A NEW APPROACH TO MANAGE ABN U BLEEDING,C S D,NOT YET CLASSIFIED CATEGORY.VAGINAL LIGATION UTERINE ARTERY

1. Management of Not yet Classified
group of Abnormal uterine bleeding
(AUB-N(
Prof . Refaat I El-Sheemy
Professor of Obstetrics and Gynecology
Faculty of medicine – Al-Azhar University (Damietta(

3. • To describe the new nomenclatures
• Why Changes …. What Changed.?
• Is it could be applied.?
• Is Still we need more researches
forUnexplained causes ………
• Is there any new treatment apart from
hysterectomy??
.

4. • Mostly .PUBLISHED IN
AM J and those under
publication.
• In Auther website.
Researches at
our
department
in DOMYAT.

5. • Mostly .PUBLISHED IN
AM J and those under
publication.
• In Auther s website.
• www. Prof_shimy8m.com
Researches at
our
department
in DOMYAT.

8. History
Long time use of non-standardized,
ambiguous terminology.
English language terminologies
with Greek or Latin roots are poorly
defined and create ambiguity in
meaning and usage.
.

10. In 2005, interest group of 35 experts did
historical review, and recommendations
made for uniform terminology
published.
They recommended discarding the
confusing terminology, and replace
with simple descriptive terms that
could be understood by patients and
translated into most languages

12. DISCARDED TERMINOLOGY CONT.
Dysfunctional uterine bleeding
Functional uterine bleeding
Metropathica hemorrhagica .
Amenorrhea – retained term

13. Accepted Abbreviations Describing
Menstrual Symptoms
AUB…….. Abnormal uterine
bleeding
HMB……. Heavy menstrual
bleeding
HPMB.. Heavy and prolonged
menstrual bleeding
IMB… Intermenstrual

17. The PALM-COEIN Classification System for
Causes of AUB
PALM – visually objective structural criteria
COEI – unrelated to structural anomalies
N – entities not yet classified
Coagulopathy (AUB-C)
Polyps (AUB-P) ,Ovulatory disorders (AUB-O)
Adenomyosis (AUB-A) ,Endometrial (AUB-E)
Leiomyoma (AUB-L) ,Iatrogenic (AUB-I)
Malignancy (AUB-M) ,Not yet Classified

18. Components of the PALM-COEIN
Classification System
Polyps (AUB-P)
Polyps are categorized as either present or absent.
Diagnosed by TVUS, saline infusion sonography or
hysteroscopy.
Adenomyosis (AUB-A)
Diagnosed by ultrasound or MRI.

19. Leiomyomas (AUB-L)
Higher association of AUB with
submucosal lesions, compared to
intramural and subserosal leiomyomas.
Malignancy (AUB-M)
Includes both premalignant and
malignant lesions.

22. Coagulopathies (AUB-C)
13% of women with HMB have a disorder of
hemostasis that may be overlooked during the
differential diagnosis.
Ovulatory Dysfunction (AUB-O)
Usually associated with endocrinopathies, such as
polycyctic ovary syndrome or hypothyroidism. Evaluate
for ovulatory dysfunction.
Endometrial Causes (AUB-E)
Most patients in this category will have regular cycles,
normal ovulation and no definable cause of AUB.

23. Iatrogenic (AUB-I)
Causes include IUD, exogenous gonadal steroids and other
systemic agents that affect blood coagulation or ovulation.
Bleeding from anticoagulation therapy is listed under AUB-C
rather than AUB-I.
Not Yet Classified (AUB-N)
Reserved for entities that are poorly defined and/or not well
examined, such as :
Arteriovenous malformation
Myometrial hypertrophy.
Chronic endometritis.,,,,,,,and new that will be discovered ,

24. NOT YET CLASSIFIED (AUB-N)
With more evidence, entities that
discovered will be placed into a new or
existing class
Accordingly our ongoing studies
supported that CS scar defect should
be included among a new category of
FIGO 2012.

25. Myometrial Hyperplasia
(AUB.N(

27. LOCALIZED MYOMETRIAL H

28. ADENO(AUB.A)

29. ADENO(AUB.A)

31. Myometrial hyperplasia
(MMH) is a structural variation with irregular
zones of hypercellularity and increased
nucleus/cell ratio that appears in adolescence,
can progress during the childbearing years,
and can sometimes cause grossly detectable
bulges on pathologic examination. MMH can
be inframucosal, intramural (microscopic), or
subserosal.myometrial hyperplasia which may
be localized or diffuse

32. AUB.N AV FISTULA
Cong or Acquired
Any uterine manipulation can cause it.
Acquired AVMs are small arteriovenous fistulas
between intramural arterial branches and the
myometrial venous plexus. They appear as a
vascular tangle
5%

33. The classical presentation of uterine AVMs is often
one of severe uterine bleeding with no obvious cause.
The onset and cessation of bleeding are abrupt,
comparable to the opening and closing of a faucet

36. AUB N – UAV FISTULA

37. ULTRASONOGRAPHY OF UTERUS IN TRANSVERSE AXIS
WITH COLOR DOPPLER FLOW SHOWING PULSATILE
VENOUS FLOW INSIDE THE ENDOMETRIAL CAVITY.

39. 05/15/13
CS SCAR DEFECT (NICHE OR ISTHMOCELE)

40. HYSTERECTOMY SPECIMENS ISTHMOCELE

43. 05/15/13
MEASUREMENT OF THE NICHE
{Intact myom
Remaining myom >
Niche
C…..=remaining myometrium…D=Intact myometrium
endometrium

44. RESIDUAL MYOMETRIUM
MEASURE

45. 05/15/13
BIODEVIN1961
<Isthmocele

46. 05/15/13
Transabdominal sonography in 1982
(Burge et al., 1982)
niche

47. 05/15/13
WITH TRANSVAGINAL ULTRASOUND
IN 1990 (CHEN ET AL., 1990)

48. 05/15/13
3D
1 2
22C S Scar defects one is high,oth
is
low
Endocervical canal
3D one woman in this study two CS scars ARE seen

49. 05/15/13
HYSTEROSCOPY AND MRI
isthmocele

50. Ultrasound scans showing the most common niche shapes: the
semicircular niche (a), triangular niche (b), droplet-shaped niche (c)
and inclusion cysts (d(.
a b
c d

51. Scar defect in the sagittal plane

54. WHAT ADDED BY
FIGO2012
In management

56. )ADOPTED FROM: SCHORGE ET AL., 2010(.

57. Previously………..Unexplained

59. FIRST STUDY:
HISTOPATHOLOGY OF SYMPTOMATIC SCAR DEFECT

60. Lymphocytic infiltration of uterine scar (arrow) of aLymphocytic infiltration of uterine scar (arrow) of a
case of previous C.Scase of previous C.S
(hematoxylin-eosin stain, original magnification ×200).(hematoxylin-eosin stain, original magnification ×200).
ALSheemy et al 2014 Am J life Sc

61. Focal adenomyosis of uterine scar of a case ofFocal adenomyosis of uterine scar of a case of
previous C.Sprevious C.S
(hematoxylin-eosin stain, original magnification ×200).(hematoxylin-eosin stain, original magnification ×200).
ALSheemy et al 2014 Am J life Sc

62. Localized
Adenomyosis
Beside the niche

63. frequency of scar defect in studied cases, it was reported
in 22 cases out of 100 cases (22.0%(.
78%78%

64. Relation between scar defect cases and
clinical symptoms
Clinical symptoms Number of cases %
Abnormal uterine
bleeding
9 40%
Dysmenorrhea 5 22%
Chronic pelvic pain 4 18%
Infertility 7 31%

65. Screening for all women with CS scar is
mandatory to correlate the scar pattern
with the clinical presentation as abnormal
uterine bleeding pelvic pain dysmenorrhea
infertility and dyspareunia.
Recommendation of the first study

66. The Second study

67. 05/15/13

68. The aim of the study was to evaluate
a new operation of vaginal uterine
artery ligation in treatment of
abnormal bleeding related to the
scar and this was presented in 17th
Ain shams conference 2013
Aim
AlSheemy et al 2015

72. 2014
Idea of Vaginal ligation of the uterine
artery is to ligate the artery in continuity
close to the cervix, the cervical tissues are
included in the suture so the edges of the
CS scar defect is included in the sutures
laterally. Ligation Of the uterine artery
has its own benefit of controlling
menorrhagia
Idea of Vaginal ligation
of the uterine artery
Alsheemy & Samia E 2014 MD thesis

73. >
Site of vaginal ligation of U
A,at 2 levels.

74. MATERIALS
using Voluson 730
Pro.( USA) or
Medison 8000SA
live (Korea),
ultrasound
machine,
equipped with a
7–9-MHz
transvaginal
probe.

76. Previously………..Unexplained

77. n
No lesion Uterine fibroid less than 3cm
Uterine fibroid morethan3 cm Uterine fibroid with adenomyosis
Diffuse adenomyosis C scar defect
Arterio venous fistula
C S S D
No Lesion
M (Large)
SmallM
M+A
A VF

78. Steps of vaginal bilateral uterine
artery ligation operation:
1- The posterior vaginal wall was retracted with a Sims speculum, and the
anterior lip of the cervix was held with a vulsellum.

79. 2-. Transverse incision was made at the
cervicovaginal junction. The bladder is separated
from the cx and reflected upward for 3 cm.

80. 3-. A curved rounded needle was passed from the
lateral to the medial side, and the uterine artery
along with some myometrial tissue was ligated with
1–0 non absorbable suture.

84. 4- Cystoscopic examination was performed to confirm bilateral ureteric patency

85. 2014
4

86. 2014
3

87. 2014
5

88. 2014
7

89. • The operative time without cystoscopy
was 22 minutes.
• The mean hospital stay time was 3hours.
Results

90. Serial post operative follow up every 2 months
then applied for 3 years to record the response to
the operation as regard bleeding cycles regularity
degree of pain with TVS;CD , niche
width,pregnancy rate with its outcome and
uterine volume measurement.
90

91. Scar defect width (mm) Mean SD Minimum Maximum
Preoperative
7.2 2.2 5 9
3 months postoperative 5.2 1.8 4.2 6.3
6 months postoperative 4.3 1.7 4 7
12 months postoperative 3.0 1.2 0 5
Paired comparison Preoperative vs 3 months; t = 12.15, p < 0.001*
Preoperative vs 12 months; t= 16.31, p <0.001*
Pre and postoperative
evaluation of Cesarean scar defect width (mm) by ultrasonography

92. 0
1
2
3
4
5
6
7
8
9
10
Mean Minimum Maximum
Preoperative 3 months postoperative
6 months postoperative 12 months postoperative
Pre and postoperative evaluation of
Cesarean scar defect width by ultrasonography

94. 0
50
100
150
200
250
300
350
400
450
500
Mean Minimum Maximum
Preoperative 3 months postoperative
6 months postoperative 12 months postoperative
pre and postoperative uterine volume during follow up period

95. After 3 month VBUAL..
..Niche dimension decreased

96. 05/15/13
After 6 months of vaginal repair

97. 2014
Pregnancy after vaginal repair

98. Get pregnant Satisfied Not satisfied Complicated
satisfied
Not satisfied
Pregnant
1222
of infertile
12%
88%

99. • VBUAL and Vaginal repair are simple safe,
minimally invasive and not time consuming
and can be applied before deciding
histerectomy specially in young women
• Clinical and sonographic results of both are
promising specially as regard patient
satisfaction.
• Our primary results indicate that
unremarkable pregnancy can occur with good
pregnancy outcome .
99
Conclusion of three studies

100. ACKNOWLEDGM
ENTSAll staff members in department
,my family members..
dr.reffat45@gmail.com

101. www.prof-shimy.8m.com

102. Not yet Classified?

103. Thank youdr.reffat45@gmail.com

104. 4- Design large future controlled studies that will
include large sample size for more validation and
confirmation of the results.
5- Design further studies to compare VBUAL
operation with other methods of operative uterine
artery occlusion as laparoscopic BUAL, Doppler
-assisted trans-vaginal uterine artery clamping
as treatment options for refractory menorrhagia

105. Discarded Terminology
 Menorrhagia,
 Hypermenorrhea.
 Hypomenorrhea
 Menometrorrhagia
 Polymenorrhea ,Polymenorrhagia
 Oligomenorrhea

106. DISCARDED TERMINOLOGY CONT.
Dysfunctional uterine bleeding
Functional uterine bleeding
Metropathica hemorrhagica
Amenorrhea – retained term

107. TRANSVAGINAL COLOR DOPPLER SONOGRAPHY OF AN ENDOMETRIAL
POLYP. COLOR FLOW FEATURE IDENTIFIES A SINGLE FEEDER VESSEL, WHICH IS
CHARACTERISTIC OF POLYPS (ADOPTED FROM: SCHORGE ET AL., 2010).

109. MYOMET HYPERTROPHY
(DIFFUSE)

111. ETIOLOGY OF HEAVY MENSTRUAL
BLEEDING
(R. Hurskainen et al., 2007)
Systemic causes Local uterine causes Treatment–related
causes
Idiopathic causes
Hypothyroidism Polyp
Poor execution of
anticoagulant therapy
Increased fibrinolysis
Diabetes Myoma Copper IUD
Overproduction of
prostacyclin or
prostaglandin E2
Chronic cardiac or renal
disease
Lack of thromboxane
Chronic hepatic disease Adenomyosis
Lack of prostaglandin
F2alfa
Systemic lupus
erythematosus
Infection Lack of endothelin
Obesity Carcinoma
Disorder in vasoactive
peptide hormones
Coagulation disorders
pelvic arteriovenous
malformation
Delayed endometrial
regeneration
Disorder in
endometrial
angiogenesis
overproduction of
nitrogen oxide

112. Transvaginal sonography showed localized
posterior wall lesion (localized adeno myosis ).
(AUB-A)
P0 A1 L0 M0 - C0 O0 E0 I0 N0

113. Uterine arteriovenous malformation (AVM)
is a rare but potentially life-threatening source of
bleeding. Dubreil and Loubat described the first clinical
case involving a uterine AVM in 1926.
The true incidence is unknown, but with increased use of
ultrasound to evaluate abnormal vaginal bleeding,
O’Brien et al propose a rough predicted incidence of
4.5% .AVMs have been reported in patients from 18 to
72 years old but only rarely in nulliparous women .

114. AVMs are characterized by multiple
communications of varying sizes between arteries
and veins in the same vicinity. Uterine AVMs have
been classified as congenital or acquired
Congenital uterine AVMs arise from an abnormality
in the embryological development of primitive
vascular structures, resulting in multiple abnormal
communications between arteries and veins.
Acquired uterine AVMs are usually traumatic,
resulting from prior dilation and curettage (D&C),
uterine surgery, or direct uterine trauma,

115. 2014
2

116. Item
N
Studied
Decrease in the mean uterine volume. 18cases 35. 5%
Mean niche diameters. 8 cases 70.1%
Peak systolic velocity inintramyometrialarteries 18cases 32cm/s
Pregnancy in infertile group 12cases 75%
*R I: Resistance Index.
Results Of Sonographic And Color Doppler
Study During The First Year Of Operation.
Results
117

117. Levo Norgesterol Intrauterine System
The Levonorgesterol Intrauterine System (ius;
Mirena) Provides Another Great Option For Aub
Therapy. This New Ius Produces A Dramatic
Decline In Menstrual Blood Loss By 65% To 98%
Within 12 Months Of Use.
There Is Little Systemic
Absorption Of Progesterone
)Hurskainen et al., 2001) and ( Bilian, 2002(.

119. ENDOMETRIAL
DYSFUNCTION (AUB-E)
A DIAGNOSIS OF EXCLUSION
PATIENT HAS PREDICTABLE AND CYCLIC BLEEDING TYPICAL OF OVULATORY CYCLES
MECHANISM: A PRIMARY DISORDER OF THE ENDOMETRIUM
DISTURBANCES OF METABOLIC MOLECULAR PATHWAYS – TISSUEFIBRINOLYTIC ACTIVITY, PROSTAGLANDINS, INFLAMMATORY AND VASOACTIVE MEDIATORS
NO

120. DIAGNOSIS OF(AVM)
Traditionally, uterine AVMs were diagnosed after
hysterectomy with histopathologic evidence of the
arteriovenous fistulas. (Fleming et al 1989).
Several imaging methods, such as Doppler
ultrasonography, computed tomography, magnetic
resonance imaging (MRI), and angiography, have been
employed to diagnose AVMs.
Angiography is the gold standard for diagnosis, whereas
Doppler ultrasonography and MRI are the modalities of
choice for the evaluation of a suspected AVM.
Ultrasonography and MRI can not only define

121. angiography is an invasive procedure, and should be
reserved for cases in which surgical intervention or
therapeutic embolization of the lesion is planned .
Gray-scale and color and duplex Doppler ultrasound
(US) and the magnetic resonance (MR) imaging are
noninvasive methods for diagnosis of uterine
arteriovenous malformations (AVMs) at gray-scale
US, uterine AVMs were nonspecific and manifested
as subtle myometrial in homogeneity, tubular spaces
within the myometrium, intramural uterine mass,
endometrial mass,