24 weeks of pregnancy)



  • Placenta praevia: painless bleeding; soft, non-tender uterus; high presenting part or malpresentation


  • Placental abruption: severe abdominal or back pain; uterine contractions may be present; uterine tenderness


  • Vasa praevia


  • Uterine inversion


  • Retained placenta


  • Endometritis

Non-pregnancy-related

Dysfunctional uterine bleeding: anovulatory bleeding; corpus luteum dysfunction.

Structural abnormalities



  • Genital tract neoplasia: cervix; endometrium; vulva; vagina; Fallopian tube


  • Polyps: cervix; endometrium

Infection:



  • Endometritis


  • Atrophic endometritis (post-menopausal)


  • Cervicitis

Endocrine dysfunction:



  • Hypothalamus/pituitary


  • Adrenal


  • Thyroid

Foreign bodies

Iatrogenic:



  • Intrauterine devices


  • Hormonal treatment

Blood dyscrasias:



  • Platelet disorders:idiopathic thrombocytopenic purpura


  • Clotting factor abnormalities: von Willebrand disease


Symptoms accompanying menorrhagia that indicate significant pathology





  • Malignancy: persistent inter-menstrual or post-coital bleeding; unexplained vulval lump or vulval bleeding due to ulceration


  • Other structural disease: pelvic pain; pressure symptoms


Causes of premenarcheal genital tract bleeding





  • Trauma


  • Lower genital tract neoplasm: cervix; vagina


  • Foreign body


  • Exogenous oestrogen


  • Sporadic gonadotrophin surge


  • Precocious puberty or pseudopuberty


  • Gastrointestinal bleeding


  • Urinary tract bleeding


Causes of menorrhagia



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Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Gynaecological Emergencies

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