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 estrogen-
producing 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 hypothalamic-
pituitary-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 OB-

GYNE for evaluation and management

V. PAST MEDICAL HISTORY

Hospitalization: DFS 4 y/o

Operations: (-)

VI. FAMILY HISTORY

(+)HPN - Mother

VII. REVIEW OF SYSTEMS

Menstrual History:

Menarche: 10 y/o Cycle: regular, 3 days

(-) Dysmenorrhea

Physical Assessment:

Pelvic: (+) Vaginal Spotting

VIII. DRUG STUDY

GENERIC MECHANISM INDICATION SIDE EFFECTS NURSING

NAME OF ACTION IMPLICATIONS

Ranitidine
(1 amp q8)

GENERIC MECHANISM INDICATION SIDE EFFECTS NURSING

NAME OF ACTION IMPLICATIONS
Tranexamic

GENERIC MECHANISM INDICATION SIDE EFFECTS NURSING

NAME OF ACTION IMPLICATIONS

Ferrous
Fumerde

GENERIC MECHANISM INDICATION SIDE EFFECTS NURSING

NAME OF ACTION IMPLICATIONS
Ascorbic
Acid

GENERIC MECHANISM INDICATION SIDE EFFECTS NURSING

NAME OF ACTION IMPLICATIONS

Cu
Canbyde

IX. NURSING CARE PLAN

Assessment Nursing Diagnosis Planning

Subjective Data:
Patient verbalized,
Objective Data:
Decreased verbal
response

Implementation Rationale Evaluation

X. REFERENCES