Batch Notes Gyne Ddx of Vaginal Bleeding

Differential Diagnosis of Vaginal Bleeding Dr. Ursua PQ1 Differential Diagnosis of Vaginal bleeding *differentiate pathologic from non normal (menstruation). Take consideration the AGE of the patient. *if the patient is in age of reproduction, check SEXUAL ACTIVITY *amount of bleeding - normal bleeding : 50 ml - spotting : ectopic pregnancy

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Placenta precedes the uterus

2. ABRUPTIO PLACENTA - Ablatio Placentae - Premature separation of placenta that is NORMALLY IMPLANTED - Types: a. Concealed - The placenta is centrally detached causing HEMATOMA - (+) BOARD LIKE RIGIDITY - (+) SEVEREDIRECT BOUND TENDERNESS

*fully soaked napkin : 30-40 ml b. Outright bleeding - The placenta peripherally

Obstetric (pregnancy related causes) *the first diagnosis PREGNANCY FIRST HALF 1. ABORTION - The fetus is less than the age of the viability (20 weeks AOG) - Depending of type of abortion 2. ECTOPIC PREGANCY - (+) bleeding is due to the hormones which affects the endometrium. - The endometrium regresses as decidualization and secreted as decidual cast - The space in the fallopian tube is not enough, hence there is no enough stimulus to stimulate corpus luteum to produce HCG, decreasing the progesterone levelsm hence decidua will not attach which then result to vaginal bleeding 3. GESTATION TROPHOBLASTIC DISEASE - Hydatidiform mole (H-mole) will result into cancer - Classic manifestation : (+) pearls, sago like consistency along with bleeding 4. LOW LYING PLACENTA - *doc said due to placenta previa SECOND HALF 1. PLACENTA PREVIA - Normal: placenta is implanted at fundal region

is

detached

3. VASA PREVIA - Normal: all vessels are enlarged - Crisscrossing of vessels - Ddx: intrauterine fetal death ♥ Dead fetus is perceived by the body as foreign, causing the uterus to contract resulting to dilatation of cervix, hence expulsion POST PARTUM ♥FOUR T’S 1. TONE - uterine atony (failure of the uterus to contract) 2. TISSUE a. Retained Placenta fragments  Placenta accrete  Mismanagement of placenta b. Unclotted round 3. TRAUMA a. Ruptured vagina  Use of RITGENS MANEUVER to prevent forceful release of fetus 4. THROMBIN - Coagulation factor problems a. Aplastic anemia b. Hemophilia

1 Saint Louis University School of Medicine Batch 2015

Differential Diagnosis of Vaginal Bleeding Dr. Ursua PQ1 c. d. e. f.

Blood dyscrasia Decreased fibrinogen Decreased calcium Used of drugs : heparin, aspirin

Gynecologic causes 1. TUMORS (please educate patient that not all tumors are malignant.) a. Benign - Polyps - Fibroids : myoma o Well circumscribed o More bleeding at intracavity

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FIBROTHECOMA: functional bleeding

produces

Medical Causes 1. PLATELET DISORDERS - Dengue hemorrhagic fever 2. CLOTTING FACTOR ABNORMALITY Prepubertal Period 1. PHYSIOLOGIC - Withdrawal from exposure to estrogen - Vulvar o Vulvitis

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Trauma : straddle injury Lichen sclerosus : scarring around genital skin

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Condylomata: Molloscum contagiosum: warts

b. Malignant - Cervical Ca : due to STDs which are highly preventable - Endometrial Ca - Fallopian tube Ca 2. INFECTION a. Endometritis b. Cervivitis 3. FOREIGN BODY - Recurrent bleeding especially in children o Toys o Coin o Lego parts o M&Ms o Wisp of cotton 4. HORMONAL ABNORMALITIES a. Endogenous : medications b. Exogenous - Breakthrough bleeding 2 Saint Louis University School of Medicine Batch 2015

- Urethral prolapsed : a. Vaginal - Vaginitis - Foreign bodies - Trauma - Vaginal tumor

Differential Diagnosis of Vaginal Bleeding Dr. Ursua PQ1 b. Hormones - Precocious puberty - Ovarian tumors (fibrothecoma) - Exogenous estrogen Adolescent Period a. Anovulation Dysfunctional uterinebleeding : follicles not maturing due to problem at hypothalamo –pituitary gonadal axis b. Pregnancy related c. Exogenous hormones d. Hematologic abnormalities e. Infections f. Endogenous g. Anatomic causes Reproductive Age Group 1. Dysfunctional uterine bleeding 2. Pregnancy related bleeding 3. Exogenous hormones 4. Endocrine causes *eat mungo beans :high in estrogen 5. Anatomic derangements Post Menopausal Stage Group 1. Exogenous estrogen - To prevent osteoporosis - Thickening of vagina 2. Atrophic endometritis/ vaginitis 3. Endometrium/ cervical/ uterine/ ovarian cancer and lesions 4. Endometrial polyps and cervical polyps 5. Endometrial hyperplasia 6. Trauma 7. Urethral carunlce

3 Saint Louis University School of Medicine Batch 2015