Importância do diagnóstico por imagem em pacientes com sangramento uterino anormal / Importance of diagnostic imaging in patients with abnormal uterine bleeding

O sangramento uterino anormal é diagnóstico sindrômico comum no consultório do ginecologista e pode comprometer substancialmente a qualidade de vida. O objetivo no diagnóstico de sangramento uterino anormal é distinguir pacientes com causas estruturais (anatômicas), como pólipo, adenomiose, leiomioma, malignidade e hiperplasia, de pacientes que apresentam anatomia normal, nas quais o sangramento pode ser devido a alteração dos mecanismos de coagulação, distúrbios ovulatórios, distúrbios primários do endométrio, iatrogenia, ou ter outra causa não classificada. O diagnóstico se inicia a partir de anamnese detalhada e exame físico geral e ginecológico completos, seguidos da solicitação de exames complementares (laboratoriais e de imagem), conforme indicado. O exame de imagem de primeira linha para identificação das causas estruturais inclui a ultrassonografia pélvica. Histerossonografia, histeroscopia, ressonância magnética e amostragem endometrial para exame de anatomia patológica são opções que podem ser incluídas no diagnóstico a depender da necessidade. O objetivo deste artigo é apresentar a relevância dos exames de imagem na investigação das causas de sangramento uterino anormal.

Abnormal uterine bleeding is one of the commonest presenting complaints encountered in a gynecologist's office and may substantially affect quality of life. The aim in the diagnosis of abnormal uterine bleeding is to distinguish women with anatomic causes such as polyp, adenomyosis, leiomyoma, malignancy and hyperplasia from women with normal anatomy where the cause may be coagulopathy, ovulatory disorders, endometrial, iatrogenic and not otherwise classified. Diagnosis begins with a thorough history and physical examination followed by appropriate laboratory and imaging tests as indicated. The primary imaging test for the identification of anatomic causes include ultrasonography. Saline infusion sonohysterography, magnetic resonance, hysteroscopy, endometrial sampling are options that can be included in the diagnosis depending on the need. The aim of this article is to present the relevance of imaging exams in the investigation of the causes of abnormal uterine bleeding.

Hematometra y hematocervix en paciente postmenopáusica: reporte de caso / Hematometry and hematocervix in postmenopausal patient: case repor

El hematometra es la retención de sangre en el útero y comúnmente se presenta en mujeres jóvenes con anomalías mullerianas pero puede aparecer también en mujeres postmenopausicas por causas secundarias como traumas, tumores, terapia de remplazo hormonal, estenosis cervical, entre otras. En esta presentación de caso interesante se describe una mujer postmenopáusica bajo terapia de remplazo hormonal. Dicha mujer inicia con hemorragia uterina anormal por lo que se le realiza ultrasonido evidenciando hematómetra y hematocervix. Como método diagnóstico y terapéutico de la hemorragia postmenopáusica se le realiza histerectomía abdominal en la cual la patología evidencia leiomiomatosis uterina con endometrio secretor

Hematometra is the retention of blood in the uterus and commonly occurs in young women with Mullerian abnormalities but can also appear in postmenopausal women due to secondary causes such as trauma, tumors, hormone replacement therapy, cervical stenosis, among others. In this presentation an interesting case is described a postmenopausal woman under hormone replacement therapy. She said woman began with abnormal uterine bleeding, so an ultrasound was performed showing hematometer and hematocervix. As a method diagnosis and treatment of postmenopausal hemorrhage, abdominal hysterectomy is performed in which the pathology shows uterine leiomyomatosis with secretory endometrium

Uterine rescue in high-risk gestational trophoblastic neoplasia treated with ema-co by uterine arteries embolization due to arteriovenous malformations / Resgate uterino em neoplasia trofoblástica gestacional de alto risco tratada com EMA-CO por embolização de artérias uterinas devido a malformações arteriovenosas

Abstract Complete hydatidiform mole (CHM) is a rare type of pregnancy, in which 15 to 20% of the cases may develop into gestational trophoblastic neoplasia (GTN). The diagnostic of GTN must be done as early as possible through weekly surveillance of serum hCG after uterine evacuation.We report the case of 23-year-old primigravida, with CHM but without surveillance of hCG after uterine evacuation. Two months later, the patient presented to the emergency with vaginal bleeding and was referred to the Centro de Doenças Trofoblásticas do Hospital São Paulo. She was diagnosed with high risk GTN stage/score III:7 as per The International Federation of Gynecology and Obstetrics/World Health Organization (FIGO/WHO). The sonographic examination revealed enlarged uterus with a heterogeneous mass constituted of multiple large vessels invading and causing disarrangement of the myometrium. The patient evolved with progressive worsening of vaginal bleeding after chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) regimen. She underwent blood transfusion and embolization of uterine arteries due to severe vaginal hemorrhage episodes, with complete control of bleeding. The hCG reached a negative value after the third cycle, and there was a complete regression of the anomalous vascularization of the uterus as well as full recovery of the uterine anatomy. The treatment in a reference center was essential for the appropriate management, especially regarding the uterine arteries embolization trough percutaneous femoral

Resumo Mola hidatiforme completa (MHC) é um tipo raro de gravidez, na qual 15 a 20% dos casos podem desenvolver neoplasia trofoblástica gestacional (NTG). O diagnóstico de NTG deve ser feito o mais cedo possível, pelo monitoramento semanal do hCG sérico após esvaziamento uterino. Relatamos o caso de uma paciente primigesta, de 23 anos de idade, com MHC, sem vigilância de hCG após esvaziamento uterino. Dois meses depois, a paciente compareceu na emergência com sangramento vaginal, sendo encaminhada ao Centro de Doenças Trofoblásticas do Hospital São Paulo, onde foi diagnosticada com NTG de alto risco, estádio e score de risco III:7 de acordo com a The International Federation of Gynecology and Obstetrics/Organização Mundial de Saúde (FIGO/OMS). O exame ultrassonográfico revelou útero aumentado com uma massa heterogênea constituída pormúltiplos vasos volumosos invadindo e desestruturando o miométrio. A paciente evoluiu com piora progressiva do sangramento vaginal após quimioterapia com o regime etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO). Ela foi submetida a transfusão de sangue e embolização das artérias uterinas devido aos episódios graves de hemorragia vaginal, com completo controle do sangramento. O hCG atingiu valor negativo após o terceiro ciclo, havendo regressão completa da vascularização uterina anômala, assim como recuperação da anatomia uterina. O tratamento em um centro de referência permitiu o manejo adequado, principalmente no que se refere à embolização das artérias uterinas através da punção percutânea da artéria femoral, que foi crucial para evitar a histerectomia, permitindo a cura da NTG e a manutenção da vida reprodutiva.

[Comparison of sensitivity and specificity of transvaginal sonography, saline infusion sonohysterography and hysteroscopy in evaluation of women with abnormal uterine bleeding]

Bleeding disorders are a common problem in daily practice, especially in premenopausal women. In our investigation, we compared the sensitivity and specificity of three different diagnostic methods; Trans-vaginal sonography [TVS], saline infusion sonohystrography [SIS] and Hysteroscopy. It was a cross-sectional study with a study population of ninety-nine women suffering from AUB attending the outpatient clinic of Imam and Razi hospital in Ahvaz-Iran. They were evaluated by three different diagnostic methods and the results were compared. This study started from March 2008 to December 2008. The sensitivity, specificity, positive predictive and negative predictive values were measured in TVS, SIS, and finally these two methods were compared with hysteroscopy [as a gold standard]. The sensitivity and specificity of TVS was 74.2% and 49.7%, respectively, while that of SIS was 91.6% and 86%, respectively. The positive predictive value and negative predictive value of TVS was 71.9% and 54.3%, respectively, while that of SIS was 85.9% and 85.75%, respectively. The sensitivity, specificity, the positive predictive and negative predictive values of SIS was more than TVS, and it was similar to hysteroscopy. The findings obtained in the present study indicate that in AUB, sensitivity, specificity, positive and negative predictive value of SIS is more than TVS and therefore can be considered as a first step for diagnosis of AUB

Ultrasonography; Its value in the management of first trimester vaginal bleeding

To find the value of ultrasound in the management of first trimester vaginal bleeding. All patients reporting with vaginal bleeding in obstetrics and gynaecology Unit-Ill, Nishtar Hospital, Multan were included in the study. Non-pregnant patients and patients with vaginal bleeding due to the cause other than conception were excluded. After history, clinical examination and pregnancy test, ultrasonography was done with abdominal convex probe [3.5 Mhz] and/or vaginal [5 Mhz] probe to every patient. Overall incidence of first trimester vaginal bleeding was 12.23%. Disparity between clinical and ultrasonic diagnosis was 17.3% in cases of incomplete abortion, 11.6% in cases of inevitable abortion, 9.7% in cases of threatened abortion, 3.8% in cases of missed abortion and 1.9% in cases of lghted ovum and 1.9% in cases of molar pregnancy. The confirmation of diagnosis after histopathology of surgically obtained specimen revealed least percentage of misdiagnosis on ultrasound evaluation. While in ectopic pregnancy no disparity found on clinical, ultrasonographic and surgical results, but it was misleading as only late cases with ruptured ectopic pregnancy and obvious clinical signs and symptoms were referred to the hospital. Otherwise USG would have shown increased sensitivity and specificity. Study has confirmed the superiority of USG scanning over conventional methods in earlier and more precise diagnosis and thus better treatment of patients having first trimester vaginal bleeding. It is more accurate, safe, non-invasive and quick in diagnosis and management. It prevents from undue surgical intervention as well as undue delay in surgery when required. Once bleeding has occurred repeat pregnancy test should he ignored and better not done at all, Thus USG should he an important diagnostic tool in every emergency unit but importance of clinical diagnosis cannot be overlooked

[Postmenopausal uterine bleeding. Analytic study about 65 cases]

Postmenopausal uterine bleeding is frequent in gynecology. This symptom can reveal benign causes as well as cancers. So it's essential to rule out organic pathology. We propose a retrospective study of 65 postmenopausal women who had uterine bleeding for two years. To study the relative frequency of different causes of post-menopausal uterine bleeding.- To evaluate the different investigation procedures. In 65 cases of postmenopausal bleeding, we found:- 6 cases of cancer [9.2%]: 4 cases of cancer of uterine corpus and 2 cases of cancer of uterine cervix.- Benign pathology was more frequent [59 cases: 90.8%], essentially represented by endometrial atrophy [37 cases] and hyperplasia [11 cases].- Hysteroscopic aspect in the 4 cases of endometrial cancer:- Polypoid hypertrophy: 2 cases.- Simple hyperplasia: 2 cases. Despite the fact that benign pathology is more frequent than malignancy as a cause postmenopausal uterine bleeding, we must always rule out a cancer by oriented biopsy

Placenta previa: the role of ultrasound in assessment during third trimester

To assess the role of ultrasound in detecting the migration of placenta previa during the third trimester at Lady Willingdon Hospital and Jinnah Hospital, Lahore during the period July 2000 to September 2002. Eighty pregnant women with the diagnosis of placenta previa at 28 to 32 weeks of gestation were included in the study. After base line ultrasound, scan was repeated every two weeks until delivery or placental migration for more than 3 cm from internal cervical os. Detailed information for placental position, distance from cervical os and relation to presenting part was recorded. Women with major degree placenta previa were admitted in the hospital at 32 -34 weeks of gestation. Delivery plan was made according to degree of placenta previa by completed 37 weeks of gestation. Cesarean section was done for the women with major degree placenta previa and minor degree placenta previa with antepartum hemorrhage and obstetric indication.Out of 80 women placental migration to a distance of more than 3-5 cm from the internal cervical os occurred in 20 cases [12 anterior/anterolateral, 8 posterior/posterolateral] by 36 weeks of gestation and 20 had complete placenta previa. Out of remaining 40 cases, 12 patients had vaginal delivery and 28 had cesarean section. Placental migration was not observed in women with total placenta previa or posterior placenta previa when the distance of lower edge of placenta was less than 1 cm from the internal os. Ultrasound is important for the diagnosis of placental localization and placental migration during third trimester. Placental migration takes place more often in anterior than in complete or posterior placenta previa

Comparative study of transvaginal hysterosonography and biopsy for the evaluation of post-menopausal bleeding

The aim of this prospective study was to evaluate transvaginal hysterosonography [TVHS] in post-menopausal bleeding [PMB] as an alternative to endometrial biopsy. The study was conducted at the Zarka Military Hospital, Amman, Jordan, over a one-year period from 1996 to 1997. Patients and The study comprised 98 women presenting with post-menopausal bleeding who had been listed for diagnostic dilatation and curettage. Transvaginal sonography [TVS] and transvaginal hysterosonography were performed one week before operation. The mean age of the women was 57 years, and all of them had had their menopause for at least six months. Sixty-one women [62%] demonstrated endometrial thickness of more than 5 mm by transvaginal sonography. All the women had transvaginal hysterosonography, except seven on whom hysterosonography could not be performed for technical reasons and who had to be excluded from the study, leaving a total of 54 women. TVS confirmed the presence of endoluminal mass in 30 of 54 women [60%]. Twenty-two of the 30 endoluminal mass cases were pedunculated while eight were sessile. Sixteen of the pedunculated cases were endometrial polyps while the remaining six were fibroid polyps. Five of the sessile cases were fibroid, two were endometrial hyperplasia, and the last one endometrial carcinoma. The other 44 out of the 98 patients also underwent transvaginal hysterosonography. No pathology could be detected in these patients, but they were noted to have atrophic endometrium after dilatation and curettage. The combination of transvaginal sonography and transvaginal hysterosonography is both sensitive and specific with regard to detecting and excluding endoluminal masses as the cause of post-menopausal bleeding. Diagnostic dilatation and curettage fails to detect a large percentage of some lesions, so TVS in combination with TVHS should be considered as the initial examination in the evaluation of all women with post-menopausal bleeding

Correlation between endometrial thickness as measured by endovaginal ultrasongraphy and histopathological finding in abnormal uterine bleeding

The present study was proposed to find if there is a correlation between endometrial thickness as measured by Endovaginal Ultrasonography and Histopathological Finding in Abnormal uterine bleeding. [40] patients participated in this study divided into two groups, [30] patients in the study group with abnormal uterine bleeding with special criteria, and control group of [10] patients having no abnormal uterine bleeding. Their ages ranged from [25] to [50] years. Where measuring of endometrial thickness with the use of endovaginal sonography were done and one day later endometrial biopsy and histopathological examination were done. Finally, the sonographically measured endometrial thickness and histopathology obtained were correlated with each other and statistically analysed. From this study it is concluded that when endometrial thickness is >/= 6 mm in post menopausal women or >/= 10 mm in perimenopausal women or >/= 13 mm at child bearing age is considered abnormal necessitating diagnostic curettage and histopathological examination

Correlation of vaginal sonographic and histopathologic examinations and some turner markers in cases of perimenopausal bleeding

The study included 62 women. They were divided into 2 groups. The first group consisted of 42 cases, who presented with perimenopausal bleeding, of whom 10 cases were previously histologically proven to have endometrial adenocarcinoma. The second group included 20 cases [10 cases premenopausal and other 10 cases were postmenopausal women] who had no complain and taken as control. All patients were subjected to full history taken, general, abdominal and local physical examination, transvaginal sonography and Doppler velocimetry of uterine artery were done one day prior to endometrial curettage for evaluation of endometrial thickness and RI of uterine artery. This study revealed that 71.7% of patients with abnormal endometrium [80% of cancer group and 68.8% of benign group] were found to have low RI of uterine artery. The lowest mean uterine artery RI was obtained in patient with endometrial carcinoma [mean RI = SE = 0.76 +/- 0.016 P <0.001]. Combination of endometrial thickness with RI of uterine artery by EVS and Doppler increase efficacy for detection of endometrial abnormalities up to 76.2%. UGP can detect about 80% of cases with endometrial carcinoma, while no change was obtained regarding the false positive result of UGP in endometrial hyperplasis. UGP could not differentiate between hyperplasia with or without atypis

Role of transvaginal ultrasonography in the diagnosis of abnormal uterine bleeding refractory to hormonal therapy

TAS and TVS were done simultaneously for 160 cases of abnormal uterine bleeding resistant to hormonal therapy in order to detect the presence of small underlying organic lesions. The results were compared with histopathologic examinations of hysterectomy specimens. The most prevalent lesions on histopathologic study were small leiomyomata <2 cm [68.6%], adenomyosis uteri [39.2%] and endometrial polypi [6.8%]. It was found that the sensitivity of TVS in detection of small leiomyomata was 92.9%, for adenomyosis uteri 65% and for endometrial polypi 85.7%. TAS had a sensitivity of 71.4%, 55% and 71.5% for the same lesions, respectively. The specificity of TVS for leiomyomata was 93.9%, for adenomyosis uteri 96.2% and for endometrial polypi 96.1%, compared with TAS, which showed a specificity of 91%, 65.6% and 85.6% for the same lesions, respectively. It was concluded that TVS had higher sensitivity and specificity compared with TAS in the detection of small underlying organic lesions in cases of abnormal uterine bleeding