Journal Reading

MANAGEMENT OF ACUTE
ABNORMAL UTERINE BLEEDING IN NONPREGNANT
REPRODUCTIVE-AGED WOMEN

Presented by:
Anggi Dwi Prasetyo

Adviser:
dr. Juhesni, Sp.OG(K)

SENIOR CLERKSHIP
DEPARTEMENT OF OBSTETRICS AND GYNECOLOGY
FACULTY OF MEDICINE AND HEALTH SCIENCES UNIVERSITAS ABDURRAB
RSUD DUMAI
DUMAI
2018
Abstract
Keypoints of this article

Initial evaluation of AUB1

 determine etiology(s)
using PALM-COEIN2
initiate medical therapy3
or prompt surgical
therapy if indicated4

1Prompt assessment for signs of hypovolemia and hemodynamic instability

2related or unrelated to uterine structural abnormalities 3Medical management should be

the first approach for most patients 4Mostly if patients is clinically unstable
 I
Introduction
AUB definition

bleeding from the uterine

corpus that is abnormal in
regularity, volume,
frequency, or duration
and occurs in the absence
of pregnancy, may be
acute or chronic

Acute AUB may occur spontaneously or within the context of chronic AUB (abnormal
uterine bleeding present for most of the previous 6 months
3 Stages of evaluating
patients with AUB

3Decide the most

2Determine
appropriate treatment
etiology
1Determine

acuity
 II
Assesment of Patients
Assessment of the Patient
With Acute AUB

prompt assessment Stabilize the patient

for signs of  evaluate the most
hypovolemia and likely etiology 
potential decide the most
hemodynamic appropriate
instability* treatment strategy

*Initiate 1 or 2 large bore IV lines, prepare for blood transfusion and clotting factor
replacement
 III
Etiology
Etiology of AUB: the PALM-
COEIN* System

Non-structural causes
Structural causes Coagulopathies
Polyp Ovulatory disfx
Adenomyosis Endometrial
Leiomyoma Iatrogenic
Malignancy Not otherwise
classified

*Accomplished by obtaining a history, performing a physical examination, and requesting

laboratory and imaging tests, when indicated
Determining the Etiology of
AUB

Medical Physical Lab/Imaging

History* Exam Test

*details of the current bleeding episode; related symptoms; and past menstrual,
gynecologic, and medical history
13% of women with HMB  vWD; 20% of women  coagulation disorder
Determining the Etiology of
AUB

Medical
History*

Using a screening tool in Box 1 can assist the clinician in determining which patients may
benefit from laboratory testing for disorders of hemostasis
Determining the Etiology of
AUB

Medical Physical Lab/Imaging

History Exam** Test

**focus on signs of acute blood loss and findings that suggest the etiology
Make sure that the bleeding is not from other areas of genital tract  pelvic examination
(speculum and bimanual examination)
Determining the Etiology of
AUB

Medical Physical Lab/Imaging

History Exam Test***

***All adolescents and women with either abnormalities in initial laboratory testing or
positive screening results for disorders of hemostasis should be considered for specific
tests for von Willebrand disease and other coagulopathies
Determining the Etiology of
AUB

Lab/Imaging
Test***

***All adolescents and women with either abnormalities in initial laboratory testing or
positive screening results for disorders of hemostasis should be considered for specific
tests for von Willebrand disease and other coagulopathies
 IV
Treatments
2 Main Objectives of AUB
Therapy

2reduce
1control the menstrual blood
current episode loss in
of heavy bleeding subsequent
cycles
2 Approach of AUB
Management

1Medical 2Surgical

therapy management

Medical therapy is considered the preferred initial treatment, however, certain situations
may call for prompt surgical management
Medical Therapy

1Hormonal

-Conjugated equine 2Non-hormonal

estrogen
-Antifibrinolytics
-Combined OCs
-Oral progestin
Medical Therapy (Hormonal)

Conjugated
Combined Oral
equine
OCs** progestin**
estrogen*

*Little data exist regarding the use of IV estrogen in patients with cardiovascular or
thromboembolic risk factors
**Commonly used for AUB,in multi-dose regimens
Medical Therapy (Non-
Hormonal)

2Intrauterine

tamponade with
1Antifibrinolytics a 26F Foley
(tranexamic acid) catheter infused
with 30 mL of
saline solution

1preventing fibrin degradation and are effective treatments for patients with chronic AUB
reduce bleeding in these patients by 30–55%
effectively reduces intraoperative bleeding and the need for transfusion in surgical patients
Medical Treatment Regimens

Conjugated equine estrogen

Conjugated DeVore GR, 25 mg IV Every 4–6 Contraindications
equine Owens O, hours for 24 include, but
estrogren Kase N. Use of hours are not limited, to
intravenous breast
Premarin cancer, active or past
in the treatment venous thrombosis or
of arterial
dysfunctional thromboembolic
uterine disease,
bleeding—a and liver dysfunction
double-blind or
randomized disease. The agent
control study. should be
Obstet Gynecol used with caution in
1982;59: 285– patients
91. with cardiovascular or
thromboembolic risk
factors.
Medical Treatment Regimens

Combined oral contraceptives

Combined oral Munro MG, Mainor Monophasic Three Contraindications include, but
†
contraceptives N, Basu R, combined oral times are not limited to, cigarette
Brisinger M, contraceptive per da smoking (in women aged 35
Barreda L. Oral that contains 35 y for 7 years or older), hypertension,
medroxyprogestero micrograms of days history of deep vein thrombosis
ne ethinyl estradiol or pulmonary embolism, known
acetate and thromboembolic disorders,
combination cerebrovascular disease,
oral contraceptives ischemic heart disease, migraine
for with aura, current or past breast
acute uterine cancer, severe liver disease,
bleeding: a diabetes with vascular
randomized involvement, valvular heart
controlled disease with complications, and
trial. Obstet major surgery with prolonged
Gynecol immobilization.
2006;108:924–9.
Medical Treatment Regimens

Medroxyprogesterone acetate
Medroxypro- Munro MG, 20 mg orally Three times Contraindications
gesterone Mainor N, Basu per day for 7 include, but are not
‡
acetate R, Brisinger M, days limited to, active or
Barreda L. Oral past deep vein
medroxyprogest thrombosis or
erone acetate pulmonary embolism,
and combination active or recent arterial
oral thromboembolic
contraceptives disease, current or
for acute uterine past breast cancer,
bleeding: a and impaired liver
randomized function or liver
controlled trial. disease.
Obstet Gynecol
2006;108:924–9.
Medical Treatment Regimens

Tranexamic acid
§
Tranexamic acid James AH, Kouides 1.3 g orally Three times per Contraindications include,
PA, Abdul-Kadir R, or day for 5 days but are not limited to,
Dietrich JE, Edlund 10 mg/kg IV (every 8 hours ) acquired impaired color
M, Federici AB, et (maximum 600 vision and current
al. Evaluation and mg/dose) thrombotic or
management of thromboembolic disease.
acute menorrhagia The agent should be used
in women with and with caution in patients
without underlying with a history of
bleeding disorders: thrombosis (because of
consensus from an uncertain thrombotic
international risks), and concomitant
expert panel. Eur J administration of
Obstet Gynecol combined oral
Reprod Biol contraceptives needs to
2011;158:124–34. be carefully considered.
Long-term Treatments for
Chronic AUB
1levonor- 2OCs 3progestin
gestrel (monthly therapy
Intraute- or (oral or
rine extended intramus-
system cycles) cular)

3tranexa-
4NSAID
mic acid

1Healthcare provider should add progestin or transition to OCs

4Should be avoided by patients with bleeding disorder
Surgical Treatments*

1Dilation
2Endome-
&
trial
Curretage
Ablation**
(D&C)
3uterine

artery 4hysterec-

emboliza- tomy**
tion

*Choice is based on the aforementioned factors plus the patient’s desire for future fertility
**only if patients don’t have plan for future childbearing and when malignancy has been
ruled out
 V
Conclusion and Recommendations
Conclusion and
Recommendations

1Etiology 2Medical

should be management
classified based should be initial
on PALM- treatment for
COEIN system most patients

4Acute bleeding
3Surgical
is controlled 
treatment
long term
should be done
maintenance
only if indicated
therapy
 “
Thankyou