《妇科阴道流血》ppt课件

1、Abnormal Vaginal /Uterine BleedingZhejiang University School of Medicine,Womens HospitalWu Ruijin Abnormal vaginal bleedingnOne of the most common gynecologic symptoms.nInclude bleeding from uterus, cervix, vaginal, hymen etc.nMost from uterine, but called vaginal bleeding except normal cycle of men

2、struation.nAppearance of bleeding vary from their causes.Abnormal Uterine BleedingnIncludes abnormal menstrual bleeding and bleeding due to other causes such as pregnancy,systemic diseases, or cancer.nThe diagnosis and management present some of the most difficult problems in gynecology.nIn childbea

3、ring women, a complication of pregnancy must always be considered, and more than one entity may be present, eg, uterine myomas and cervical cancer.Part I Etiological factors of abnormal vaginal bleedingnOvarian endocrine dysfunctionnPregnancy-related bleedingnInfectionsnMalignant LesionsnGenitals da

4、mage, extraneous material and exogenous hormonenBleeding due to systemic diseases1. Ovarian endocrine dysfunctionDue to dysfunction of the hypothalamic-pituitary-ovarian axis (HPOA).anovulatory dysfunctional uterine bleeding (无排卵性功能失调性子宫出血)ovulatory menstrual dysfunction (排卵性月经失调)intermenstrual blee

5、ding (经间期出血)(1) Anovulatory dysfunctional uterine bleeding nPuberty20%： unstable HPOA regulation with growing follicle but no LH peak and ovulation does not occur.nPerimenopause 50%：ovary becomes low responsive to Gn and its function declines.nChild bearing period 30%：inside/n outside interference,

6、such as psychologic factor, environment,stress,etc.(2) Ovulatory menstrual dysfunctionnLuteal phase defect (LPD) (黄体功能不全) n Abnormal FSH/LH or ratio, low LH peak or following pulse defect.nIrregular shedding of endometrium(子宫内膜不规那么零落n HPOA dysfuction and corpus luteum degenerate uncompletely(3) inte

7、rmenstrual bleeding nWith the rupture of dominant follicle, estrogens declines in a short time and endometrium break-through bleeding.2. Bleeding due to pregnancynAbortion 流产nEctopic pregnancy异位妊娠nGestational trophoblastic disease (GTD)n 妊娠滋养细胞疾病nAnomaly of placenta 胎盘异常n-placenta praevia(前置)、abrupt

8、ion(早剥)、adherence(粘连)、implantation(植入)nPostpartum part placenta remain胎盘部分残留nInvolution of uterus unhealthy 子宫复旧不良 AbortionnMorphologic and genetic abnormalities: Abnormal chromosome is the main factor.nMaternal factors:nSystemic diseases：infections, cardiovascular disorders, severe anaemia, etc.nEn

9、docrine disorder：hypothyroidism, poorly controlled diabetes mellitus.nImmunologic disordersnUterine defects：congenital anomalies, submucous or intramural myomas, intrauterine adhensious.nTrauma (创伤刺激创伤刺激)nToxic factors：unhealthy life style, radiation, uncontrolled drugsEctopic pregnancyMore than 95%

10、 occur in the fallopian tube.50% had salpingitis. History of fallopian operation.Intrauterine Device (IUD)Fallopian dysplasia or dysfunction, affect the transmigration of fertilized ovum.Others：surrounding oncothlipsis, EMsGestational Trophoblastic Disease Trophohyper plasiacyte, erosin and destroy

11、surrounding blood vessel.Hydatidiform mole (葡萄胎)Invasive hydatidiform mole(侵蚀性葡萄胎)Chorionic carcinoma(绒毛膜癌)3. Genitals inflammationnVulvovaginitis(外阴阴道炎)：disorder of vaginal ecological balance or exogenous pathogen invasionnCervicitis(宫颈炎)nCervical polyp(宫颈息肉): long-term chronic inflammation stimula

12、tionnEndometritis (子宫内膜炎)：common in after abortion, parturition, postmenopause women and IUD4. Genitals tumor1Tumor erosion the vessel wall, cause cellular necrosis, ulcer.2Tumor cause steroid hormone disorder.3Myoma enlarged endometrial area, interfere uterine contraction and blood sinus shut.Vulov

13、aginal tumor, cervix cancer, myoma, endometrial carcinoma, sarcoma of uterus, ovarian cancer, oviduct cancer5. Genitals damage, extraneous material and exogenous hormonenGenitals damage: vulovaginal straddle injury (外阴阴道骑跨伤)nSexual intercause cause hymen and vaginal injury and bleeding.nIUD: hard an

14、d large area IUD oppress cause local endometrium necrosis and ulcernE2 /P misapply.n 6. Bleeding due to systemic diseasesnPurpura haemorragica (血小板减少性紫癜)nAplastic anemia(再生妨碍性贫血)nLeukemia (白血病)nHepatic function damage n disturbances of blood coagulation(凝血机制妨碍)n thrombocytopenia (血小板减少)n increased c

15、apillary permeability (毛细血管通透性添加) n some liver disorder hormone change.7. Others nPelvic inflammation：congestion (充血), vessel wall brittleness (脆性 ) increasednEndometrial polypsnEMs：steroid hormone disordern Part II Patterns of Abnormal Uterine Bleeding(阴道流血特点与相关疾病的联络)nAge factorsnRegulation of peri

16、od or notnPregnancy or notn menorragia/ hypermenorrhea(经量增多)Heavy (80ml) or prolonged 7d menstrual flow.Submucous myomas (子宫粘膜下肌瘤)Complications of pregnancyEndometrial hyperplasiasMalignant tumorsEndometrial polyps (子宫内膜息肉)Adenomyosis (子宫腺肌病)Dysfunctional bleeding (排卵性月经失调)IUDs (放置宫内节育器)MyomasSympto

17、ms：Abnormal uterine bleeding：30%, prolonged and heavy menses，irregular uterine bleeding often in submucous myomasAbdominal mass (腹块腹块)Leucorrhea (白带白带) increasedPain or sore waist (腰酸腰酸)Pressure effectsInfertility, spontaneous abortion, malposition (胎位不正胎位不正等等)Secondary anemia (继发贫血继发贫血)B type ultra

18、sound, CT, MRI help to diagnosisEndometrial polypsnSpotting or irregular uterine bleedingnUltrasound help to diagnosisnDiagnosis curettage(诊断性刮宫), hysteroscope (宫腔镜检查) and pathology examination help final diagnosisAdenomyosisnMenstruation change: 50% hypermenorrheanMenalgia (痛经)，increasingly severen

19、Enlarged uterus, hardnUltrasound, MRI help to diagnosisOvulatory menstrual dysfunctionnLuteal phase defect (LPD) (黄体功能不全黄体功能不全) n1shorten cycle,luteal phase 11d,frequently cyclen2infertilityn3repeating spontaneous abortionn4D & C：luteal phase endometrium defected and backward 2d to standard phas

20、enIrregular shedding of endometrium(子宫内膜不规那么零落子宫内膜不规那么零落n1 prolonged and heavy mensesn2 D & C: proliferative and secretary endometrium coexist in cycle d5 n3BBT high temperature phase prolonged to next menstruationn (4) Serum E2,P and BBT,D&G, cervix mucus score help to diagnosis2. Menometro

21、rrhagia(周期不规那么的阴道流血)nBleeding occurs at irregular intervals. nAmount and duration of bleeding also vary. nAnovulatory dysfunctional uterine bleedingnExclude early endometrial cancernComplications of pregnancyAnovulatory dysfunctional uterine bleedingnIrregular uterus bleedingnCharacteristic of bleed

22、ing:n1irregular cycle and durationn2not stop by oneselfn3irregular amountn4no menalgia (痛经)n5anaemiaEndometrial cancer1. Irregular bleeding： Post-menopause bleeding: middle or less amount, durative(继续性) or intermittence(间歇性)； Child-bearing age women: prolonged and heavy menses or intermenstrual blee

23、ding2. Vaginal apocenosis (排液)3. pain4. General symptom5. Enlarged uterus, tender, tissue emersion in advanced stage( 组织物脱出)。6. Segmenting diagnosis curettage(分段诊刮) help to diagnose lesions whether involve cervix canal.7. Hysteroscope, ultrasound, CT、MRI help to diagnosis.3. Last and durative uterin

24、e bleeding(长期继续阴道流血 )nOften happen in reproductive malignant tumornNeed exclude carcinoma of cervix uteri and corpus uteriCervix cancer1. Contact bleeding (接触性出血): after sex intercross or pelvic examination young： prolonged and heavy menses, short cycle old：post-menopause irregular bleeding2. Vagina

25、 apocenosis (流液)：white or uprightness(血性)、smell of fish(腥臭) or foul smell (恶臭)3. Often early onset of sexual activity or marriage and child bear, multiple sexual partner(多个性同伴).4. Pelvic examination5. Special examination: cervical cytology, HPV testing, iodine test, colposcopy(阴道镜), biopsy, endocerv

26、ical curettage, cone biopsy(宫颈锥切)4. Bleeding after menelipsis(停经后阴道流血) nChild-bearing age: first consider pregnancy-related diseasen Abortionn Ectopic pregnancyn Gestational trophoblastic disease (GTD) nPeri-menopause period:n Anovulatory dysfunctional uterine bleedingn Exclude genital malignant tum

27、or AbortionnBleeding and pelvic pain after menelipsis (停经).nClinic types and feature：n amount pelvic pain tissue discharge cervix uterus zisenThreatened less no or light no close match nInevitable middle to heavy severe no expand match/ smallnIncomplete less to heavy light part discharge expandn /cl

28、ose/block smaller nComplete less to heavy no total discharge close normal/larger Three special types: missed (稽留流产), habitual (习惯性流产) or recurrence (复发性流产, abortion infection (流产感染)Ectopic pregnancy1. Menelipsis (停经)2. Pelvic pain3. Bleeding： less and irregular4. Faint and shock (晕厥与休克)5. Abdomen ma

29、ssGeneral stateAbdomen examination:3. Pelvic examination： Lifting pain(宫颈举痛宫颈举痛), pelvic mass(盆腔包块盆腔包块), uterus soft and a little largerGestational trophoblastic disease (GTD)nBleeding after MenelipsisnUterus significantly larger and softnSerum HCG abnormal highernPainnVomiting of pregnancy (妊娠呕吐)nO

30、varian luteinizing cysts (黄素化囊肿)nGestational hypertension (妊娠高血压疾病) and hyperthyreosis signDifferentiate (鉴别)1.History:menelipsis, morning sickness (早孕反响2.Pelvic examination3.Specific examination： Serum or urine HCG Ultrasound Retro-fornix puncture (后穹隆穿刺) Laproscope (腹腔镜检查)5.Vaginal bleeding with i

31、ncreased leucorrhea (阴道流血伴白带增多) nAdvanced stage cervix cancernEndometrial cancernSubmucous myomas infected nUltrasound, CT, MRI, hysteroscope, colposcopy, cervical scraping smear (or TCT), biopsy.6. Postcoital Bleeding (性交后出血) nCervical erosion(宫颈糜烂)：fluor sanguinolentus (血性白带), contact bleeding, in

32、creased vaginal dischargenCervical polyps：sprinkle or contact bleeding, increased vaginal dischargenSubmucous myomasnInvasive cervical cancer: early stage appear as cervical erosion, contact bleeding nPelvic examination, cervical scraping smear, colposcopy, ultrasound and biopsy.7. intermenstrual bl

33、eeding(月经间期出血)nBleeding occurring at any time between menstrual periods. nOccurs at mid-cycle as spotting (排卵期出血)nSymptoms：14-15d before next menstruation，sparking bleeding last 3-4 dnCan be documented with basal body temperatures. nEndometrial polyps and endometrial and cervical carcinomas are path

34、ologic causes. nExogenousnEstrogen administration 8. Peri-menstruation spotting bleeding (经前或经后点滴出血) nOvulatory menstrual dysfunction nIUDnEMs EndometriosisnMenalgia (痛经) nDyspareunia (性交不快)nInfertilitynPelvic examination：tender nodules in posterior vaginal fornix, cul-de-sac (子宫直肠陷窝), uterosacral l

35、igament(宫骶韧带) and tender adnexal masses may be felt when lesions involve ovary and form endometriomas.nUltrasound, CT, Laproscope.nSerum CA125may light increased9.Bleeding after years of menopause (绝经多年后阴道出血) nSmall amount, last 2-3d，normally menopause endometrial ablate (零落), or senile vaginitis (老

36、年性阴道炎).nLarge amount or continue repeatedly bleeding, consider endometrial cancer. 10. Intermittence bleeding or apocenosis (间歇性阴道排液流血 ) nExclude fallopian carcinoma n70% may be chronic salpingitisn50% infertility historynTrilogy(三联症) of fallopian carcinoma:n vagina apocenosis, pelvic pain and pelvi

37、c massnSymptoms, vagina cytological examination, D&C, ultrasound, CT, MRI, Laproscope, serum CA125may light increased11. Bleeding after injury(外伤后阴道流血) nOften after straddle injury (骑跨伤)nBleeding amount varynCompany with local pain Part IIIEvaluation of abnormal uterine bleedingnHistory(病史病史)nPh

38、ysical examination and pelvic examination(全身与妇科体全身与妇科体检检)nAuxiliary examination(辅助检查辅助检查)n1HCGn2Endometrial biopsy /Dilatation and Curettage (D&C)n诊断性刮宫诊断性刮宫n3Ultrasound (or saline hysterosonogram)/CT/MRIn4Hysteroscopy宫腔镜宫腔镜/ Laparoscope腹腔镜腹腔镜/colposcope 阴道镜阴道镜n5BBTn6Steroid hormonen7Cytologic e

39、xamination(细胞学检查细胞学检查): cervical and vaginal.n8Others：tumor markers, leucorrhea examination, cervical discharging, blood/live/clotting function test and retro-fornix puncture. Part Treatment nGeneral treatment:antiinflammatory,stop bleeding,retrieve anaemia (纠正贫血), enhance nutritionnIdentify etiolog

40、ical factor, etiological treatment nDrug treatment：hormonal therapy, chemotherapy and medical treatment.n(1)dysfunctional bleeding：stop bleeding, cycle regulation, induce ovulation；n(2)endometrial cancer: PnCervix physiotherapeutics(理疗), polyps removal, cervix cone biopsy or leep.nExtraneous material remove：extraneous material, IUD residOperation treatmentnWound neoplasty (修补术)：straddle injury (骑跨伤) and defloration (处女膜破裂)bleeding .nComplete Curettage：hydatidiform mole (葡萄胎), inevitable and incomplete abortion nDiagnosis Curettage: often used in acute heavy bleeding or exist high risk of end