Gynaecology and Obstetrics

1. ABNORMAL UTERINE
BLEEDING
CASE PRESENTATION
By Intern:
Prabesh Pokhrel
Pratima Chaulagain
Dept.of Obstetrics/Gynaecology
3/3/2023 1

2. OBJECTIVES
To be able to present a case of AUB
•History
•Physical examination
•Course of treatment in the ward
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3. PATIENT’S PROFILE
• NAME : Mrs Adhikari
• AGE : 45 years
• ADDRESS (Permanent): Ratna chowk- 7 , Pokhara
• MARITAL STATUS : Married
• OCCUPATION: Homemaker HUSBAND : Retired army
• EDUCATION : SLC HUSBAND: Bachelor
• RELIGION: Hindu
• DATE OF ADMISSION: 2079/09/20 at 2:00 pm from OPD
• DATE OF HISTORY TAKING: 2079/09/20
• INPATIENT NO. 79058471
• BED NO. 7
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4. CHIEF COMPLAINTS
Irregular menstrual cycle since 2 Years
Excessive per vaginal bleeding during menstruation for 3
months
Lower abdominal pain for 3 months
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5. HISTORY OF PRESENTING ILLNESS
Excessive bleeding during menstruation since 3 month
Acute in onset
Shortest cycle of 10-15 days
Longest cycle of 30-35 days
Fully soaking 3 pads each day and associated with passage
of clots
No any aggravating and relieving factors
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6. HISTORY OF PRESENTING ILLNESS
No history of
Trauma
Gum bleeding
Nasal bleeding
Easy bruising
Intake of blood thinner medication
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7. HISTORY OF PRESENTING ILLNESS
Lower abdominal pain for 3 months
Site : lower abdomen
Onset : insidious
Character : dull aching type, continuous
Radiation: no radiation
No any Alleviating and relieving factor
Time /duration : no postural/diurnal variation
Severity :mild
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8. NO HISTORY OF :
Increase urinary frequency
Difficulty in passing urine
Difficulty in passing stool
Vomiting
Abdominal distension
Shortness of breath
Palpitations
Fever
Past medication history
Weight loss and use of any
medications
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9. OBSTETRIC HISTORY
 Married for 20 Years
P2L2A1
L1 – 17 years, Female, Home delivery, Weight: Unknown
L2 – 15 years, Male, Normal delivery, hospital, birth
weight -3000 grams
A1- 13 years back, spontaneous at 6 week of gestation
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10. MENSTRUAL HISTORY
Age at menarche: 13 years
Menstrual cycle: Irregular , 15-20 days since 2-3 months
Flow : 5 -7 days
Pads used: 3 per day, fully soaked
Dysmenorrhoea present
Associated with passage of clots
 No Intermenstrual and postcoital bleeding
LMP : 2079/09/05
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11. CONTRACEPTIVE HISTORY
 Depot medroxy progesterone acetate injection for 10
years
 Last dose on kartik 05 , 2079
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12. PAST HISTORY
Hypertension (-)
Diabetes Mellitus (-)
Tuberculosis, Epilepsy (-)
Heart disease and Thyroid disorder (-)
Surgical history (-)
Blood Transfusion(-)
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13. FAMILY HISTORY
 No similar history in immediate family member.
No history of malignancy like cervical cancer, endometrium
cancer, breast and colon cancer
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14. PERSONAL HISTORY
Non vegetarian.
Non- smoker and Non- alcoholic.
Denies history of substance abuse.
No h/o allergy to any drug.
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15. GENERAL CONDITION
Fair , average built, conscious, co-operative, well
oriented to time, place and person, and examined on
day light
Height :157cm
Weight :60 kg
B.M.I : 24.3kg/m2 (Normal)
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16. VITALS
PULSE: 80 BPM, taken on right radial artery, regular in
rhythm , adequate in volume, no radio –radial delay.
RESPIRATORY RATE: 18 breaths Per minute, Thoraco-
abdominal
BLOOD PRESSURE: 110/70 MM OF HG taken over right
arm in supine position
TEMPERATURE: 97 °F over left axilla
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17. Cardinals
Pallor present on lower palpebral conjunctiva
No signs of icterus, lymphadenopathy, cyanosis, clubbing,
edema
Hydration status adequate
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18. THYROID: Normal, no visible mass or pulsation.
BREAST: B/L symmetrical in size, nipple areolar complex
normal, no localized rise in temperature, non tender, with no
palpable mass or lesion
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19. PER ABDOMINAL EXAMINATION
INSPECTION
Abdomen is flat
Umbilicus centrally placed and inverted
All quadrants move equally with respiration.
No scar marks, visible, pulsations, venous prominences
, swelling.
Hernial orifice seems to be intact
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20. PER ABDOMINAL EXAMINATION
PALPATION
On superficial palpation: No localized rise in temperature
,non tender
On deep palpation: No organomegaly
PERCUSSION
Tympanic note heard
AUSCULTATION
Bowel sounds heard (6/min)
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21. SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
 Bilateral vesicular breath sounds heard
CARDIOVASCULAR SYSTEM
First and second heart sound heard
No murmurs
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22. VULVA,PERINEALAND PERIANAL
AREA
 Normal distribution of pubic hairs
 No active bleeding from external genitalia
 No sign of inflammation or visible swelling, vulval varicosities, no
discharge
 No any perineal tear
 No presence of ulcer or pigmentation
 No bleeding or ulceration in perianal area
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23. PER SPECULUM EXAMINATION
Bleeding (-)
Mild discharge(+), whitish coloured, non foul smelling,
mucoid discharge (+)
Cervix: Smooth, no erosions
Reddish, fleshy mass, around 2*1 cm arising from cervical
os seen at 10 o’clock position
Lateral vaginal wall rugosities intact
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24. Bimanual Examination
Uterus 6 weeks size
 Mobile
Non tender
 Smooth surface
 Regular margin
 Bilateral fornices free
Cervical motion tenderness (-)
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25. Provisional diagnosis
Abnormal uterine bleeding (polyp) with
anemia
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26. DIFFERENTIAL DIAGNOSIS
LOCAL TRAUMA
FIBROID
ADENOMYOSIS
ENDOMETRIOSIS
COAGULOPATHY
OVULATORY DISORDER
PREGNANCY
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27. INVESTIGATION
Hematology Reference Range
•Hb – 10.5 g/dl 11-16 g/dl
•Platelets – 192000 cells/mm^3 1,50,00-3,00,000
•Blood group – “O” Positive
Serology
•HIV Spot – Non reactive
•HBsAg Spot – Non reactive
•VDRL – Non reactive
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28. RENAL FUNCTION TEST
•Serum Urea – 22 mg/dl 15-40 mg/dl
•Serum Creatinine – 0.9 mg/dl 0.6-1.5 mg/dl
• Sodium – 141 mg/dl 135-150 mmol/L
•Potassium – 3.9 mg/dl 3.5-5.3 mmol/L
PT -14 Control Time :13sec
INR – 1.0 INR : 1.6
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29. URINE R/E
•Color : YELLOW
•Transparency : CLEAR
•pH :ACIDIC
•Protein : NIL
•Sugar: NIL
•Pus cells : 0-2 /HPF
•RBC : NIL
•Epithelial cells : 1-3 /HPF
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30. Biochemistry report Reference range
•TSH : 1.47 0.55 - 4.78 mIU/L
•RBS – 120 mg/dl 70-100 mg/dl
•Urine pregnancy test : NEGATIVE
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31. ULTRASOUND OF ABDOMEN AND
PELVIS
• Uterus anteverted and measures approx. 10.9*5.0*6.7 Cms
• Normal in outline
• Homogenous in echotexture
• Endometrial echo complex is normal ( 7.6mm)
• Empty uterine cavity
• No significant free fluid collection
• Upper abdominal scan normal
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32. FINAL DIAGNOSIS
ABNORMAL UTERINE BLEEDING
(POLYP) WITH MILD ANEMIA
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33. PLAN
CERVICAL POLYPECTOMY WITH
ENDOMETRIAL BIOPSY
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34. OT FINDINGS
Cervix was visualized and polyp was noted
Polyp was avulsed
Anterior lip of cervix was held by vulsellum and sent for
HPE
IPAS cannula 4 was inserted, 5 cc of endometrial tissue
was taken and send for histopathological examination.
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35. MEDICATION
INJECTION CEFTRIAXONE 1 GM IV BD
INJECTION METRON 500 MG IV TDS
INJECTION PANTOP 40MG IV BD
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36. Diagnosis at discharge
Cervical polypectomy with endometrial biopsy
for abnormal uterine bleeding (polyp)
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37. Medication on discharge
• TAB CEFIXIME 200MG PO BD FOR 7 DAYS
• TAB METRONIDAZOLE 400MG PO TDS FOR 7 DAYS
• TAB PANTOPRAZOLE 40MG BD FOR 7 DAYS
• TAB FLEXON 1 TAB PO SOS
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38. SUMMARY
45 Years female P2L2A1 , presented with excessive
bleeding during menstruation with irregular cycle and
pain abdomen for 3 months with examination
findings of pallor on lower palpebral conjunctiva and
cervical polyp, admitted with diagnosis of Abnormal
Uterine bleeding (Polyp), with mild anemia. Cervical
polypectomy with endometrial biopsy
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39. Thank You !!! 
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