Uterine Artery Pseudoaneurysm: A Life-Threatening Cause of Vaginal Bleeding in the Emergency Department

Background

Vaginal bleeding is a common presenting complaint in the emergency department (ED); life-threatening hemorrhage is rare. Uterine artery pseudoaneurysm (UAP) is an uncommon but potentially life-threatening cause of vaginal bleeding that is most likely to present primarily to EDs, given its delayed postpartum or postoperative presentation.

Sonography in first trimester bleeding

Vaginal bleeding is the most common cause of presentation to the emergency department in the first trimester. Approximately half of patients with first trimester vaginal bleeding will lose the pregnancy. Clinical assessment is difficult, and sonography is necessary to determine if a normal fetus is present and alive and to exclude other causes of bleeding (eg, ectopic or molar pregnancy). Diagnosis of a normal intrauterine pregnancy not only helps the physician in terms of management but also gives psychologic relief to the patient. Improved ultrasound technology and high-frequency endovaginal transducers have enabled early diagnosis of abnormal and ectopic pregnancies, decreasing maternal morbidity and mortality. The main differential considerations of first trimester bleeding are spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease. This article reviews the causes of first trimester bleeding and the sonographic findings, including normal features of first trimester pregnancy.     

Abnormal vaginal bleeding in perimenopausal women

The incidence of abnormal vaginal bleeding increases as women approach the end of their reproductive years. In the perimenopausal age group, the most common cause of abnormal vaginal bleeding is anovulation. In most patients, diagnosis and management can be accomplished in a family physician's office.     

子宫内膜癌合并子宫肌瘤或（和）子宫肌腺瘤16例临床分析

目的探讨子宫内膜癌合并子宫肌瘤或（和）子宫肌腺瘤的临床表现及诊断方法。方法回顾性分析2003～2007年收治的16例子宫内膜癌合并子宫肌瘤或（和）子宫肌腺瘤患者的病史、临床表现及诊治经过。结果16例患者平均年龄53．93岁（45～80岁），其中围绝经期妇女8例（50．00%），绝经期妇女8例（50．00%）。13例（81．25％）有异常阴道流血并术前确诊；3例合并子宫肌腺瘤患者无异常阴道流血，仅表现下腹部疼痛性质改变，术前漏诊子宫内膜癌。结论围绝经期及绝经期子宫肌瘤或（和）子宫肌腺瘤患者有异常阴道流血者首先要除外子宫内膜癌，对合并子宫肌腺瘤患者即使没有异常阴道流血，但若下腹部疼痛性质改变，要高度警觉发生子宫内膜癌可能。     

A diagnostic approach to mild bleeding disorders

Mild inherited bleeding disorders are relatively common in the general population. Despite recent advances in diagnostic approaches, mild inherited bleeding disorders still pose a significant diagnostic challenge. Hemorrhagic diathesis can be caused by disorders in primary hemostasis (von Willebrand disease, inherited platelet function disorders), secondary hemostasis (hemophilia A and B, other (rare) coagulant factor deficiencies) and fibrinolysis, and in connective tissue or vascular formation. This review summarizes the currently available diagnostic methods for mild bleeding disorders and their pitfalls, from structured patient history to highly specialized laboratory diagnosis. A comprehensive framework for a diagnostic approach to mild inherited bleeding disorders is proposed.     

超声对晚期妊娠阴道出血的诊断价值

目的　探讨超声对晚期妊娠阴道出血的诊断价值。方法　回顾性分析 2 98例晚期阴道出血的病例(孕周 >2 8周 ) ,经超声检查诊断为前置胎盘是 190例 ,胎盘早剥 6 1例 ,子宫破裂 3例。结果　超声对晚期妊娠阴道出血检出率 85 .2 % (2 5 4 / 2 98) ,上述三种产科合并症的诊断符合率分别为 98.9% (188/ 190 )、 88.5 % (5 4 / 6 1)、和 10 0 % (3/ 3)。结论　超声检查能大部分明确晚期阴道出血的病因 ,它是一种快速、安全、无创、准确的检查方法 ,且可重复检查、动态观察 ,有重要的临床应用价值。     

Value of sonography in the diagnosis of abnormal vaginal bleeding

Abnormal vaginal bleeding is one of the most common presenting complaints in women of any age seeking gynecologic health care. Two of the most frequently used diagnostic tests to investigate the cause of the bleeding are endometrial biopsy and transvaginal sonography. The most worrisome cause of abnormal bleeding is endometrial carcinoma, yet benign etiologies are far more prevalent, including fibroids, polyps, and endometrial atrophy. Endometrial biopsy and transvaginal sonography have equal sensitivities for carcinoma, but sonography is far more effective in diagnosing benign disease. This article reviews the state-of-the-art in the diagnostic evaluation of abnormal vaginal bleeding and analyzes the data, with emphasis on the prevalence of benign and malignant disease as the basis for determining whether sonography or biopsy is more cost-effective in evaluating women with abnormal vaginal bleeding.     

High‐Intensity Focused Ultrasound Treatment of Abnormal Vaginal Bleeding Secondary to Uterine Myoma

We describe the use of high‐intensity focused ultrasound for acute vaginal bleeding secondary to uterine myoma in 2 young female patients. Both patients had episodes of abnormal vaginal bleeding with severe dysmenorrhea that was not efficiently controlled by medical treatment. After high‐intensity focused ultrasound ablation, both vaginal bleeding control and symptom relief were achieved without postinterventional complications. The patients remained free of symptoms during 2 months of follow‐up and regained normal menstruation after high‐intensity focused ultrasound therapy. High‐intensity focused ultrasound treatment is one of the least invasive options for dysfunctional vaginal bleeding and may be an effective and safe alternative to other procedures in women of reproductive age with abnormal vaginal bleeding secondary to uterine myoma.     

230例药流后持续阴道出血者子宫声像图与临床对照

目的：探讨超声对药流后阴道出血的评价以及对不全流产的诊断价值。方法：对230例早孕药流后阴道出血患者行超声检查，结果：超声诊断与临床比较准确为80％，药流后随时间延长声像图改变明显，结论：超声检测药物流产后持续阴道出血者子宫的声像图改变，对判断药流是否成功有显著意义。     

Now you see/C it

Bleeding disorders are common. In addition to thinking about disorders relating to abnormal platelets or clotting factors, clinicians should consider disorders of vascular integrity in their differential diagnosis. We present a patient with atypical, spontaneous bleeding that was due to scurvy, an often overlooked cause. Clinicians should be aware of the risk factors for the development of scurvy, such as poor dietary intake, male gender, smoking, alcohol abuse, as well as its classic manifestations, including gingival bleeding, spontaneous bruising, corkscrew hairs, and poor wound healing, A heightened awareness may lead to earlier diagnosis and treatment.     

超声检查诊断子宫内膜病变的临床价值

目的探讨超声检查诊断子宫内膜病变的临床价值。 方法对105例（绝经后65例）阴道不规则流血或排液妇女的盆腔行经腹部或经阴道超声检查,重点观察子宫内膜情况。经手术治疗79例,刮宫26例,将超声与手术或刮宫的病理结果相对照。 结果子宫内膜癌超声表现为内膜增厚、回声不均、部分病灶凸向宫腔伴积液,52例中46例与病理诊断符合;内膜息肉多为宫腔内中强回声团,18例中16例符合;内膜增生以内膜增厚为主,20例中18例符合;黏膜下肌瘤回声减低通常见蒂,15例中12例符合。 结论经腹与经阴道超声检查联合应用对子宫内膜病变的诊断具有较高的价值。     

围绝经期及绝经后阴道出血患者诊断性刮宫结果分析及护理

目的 通过对6 868例围绝经期及绝经后阴道不规则出血患者的诊断性刮宫的结果分析,探讨其出血的病因及年龄特征,提出合理的护理对策.方法 对1999年6月至2009年6月,在我院行诊断性刮宫的6 868例患者的病理资料进行回顾性分析.结果 本资料中,出血原因依次为功能性子宫出血4 702例,炎性病变1 322例、非典型增生404例、复杂性增生220例、恶性肿瘤220例.功能性子宫出血、炎性病变和非典型增生的发生率随着年龄的增长而降低,但复杂性增生和恶性肿瘤随着年龄的增长而增高,65～74岁年龄组恶性肿瘤发生率为59.1%.结论 对于围绝经期和绝经后妇女一旦发现阴道异常出血,应立即到医院进行常规妇科检查,必要时应行分段诊刮取子宫内膜作病理检查,早期发现、早期治疗,提高中老年妇女的健康水平.     

药物流产后出血患者宫腔残留组织结果分析

目的通过B型超声及清宫送病理两种不同方法检测药物流产后阴道出血时间延长患者宫腔内残留组织,探讨米非司酮药物流产后阴道出血时间延长与残留组织（蜕膜／绒毛）的关系。方法对2011年6月-12月144例药物流产后出血患者根据出血时间是否延长（〉15d）,从B型超声情况及清宫病理情况分别研究。结果B型超声提示：出血时间≤15d的96例患者中20例有宫腔残留物,出血时间〉15d的48例患者中20例有官腔残留物,两组比较,差异有统计学意义（P〈0．05）。清宫病理提示：出血≤15d与出血〉15d宫腔残留组织病理构成比较差异无统计学意义（P〉0．05）。结论药物流产后阴道出血时间延长与宫腔残留有关,与残留组织是否为绒毛或蜕膜无关。     

Management of rare coagulation disorders in 2018

Rare bleeding disorders (RBDs) comprise inherited deficiencies of factors I (fibrinogen), II (prothrombin), V, VII, X, XI, and XIII as well as combined factor V?+?VIII and vitamin K-dependent factors. They represent 3–5% of all congenital bleeding disorders and are usually transmitted as autosomal recessive traits. These disorders often manifest during childhood and have varied clinical presentations from mucocutaneous bleeding to life-threatening symptoms such as central nervous system and gastrointestinal bleeding. Bleeding manifestations generally vary within the same RBD and may also vary from 1 RBD to the other. Laboratory diagnosis is based on coagulation screening tests and specific factor assays, with molecular techniques providing diagnostic accuracy and enabling prenatal counseling. The approach to treatment of bleeding episodes and invasive procedures needs to be individualized and depends on the severity, frequency and procedure-related risk of bleeding. The first line of treatment of RBDs is replacement of the deficient factor, using specific plasma-derived or recombinant products and using fresh frozen plasma or cryoprecipitate when specific products are not available or in resource-limited countries. Prophylaxis may be considered in individuals with recurrent serious bleeding and especially after life-threatening bleeding episodes. Novel no-replacement strategies promoting hemostasis by through different mechanisms need to be studied in RBDs as alternative therapeutic options.     

前置胎盘类型及产前出血与妊娠结局的分析

目的分析前置胎盘类型、阴道出血状况与妊娠结局的关系,探讨前置胎盘的处理以改善母婴预后。方法对本院2003年1月1日~2009年6月31日收治并分娩的112例前置胎盘伴产前出血患者的临床资料进行回顾性分析。结果近年来前置胎盘的发生率在上升;前置胎盘类型与产前出血、产后出血密切相关,中央性前置胎盘发生产前出血量最多(P<0.01),出血时间最早(P<0.01),产后出血概率越大(P<0.01),临床结局最严峻;边缘性前置胎盘则反之,而部分性前置胎盘则处于两者之间。结论 前置胎盘出血时间越早,出血量越多则威胁母儿生命越严重。前置胎盘患者的临床结局有很大差异,其类型及产前出血状况可预测临床结局。产前及时诊断是改善前置胎盘预后的关键因素,治疗的关键是控制出血。     

Laboratory screening and diagnosis of von Willebrand's disease

Von Willebrand's disease is caused by the quantitative or qualitative deficiency of von Willebrand factor. It is the most common congenital bleeding disorder affecting 1% of the population. The disease has a deep impact on the quality of life of the patients and in severe cases it may lead to life-threatening bleeding complications or may be fatal. A number of therapeutic options are available nowadays, and by the prophylactic use of these drugs before surgery, delivery etc., severe haemorrhagic complications can be avoided. Therefore it is extremely important to establish the correct diagnosis in time. There is no single diagnostic test due to the high variability of the disease. A number of assays are to be carried out in order to confirm the diagnosis apd identify the subtype of the disease. In this review we describe a simple approach to get to the correct diagnosis of this common bleeding disorder.     

Cervical Infections in Emergency Department Patients with Vaginal Bleeding

To the best of the authors' knowledge, no previous study has compared the prevalences of Chlamydia trachomatis (CT) or Neisseria gonorrhoeae (NG) cervical infection among pregnant and non-pregnant patients presenting to the emergency department (ED) with vaginal bleeding. OBJECTIVES: To determine the prevalence of these infections in a simultaneously assembled cohort, and to determine whether pregnancy is associated with altered rates of CT or NG cervical infection among patients with vaginal bleeding. METHODS: This was a prospective, seven-month, cross-sectional study of a convenience sample of patients (aged > or = 15 years) who presented to an urban, teaching ED with the chief complaint of vaginal bleeding. A urine pregnancy test was administered to each patient. Cervical swab specimens were analyzed for CT or NG via polymerase chain reaction technology (DNA probe). The hospital laboratory's baseline 18% rate of positive tests was used for sample size planning. Chisquare analysis and Fisher's exact test, where appropriate, were used to compare pregnant and non-pregnant patient groups. RESULTS: Cervical infection rates did not differ between pregnant and non-pregnant patients. Testing for CT showed that 13 of 114 (11%) of the pregnant patients were positive, while 11 of 147 (8%) non-pregnant patients tested positive (chi(2) = 0.759, p = 0.384). Testing for NG revealed that seven of 114 (6%) pregnant patients tested positive, while 16 of 147 (11%) non-pregnant patients tested positive (chi(2) = 1.256, p = 0.262). Combined testing showed that 18 of 114 (16%) of the pregnant patients and 25 of 147 (17%) of the non-pregnant patients harbored a cervical infection with one or both pathogens (chi(2) = 0.009, p = 0.925). CONCLUSIONS: The prevalence of CT or NG cervical infection in pregnant patients presenting to the ED with vaginal bleeding is 16%. Pregnant and non-pregnant patients with vaginal bleeding are at similar risks for having CT or NG cervical infection. Cervical swab specimens should be obtained in all patients with vaginal bleeding.     

Abnormal vaginal bleeding in the nonpregnant patient

Vaginal bleeding is a common complaint in most emergency departments. Abnormal vaginal bleeding causes many patients a great deal of stress and inconvenience. Although treatment of most cases is straightforward, vaginal bleeding can herald serious occult disease including cancer, coagulopathy, and systemic illness. Vaginal bleeding can also be the initial complaint in patients suffering sexual abuse or trauma. From an emergency medicine perspective, vaginal bleeding should be approached in terms of whether the patient is stable or not. Subsequent evaluation should exclude or treat problems that might cause the patient's condition to deteriorate. The emergency physician is able to provide initial therapy for most causes of vaginal bleeding, and in most cases the patient must be referred to a gynecologist for further evaluation and treatment.     

Prognosis of very large first-trimester hematomas.

OBJECTIVE: The aim of this study was to evaluate the outcome of pregnancies complicated by very large hematomas in the first trimester. METHODS: Between January 2001 and January 2006, 8085 patients between 5 and 14 weeks' gestation underwent routine first-trimester ultrasonographic examinations at our practice. Of these, 30 patients had a "very large" (> 50% of the gestational sac) intrauterine hematoma. These 30 patients were further classified according to pregnancy outcome (normal or adverse), maternal age, vaginal bleeding, crown-rump length, gestational age at diagnosis of the hematoma, and position and location of the hematoma. P < .05 was considered statistically significant. RESULTS: Six patients were excluded (4 were still pregnant, and 2 were lost to follow-up), leaving 24 patients eligible for analysis, of which 11 (46%) had adverse outcomes and 13 (54%) had normal outcomes. The group with adverse outcomes had a significantly lower gestational age at diagnosis than the second group (7 weeks [range, 5.7-8.4 weeks] versus 8.4 weeks [range, 6.2-14 weeks]; P = .0227), but crown-rump length, vaginal bleeding, and position and location of the hematoma were similar. CONCLUSIONS: Very large hematomas were associated with adverse outcome in 46% of the pregnancies. Vaginal bleeding was not associated with a poor prognosis. Neither position nor location of the placental hematoma was related to the outcome; however, when the hematoma was diagnosed at an early gestational age, the outcomes were worse.     

药物流产后清宫指征的探讨

目的:探讨药物流产后阴道出血行清宫0术的指征。方法:122例妇女药流后第2天常规B超探查宫内组织物残留情况,将其随机分成2组:清宫组和未清官组。对2组妇女药流后阴道出血时间、转经时间、经期和月经量进行观察和比较。结果:药物流产后转经时间、经期和月经量2组间无明显差异。B超检查宫内中强回声最大横径≤15 mm,2组药流后持续阴道出血时间相似;宫腔内中强回声最大横径≥16mm,清宫组及未清宫组药物流产后阴道出血持续时间分别为11.5±5.0d及23.2±12.5d,差异显著。结论:药物流产后应常规B超检查宫腔内组织物残留情况,B超官腔内中强回声最大横径≤15 mm,不必常规清宫。B超宫腔内中强回声最大横径≥16mm,应及时清宫。