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rorrhagia
Metrorrhagia
Genital bleed ing unrelated to th e m enstrual period . In w om en of ch ild bearing ag e,
always assess if th e bleed ing is related to a preg nancy.
In all events
– Rapid ly assess th e sev erity of bleed ing .
– In th e ev ent of h eav y h aem orrh ag e or sh ock or if a surg ical interv ention (laparotom y,
caesarean d eliv ery) is required :
• S tart an IV infusion of Ring er lactate; m onitor v ital sig ns (pulse, BP );
• P repare for a possible blood transfusion (d eterm ine patient's g roup, id entify
potential d onors);
• If a transfusion is perform ed , only use blood th at h as been screened at least for
HIV, h epatitis B, and h epatitis C.
– In th e ev ent of referral to a surg ical facility, d ifficult transport cond itions m ig h t
ag g rav ate th e h aem orrh ag e: th e patient sh ould be infused and accom panied by
fam ily m em bers wh o are potential blood d onors.
– U ltrasound is not im perativ e but it facilitates certain d iag noses (e.g . ectopic
preg nancy, placenta praev ia).
– P rev ent or treat anaem ia.
Bleeding unrelated to pregnancy
– Clinical exam ination:
• speculum exam ination: d eterm ine th e orig in of th e bleed ing [v ag ina, cerv ix, uterine
cav ity]; appearance of th e cerv ix; estim ation of blood loss;
• bim anual pelv ic exam ination: look for uterine m otion tend erness, increased
v olum e or abnorm alities of th e uterus.
– Friable, h ard , ulcerated , h ypertroph ic m ass on th e cerv ix: possible cerv ical cancer;
surg ical treatm ent is required . W h ile w aiting for surg ery, tranexamic acid P O (3 g /d ay
in 3 d iv id ed d oses for 3 to 5 d ays) m ay be used to red uce bleed ing .
– Inflam m ation of th e cerv ix, lig h t or m od erate bleed ing , purulent cerv ical d isch arg e,
pelv ic pain: consid er cerv icitis (see Abnormal vaginal discharge, pag e 233) or salping itis
(see Upper genital tract infections, pag e 240).
– E nlarg ed , m issh apen uterus: uterine fibroid s; surg ical treatm ent if larg e fibroid s
cause sig nificant bleed ing . W h ile waiting for surg ery or if surg ery is not ind icated ,
treat as a functional uterine bleed ing .
– N orm al uterus and cerv ix: possible functional uterine bleed ing : tranexamic acid P O as
abov e. In situations of repeated bleed ing , it can be com bined w ith an N S AID
(ibuprofen P O : 1200 to 2400 m g /d ay m axim um , in 3 d iv id ed d oses for 3 to 5 d ays)
and /or a long -term treatm ent w ith oral estroprog estog ens or injectable prog estog ens.
Note: rule out oth er causes of v ag inal bleed ing before d iag nosing functional uterine
bleed ing . Consid er for exam ple poorly tolerated contraceptiv e, end om etrial cancer in
postm enopausal wom en, g enitourinary sch istosom iasis in end em ic areas (pag e 151).
246
Metrorrhagia
Genital bleed ing unrelated to th e m enstrual period . In w om en of ch ild bearing ag e,
always assess if th e bleed ing is related to a preg nancy.
In all events
– Rapid ly assess th e sev erity of bleed ing .
– In th e ev ent of h eav y h aem orrh ag e or sh ock or if a surg ical interv ention (laparotom y,
caesarean d eliv ery) is required :
• S tart an IV infusion of Ring er lactate; m onitor v ital sig ns (pulse, BP );
• P repare for a possible blood transfusion (d eterm ine patient's g roup, id entify
potential d onors);
• If a transfusion is perform ed , only use blood th at h as been screened at least for
HIV, h epatitis B, and h epatitis C.
– In th e ev ent of referral to a surg ical facility, d ifficult transport cond itions m ig h t
ag g rav ate th e h aem orrh ag e: th e patient sh ould be infused and accom panied by
fam ily m em bers wh o are potential blood d onors.
– U ltrasound is not im perativ e but it facilitates certain d iag noses (e.g . ectopic
preg nancy, placenta praev ia).
– P rev ent or treat anaem ia.
Bleeding unrelated to pregnancy
– Clinical exam ination:
• speculum exam ination: d eterm ine th e orig in of th e bleed ing [v ag ina, cerv ix, uterine
cav ity]; appearance of th e cerv ix; estim ation of blood loss;
• bim anual pelv ic exam ination: look for uterine m otion tend erness, increased
v olum e or abnorm alities of th e uterus.
– Friable, h ard , ulcerated , h ypertroph ic m ass on th e cerv ix: possible cerv ical cancer;
surg ical treatm ent is required . W h ile w aiting for surg ery, tranexamic acid P O (3 g /d ay
in 3 d iv id ed d oses for 3 to 5 d ays) m ay be used to red uce bleed ing .
– Inflam m ation of th e cerv ix, lig h t or m od erate bleed ing , purulent cerv ical d isch arg e,
pelv ic pain: consid er cerv icitis (see Abnormal vaginal discharge, pag e 233) or salping itis
(see Upper genital tract infections, pag e 240).
– E nlarg ed , m issh apen uterus: uterine fibroid s; surg ical treatm ent if larg e fibroid s
cause sig nificant bleed ing . W h ile waiting for surg ery or if surg ery is not ind icated ,
treat as a functional uterine bleed ing .
– N orm al uterus and cerv ix: possible functional uterine bleed ing : tranexamic acid P O as
abov e. In situations of repeated bleed ing , it can be com bined w ith an N S AID
(ibuprofen P O : 1200 to 2400 m g /d ay m axim um , in 3 d iv id ed d oses for 3 to 5 d ays)
and /or a long -term treatm ent w ith oral estroprog estog ens or injectable prog estog ens.
Note: rule out oth er causes of v ag inal bleed ing before d iag nosing functional uterine
bleed ing . Consid er for exam ple poorly tolerated contraceptiv e, end om etrial cancer in
postm enopausal wom en, g enitourinary sch istosom iasis in end em ic areas (pag e 151).
246
