Abnormal Uterine Bleeding in Adolescent

Abnormal uterine bleeding (AUB) is defined as the abnormal bleeding from the uterine corpus in term of duration, volume, frequency and/or regularity. This condition occurs in 37% of adolescents and may affect the quality of life and increased hospitalization. Etiology is divided into structural and non-structural causes, known as PALM-COEIN. The most common etiology in adolescents is anovulatory menstruation due to immature hypothalamus-hypophysis axis. Diagnostic evaluation should include investigation in the etiology of AUB, anemia signs, and hemodynamic status. Treatment of AUB consists of hormonal and non-hormonal therapy. Therapy in adolescent is given based on the severity of bleeding, grading of anemia, and hemodynamic stability. Follow-up is required after therapy. Understanding AUB in adolescents can help clinicians deliver appropriate and comprehensive treatment. This review was aimed to explain about definition, epidemiology, etiology, pathophysiology, diagnosis, and treatment of abnormal uterine bleeding in adolescent.

Angiographic features and transarterial embolization of retained placenta with abnormal vaginal bleeding

Objectives To clarify characteristic angiographic features and clinical efficacy of selective transarterial embolization (TAE) of retained placenta with abnormal vaginal bleeding. Methods The study cohort comprised 22 patients (mean age, 33.5 years; range, 22–24 years) who underwent selective TAE for retained placenta with abnormal bleeding between January 2018 and December 2020 at our institution. Angiographic images were reviewed by two certified radiologists with consensus. Medical records were reviewed to evaluate the efficacy of TAE. Angiographic features of retained placenta, technical success (disappearance of abnormal findings on angiography), complications, clinical outcomes (hemostatic effects and recurrent bleeding) were evaluated. Results Pelvic angiography showed a dilated vascular channel mimicking arteriovenous fistulas or an aneurysm contiguous with dilated uterine arteries in the mid-arterial–capillary phase in 20 patients; it showed contrast brush in the remaining two patients. TAE technical success was achieved in all patients. No major complications were observed in any patients. Fifteen patients were followed up with expectant management after TAE; all but one patient showed no re-bleeding during the follow-up period (mean follow-up interval, 3.4 months; range, 1–17 months). One patient showed minor rebleeding, which resolved spontaneously. Seven patients underwent scheduled hysteroscopic resection within 1 week after TAE, and no excessive bleeding was observed during or after the surgical procedure in all seven patients. Conclusions The characteristic angiographic feature of retained placenta is “dilated vascular channel that mimic low flow AVM.” TAE is a safe and effective treatment to manage retained placenta with abnormal bleeding.

Menopause

Menopause is the permanent cessation of menstruation, caused by ovarian failure. It can only be diagnosed a year after the last menstrual period, and is therefore a retrospective event. This chapter covers the signs, investigations, and treatments available for menopause, including Hormone Replacement Therapy, alternatives, modes of delivery, and non-hormonal alternative options. Abnormal bleeding and sexual dysfunction at the menopause are also explained. It also covers premature ovarian insufficiency, and causes and treatments for this disorder.

Post Approval Experience with Caplacizumab for Acquired Thrombotic Thrombocytopenic Purpura at a Single Institution

Caplacizumab prevents platelet adhesion and has been approved for acquired thrombotic thrombocytopenic purpura (aTTP). This study was retrospective, including all patients diagnosed with aTTP and treated with caplacizumab since commercial availability in 2019 until 28 February 2021 at a single academic hospital with no exclusion criteria. Results used definitions for outcomes in aTTP from the International Working Group Consensus. Ten patients with aTTP received caplacizumab. The median age was 52 years. Six (60%) patients had refractory aTTP while 4 (40%) had newly diagnosed aTTP. The median laboratory values prior to therapy demonstrated: platelet count (PC) 29/uL, LDH 518 U/L (182–1850), ADAMTS13 activity 3% and ADAMTS13 inhibitor 1.4 BU. Everyone received glucocorticoids, rituximab, therapeutic plasma exchange (TPE) and caplacizumab. The median number of TPE was 12 days. Caplacizumab was started at a median of 5 days after the first TPE and the median treatment duration was 31 days. Normalization of PC, LDH and ADAMTS13 activity in days were 5, 3.5, and 32.5, respectively. Six (60%) patients achieved complete response, 3 (30%) had refractory disease and 1 (10%) had relapsed aTTP. No subject suffered abnormal bleeding, or thrombotic event. There were no deaths. Caplacizumab with TPE, glucocorticoids and rituximab was a safe and effective therapy for aTTP.

Angiographic Features and Transarterial Embolization of Retained Placenta With Abnormal Vaginal Bleeding

Objectives: To clarify characteristic angiographic features and clinical efficacy of selective transarterial embolization (TAE) of retained placenta with abnormal vaginal bleeding.Methods: The study cohort comprised 22 patients (mean age, 33.5 years; range, 22–24 years) who underwent selective TAE for retained placenta with abnormal bleeding between January 2018 and December 2020 at our institution. Angiographic images were reviewed by two certified radiologists with consensus. Medical records were reviewed to evaluate the efficacy of TAE. Angiographic features of retained placenta, technical success (disappearance of abnormal findings on angiography), complications, clinical outcomes (hemostatic effects and recurrent bleeding) were evaluated. Results: Pelvic angiography showed a dilated vascular channel mimicking arteriovenous fistulas or an aneurysm contiguous with dilated uterine arteries in the mid-arterial–capillary phase (tentatively named “serpiginous blood sinus”) in 20 patients; it showed contrast brush in the remaining two patients. TAE technical success was achieved in all patients. No major complications were observed in any patients. Fifteen patients were followed up with expectant management after TAE; all but one patient showed no re-bleeding during the follow-up period (mean follow-up interval, 3.4 months; range, 1–17 months). One patient showed minor rebleeding, which resolved spontaneously. Seven patients underwent scheduled hysteroscopic resection within 1 week after TAE, and no excessive bleeding was observed during or after the surgical procedure in all seven patients.Conclusions: The characteristic angiographic feature of retained placenta is “serpiginous blood sinus.” TAE is a safe and effective treatment to manage retained placenta with abnormal bleeding.

Determine the Frequency of Endometrial Hyperplasia in Female with Abnormal Vaginal Bleeding

Objective: To determine the frequency of endometrial hyperplasia in female with abnormal vaginal bleeding. Study Design: Cross-sectional Place and Duration of Study: Department of Obstetrics & Gynaecology, Allama Iqbal Memorial Teaching Hospital, Sialkot from 1st January 2021 to 31st March 2021. Methodology: One hundred and ten females with abnormal bleeding were presented in this study. Patients were aged between 40-65 years. Demographically details of age, weight, body mass index and socio economic status were recorded after taking written consent. Complete patients were undergone for transvaginal ultrasound. Frequency of endometrial hyperplasia was recorded. Results: Mean age of the females was 47.16±7.53 years with mean BMI 26.17±8.44 kg/m2. Mean weight of the patients were 59.16±17.66 kg. Most of the patients 65 (59.09%) were from urban area and majority of the patients 70 (63.64%) were illiterate. Sixty (54.5%) cases were from low socio-economic status and 50 (45.5%) had high socio-economic status. Endometrial hyperplasia was found in 25 (22.73%) patients, in which 18 (72%) had cystic hyperplasia, adenomatous hyperplasia found in 4 (16%) and 3 (12%) had atypical hyperplasia. Among 25 cases of hyperplasia, menorrhagia found in 15 (60%), polymenorrhea found in 8 (32%) and polymenorrhagia in 2 (8%). Medical treatment were given to 20 (80%) cases and surgical treatment were given to 5 (20%). Conclusion: The prevalence of endometrial hyperplasia was 22.73% among women with abnormal bleeding. It can be cure by early diagnosis and treatment. Keywords: Transvaginal ultrasound (TVS), Endometrial hyperplasia, Abnormal vaginal bleeding, Menorrhagia

The Correlation of the IETA Ultrasound Score with the Histopathology Results for Women with Abnormal Bleeding in Western Romania

In the early differential diagnosis of endometrial cancer (EC), decisive and mandatory histological aspects are considered, in addition to obvious clinical manifestations. In addition, sonographic aspects are characteristic in relation to the stage, degree, and histological types of identified cancer. This bi-center retrospective observational study included 594 women with abnormal uterine bleeding outside pregnancy, for which a biopsy was performed in the Obstetrics and Gynecology Departments of the Emergency County Hospitals of Arad and Timis Counties, Romania, between 2015 and 2019. Most of the cases were represented by EC or endometrial hyperplasia (EH). Of the 594 cases, 25.5% (n = 153) were EC at women aged between 41 and 85 years. High International Endometrial Tumor Analysis (IETA) scores (3, 4) were associated with a relative risk of 2.9335 compared with other endometrial lesions (95% CI 2.3046 to 3.734, P < 0.0001, NNT 1.805). Histological aspects and pelvic ultrasound using IETA scores represent valuable noninvasive assets in diagnosing and differentiating endometrial cancer from benign uterine pathology.

Antithrombin resistance rescues clotting defect of homozygous prothrombin-Tyr510N dysprothrombinemia

A patient with hematuria in our clinic was diagnosed with urolithiasis. Analysis of the patient’s plasma clotting-time indicated that both APTT (52.6 s) and PT (19.4 s) are prolonged and prothrombin activity is reduced to 12.4% of normal, though the patient exhibited no abnormal bleeding phenotype and a prothrombin antigen level of 87.9%. Genetic analysis revealed the patient is homozygous for prothrombin Y510N mutation. We expressed and characterized the prothrombin-Y510N variant in appropriate coagulation assays and found that the specificity constant for activation of the mutant zymogen by factor Xa is impaired ~5-fold. Thrombin generation assay using patient’s plasma and prothrombin-deficient plasma supplemented with either wild-type or prothrombin-Y510N revealed that both peak height and time to peak for the prothrombin mutant are decreased however the endogenous thrombin generation potential is increased. Further analysis indicated that the thrombin mutant exhibits resistance to antithrombin and is inhibited by the serpin with ~12-fold slower rate constant. Protein C activation by thrombin-Y510N was also decreased ~10-fold, however, thrombomodulin overcame the catalytic defect. The Na+-concentration-dependence of the amidolytic activities revealed that the dissociation constant for the interaction of Na+ with the mutant has been elevated ~20-fold. These results suggest that Y510 (Y184a in chymotrypsin numbering) belongs to network of residues involved in binding Na+. A normal protein C activation by thrombin-Y510N suggests that thrombomodulin modulates the conformation of the Na+-binding loop of thrombin. The clotting defect of thrombin-Y510N appears to be compensated by its markedly lower reactivity with antithrombin, explaining patient’s normal hemostatic phenotype.

Bleeding after surgery and application bleeding assessment tool to surgical patients in Hanoi Medicine University Hospital

Objectives: Describe bleeding characteristics and evaluate the correlation between surgical-related bleeding and bleeding risk according by ISTH – BATs. Methods: Research was conducted on 340 surgical patients at Hanoi Medical University Hospital. Results: The percentage of patients with bleeding during and after surgery is 13.5%. The proportion of patients at risk of bleeding according to BATs is 1.8%. There was a correlation between bleeding risk according to ISTH - BAT with bleeding status during and after surgery with p = 0.004. The positive predictive value of ISTH - BATs is 66.7%, negative predictive value is 87.4%, the sensitivity is 8.7%, the specificity is 99.3%. Conclusions: Surgery has a high risk of abnormal bleeding. Bleeding history has important implications in assessing bleeding risk during and after surgery. The ISTH - BATs is a bleeding history assessment tool that can be used to assess the risk of bleeding before surgery.

Role of Sphatik bhasma as haemostatic drug in the Management of Rakta Pradar W.R.T Heavy Menstrual Bleeding

Heavy menstrual bleeding or abnormal bleeding is most common problems in females in present era due to improper diet habits, sleeping habits due to increasing degrees of civilisation. There are various treatment on heavy menstrual flow like hormonal replacement therapy where there is hormonal imbalancement, Anti fibrinolytics drugs in dysfunctional uterine bleeding available today. According to Ayurveda it can be correlated with Raktapradar. Various drugs are suggested in raktapradar in classical text. In this study efficacy of Sphatik bhasma (potassium aluminium sulphate also known as potassium alum or potashalum, has a molecular formulae of K2(SO4).Al2(SO4)3.24H2O) as haemostatic drug is observed through clinical trial. The clinical study was conducted on 15 patients having heavy menstrual bleeding. Interventional drug Sphatik Bhasma with pakwa kadali phala (banana or Musa paradisiaca) is administered for 3 days. The clinical assessment was done on the basis of grading criteria of Rakta Pradar like amount and duration of bleeding, pain, burning sensation and weakness and were assessed on mean scores before and after treatment and analysed. The results were statistically and clinically highly significant in Raktapradar.