CASE STUDY

ABNORMAL UTERINE BLEEDING

Submitted by: Lucila O. Lugo BSN 2-1, Group 3

Submitted to: Ms. Geraldine Barbosa Clinical Instructor

Date of Submission: December 20, 2011

TABLE OF CONTENTS

INTRODUCTION.1 REVIEW OF ANATOMY AND PHYSIOLOGY...3 PATHOPHYSIOLOGY...5 DEMOGRAPHIC DATA.....8 SOURCE AND RELIABILITY OF INFORMATION....9 REASON FOR SEEKING HEALTH CARE........9 HISTORY OF PRESENT ILLNESS.9 PAST MEDICAL HISTORY...9 FAMILY HISTORY..9 REVIEW OF SYSTEMS......10 DRUG STUDY..10 NURSING CARE PLAN......15 REFERENCES.....16

INTRODUCTION

Menstrual irregularities are a common gynecologic problem, especially in adolescents. Abnormal uterine bleeding (AUB) is any form of bleeding that is irregular in amount, duration, or frequency. It can be characterized by excessive uterine bleeding that occurs regularly (menorrhagia), by heavy bleeding at irregular times (metrorrhagia), or a combination of both (menometrorrhagia). It can also be intermittent bleeding or sparse cyclical bleeding (oligomenorrhea). Dysfunctional uterine bleeding (DUB) is a subset of AUB and is defined as excessive, prolonged, or unpatterned bleeding from the endometrium without an organic cause and is frequently used synonymously with anovulatory bleeding. In adolescents, up to 95% of AUB is DUB. However, because DUB is a diagnosis of exclusion, other potential causes of abnormal bleeding must be ruled out. Although the majority of adolescents with abnormal bleeding have anovulation due to age, DUB is a diagnosis of exclusion.

Blood loss in the normal menstrual cycle is self-limited due to the action of platelets and fibrin. Individuals with thrombocytopenia or coagulation deficiency may have excessive menstrual bleeding. Several studies of the incidence of coagulopathy in teenagers admitted or evaluated for menorrhagia found coagulopathies in 12 to 33% in all admissions for menorrhagia. The most common coagulation disorders include thrombocytopenia, due to idiopathic thrombocytopenic purpura (ITP), von Willebrand's disease, which affects up to 1% of the population, and platelet function defects. Of the adolescents presenting with severe menorrhagia or hemoglobin less than 10 g/dL, 25% were found to have a coagulation disorder. In those presenting with menorrhagia at the first menses, 50% were found to have a coagulation disorder.

The possibility of pregnancy should be considered in any adolescent with abnormal bleeding, and a pregnancy test is mandatory even if the client denies

sexual intercourse. Any bleeding in early pregnancy should lead to suspicion of miscarriage or ectopic pregnancy.

Any trauma, infection, or neoplasm can cause AUB. Infections, such as Chlamydia or pelvic inflammatory disease (PID), may present with abnormal bleeding. Vaginal trauma or a foreign body may cause bleeding that might be assumed by the adolescent to be uterine in origin. Women with a foreign body in the vagina generally present with a bloody, odorous discharge. Cervical polyps, cervical carcinoma, and cervical inflammation can cause bleeding. Cervical cancer is fairly rare in adolescents but may be encountered in those who had sexual experiences at a very early age (including those with a history of sexual abuse). Ovarian estrogenproducing tumors need to be excluded in the adolescent with very heavy persistent bleeding. Finally, although rare, uterine pathology, such as polyps and fibroids, may lead to abnormal bleeding.

The most common endocrine disorder to cause abnormal bleeding is thyroid disease. In general, hypothyroidism presents with hypermenorrhea, and hyperthyroidism presents with hypomenorrhea. Hyperprolactinemia caused by a prolactinoma or certain medications, such as neuroleptics, can also cause anovulation and AUB. PCOS is underdiagnosed in adolescents and should be suspected in obese teens with hirsutism, acne, and continued irregular cycles. There is some recent evidence that PCOS is more common in women with epilepsy. Other diseases to consider are congenital adrenal hyperplasia, Cushing syndrome, hepatic dysfunction, and adrenal insufficiency.

Other causes of AUB (most commonly amenorrhea) in adolescents are eating disorders, stress, excessive exercise, and weight loss. In addition, common medications, which increase the cytochrome P450 enzymatic processes in the liver, may induce the more rapid metabolism of steroid hormones, thereby decreasing their bioavailability and result in AUB that is secondary to a relative insufficiency of estrogen or progesterone (e.g., antiseizure medications).

ANATOMY AND PHYSIOLOGY

The normal menstrual cycle is divided into proliferative, ovulatory, and secretory phases. In the proliferative phase, gonadotropin-releasing hormone (GnRH) is secreted in a pulsatile fashion by the hypothalamus and stimulates the pituitary gland to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH stimulates a group of ovarian follicular cells to grow, from which one dominant follicle is selected. The dominant follicle produces increasing amounts of estradiol. Estradiol stimulates the endometrium to proliferate and develop many progesterone receptors. When estradiol reaches a certain sustained level, a surge of LH is released from the pituitary, causing the dominant follicle to ovulate (ovulatory phase) and become the corpus luteum, which then produces estrogen and progesterone. Progesterone halts endometrial growth and stabilizes the endometrium (secretory phase). Involution of the corpus luteum in the absence of a conception causes a rapid decline in estrogen and progesterone. The endometrium collapses and sheds as menstruation occurs, approximately 14 days after ovulation. Menstrual flow stops as a result of the combined effect of prolonged vasoconstriction, tissue collapse, vascular stasis, and estrogen-induced "healing." Thrombin generation as a result of extravasation of blood is essential for hemostasis.

Therefore, normal ovulatory cycles involve regular cyclic production of estradiol, initiating ovarian follicular growth and endometrial proliferation. Following ovulation, the production of progesterone stabilizes the endometrium. Without ovulation and subsequent progesterone production, a state of "unopposed" continuous estrogen secretion occurs. This stimulates excessive dilation of the spiral arterial supply in the endometrium and abnormal endometrial growth without adequate structural support. The consequence is spontaneous breakage and sloughing of the endometrium with unpredictable bleeding. Eventually, continued elevated estrogen levels have a negative feedback effect on the hypothalamicpituitary-ovarian axis, causing a decrease in FSH, LH, and estrogen. This results in a vasoconstriction and collapse of the thickened hyperplastic endometrial lining with

heavy and often prolonged bleeding. In anovulatory cycles, the estrogen levels can either be high or low. With chronic high levels, there is intermittent heavy bleeding, and chronically low levels may result in prolonged light bleeding.

The maturation of the hypothalamic-pituitary-ovarian axis occurs slowly in the first 18 to 24 months after menarche in the adolescent female. Anovulatory cycles may last up to 5 years.

Information concerning the age that adolescents become ovulatory is conflicting. McDonough and Gantt observed anovulation in 55 to 82% of adolescents between menarche and 2 years postmenarche, 30 to 55% from 2 to 4 years postmenarche, and 20% from 4 to 5 years postmenarche. The World Health Organization (WHO) conducted a 2-year longitudinal study on menstrual and ovulatory patterns in females aged 11 to 15 and found that 19% of girls had regular cycles within the first three cycles and 67% had regular cycles by the end of 2 years. In addition, adolescents with earlier menarche tend to develop ovulatory cycles sooner than those with later onset of menarche. Gynecologic age, defined as the number of years from menarche, is therefore a much stronger predictor of ovulatory cycles than chronological age. Apter and colleagues found that the majority of cycles were still anovulatory by a gynecologic age of 2 years, but after 5 years more than 80% achieved ovulation as measured by midluteal phase progesterone levels.

Besides physiologic causes, anovulation can also have organic pathologic causes. These include hyperandrogenic states (e.g., polycystic ovary syndrome [PCOS]), hypothalamic dysfunction (e.g., anorexia nervosa and excessive exercise), endocrinopathies, and premature ovarian failure. Occasionally, the bleeding is caused by an anatomic cause (e.g., polyps or fibroids), although this is very rare in adolescents. Therefore, the differential diagnosis of DUB in adolescents prioritizes differently than does the differential diagnosis in adult women.

PATHOPHYSIOLOGY

I. DEMOGRAPHIC DATA

Patient Profile: Name of Patient: Gonzales, Maria Karen R. Age: 14 yrs. old Date of Birth: December 3, 1997 Gender: Female Weight: 47 kg Address: 194 Banjo East, Tanauan City, Batangas Religion: Roman Catholic Citizenship: Filipino LMP: November 27, 2011

Admission Date: December 18, 2011 Chief Complaint: Vaginal Bleeding Diagnosis: Abnormal Uterine Bleeding Attending Physician: Dra. Elizabeth Gardiola / Tullas

II. SOURCE AND RELIABILITY OF INFORMATION

The information presented here is based on the patients Medical Records, Kardex, Nurses Notes, charts and documentations. Subjective data are validated using the Nurse-Patient Interaction (NPI) and interviews of the patient and relatives.

III. REASON FOR SEEKING HEALTH CARE

Chief Complaint: Vaginal Spotting

IV.HISTORY OF PRESENT ILLNESS

Three weeks prior to admission, patient started to have her normal menstrual period which lasted for 3 days. No other problems encountered. Two weeks prior to admission, patient noticed vaginal spotting, no passage of blood clots noted. (-) Hypogastric pain, spotting continued for several days and general weakness noted. Persistence of symptoms prompted consult with pedia then referral to OBGYNE for evaluation and management

V. PAST MEDICAL HISTORY

Hospitalization: DFS 4 y/o Operations: (-)

VI.FAMILY HISTORY

(+)HPN - Mother

VII.
Menstrual History: Menarche: 10 y/o (-) Dysmenorrhea Physical Assessment: Pelvic: (+) Vaginal Spotting

REVIEW OF SYSTEMS

Cycle: regular, 3 days

VIII. DRUG STUDY

GENERIC NAME MECHANISM OF ACTION INDICATION SIDE EFFECTS NURSING IMPLICATIONS

Ranitidine (1 amp q8)

GENERIC NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATIONS

Tranexamic

GENERIC NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATIONS

Ferrous Fumerde

GENERIC NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATIONS

Ascorbic Acid

GENERIC NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATIONS

Cu Canbyde

IX.NURSING CARE PLAN

Assessment Subjective Data: Patient verbalized, Objective Data: Decreased verbal response Nursing Diagnosis Planning

Implementation

Rationale

Evaluation

X. REFERENCES