Topic map

1. Definitions and normal menstrual parameters (frequency, duration, regularity, volume)
2. FIGO terms: heavy menstrual bleeding (HMB), intermenstrual bleeding, acute vs chronic AUB
3. PALM-COEIN classification
   • Structural: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia
   • Non-structural: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified
4. AUB by age group: adolescent, reproductive, perimenopausal, postmenopausal
5. History, examination and investigations (pregnancy test, CBC, TSH, coagulation screen, TVS, saline sonography, hysteroscopy, endometrial biopsy)
6. Management
   • Medical: tranexamic acid, NSAIDs, combined oral contraceptives, progestins, LNG-IUS, GnRH analogues
   • Surgical: endometrial ablation, myomectomy, hysterectomy
   • Acute heavy bleeding: stabilisation and emergency treatment
7. Dysfunctional uterine bleeding (older term) and its pathophysiology

1. Definitions, incidence and aetiology (fetal chromosomal, maternal, uterine, immunological, infective, endocrine)
2. Classification: threatened, inevitable, incomplete, complete, missed, septic, recurrent
3. Clinical features and diagnosis for each type (ultrasound criteria, hCG)
4. Management: expectant, medical (mifepristone and misoprostol), surgical (suction evacuation), Rh immunoglobulin
5. Septic abortion and complications
6. Recurrent pregnancy loss: workup (APLA, karyotype, uterine anomalies, thrombophilia) and treatment
7. Cervical incompetence and cerclage
8. Medical Termination of Pregnancy (MTP) Act, and the link to ectopic and molar pregnancy

Overview

Topic map

1. Definitions and normal menstrual parameters (frequency, duration, regularity, volume)
2. FIGO terms: heavy menstrual bleeding (HMB), intermenstrual bleeding, acute vs chronic AUB
3. PALM-COEIN classification
   • Structural: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia
   • Non-structural: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified
4. AUB by age group: adolescent, reproductive, perimenopausal, postmenopausal
5. History, examination and investigations (pregnancy test, CBC, TSH, coagulation screen, TVS, saline sonography, hysteroscopy, endometrial biopsy)
6. Management
   • Medical: tranexamic acid, NSAIDs, combined oral contraceptives, progestins, LNG-IUS, GnRH analogues
   • Surgical: endometrial ablation, myomectomy, hysterectomy
   • Acute heavy bleeding: stabilisation and emergency treatment
7. Dysfunctional uterine bleeding (older term) and its pathophysiology

1. Definitions, incidence and aetiology (fetal chromosomal, maternal, uterine, immunological, infective, endocrine)
2. Classification: threatened, inevitable, incomplete, complete, missed, septic, recurrent
3. Clinical features and diagnosis for each type (ultrasound criteria, hCG)
4. Management: expectant, medical (mifepristone and misoprostol), surgical (suction evacuation), Rh immunoglobulin
5. Septic abortion and complications
6. Recurrent pregnancy loss: workup (APLA, karyotype, uterine anomalies, thrombophilia) and treatment
7. Cervical incompetence and cerclage
8. Medical Termination of Pregnancy (MTP) Act, and the link to ectopic and molar pregnancy

Overview

Notes for MBBS: Abnormal Uterine Bleeding (AUB) and Miscarriage

PART A: ABNORMAL UTERINE BLEEDING (AUB)

1. Definition and normal menstruation

• AUB is bleeding from the uterine corpus that is abnormal in regularity, volume, frequency or duration, in a non-pregnant woman. It is among the most common gynaecological complaints (Sabiston Textbook of Surgery).
• Normal parameters (FIGO 2011) [std]:

• Heavy menstrual bleeding (HMB) is the current term for what used to be called menorrhagia. It is excessive menstrual loss that interferes with a woman's physical, social, emotional or material quality of life (Goldman-Cecil). The older figure is more than 80 mL per cycle.
• Chronic AUB has been present for most of the last 6 months. Acute AUB is an episode heavy enough to need immediate intervention.
• The old terms menorrhagia, metrorrhagia, menometrorrhagia and dysfunctional uterine bleeding (DUB) have been replaced by the PALM-COEIN system (Sabiston).
• Postmenopausal bleeding is not part of PALM-COEIN. It is a separate diagnosis, and any bleeding after menopause is abnormal (Sabiston).

2. Physiology

• Follicular phase: estrogen thickens the endometrium. Ovulation happens mid-cycle.
• Luteal phase: the corpus luteum makes progesterone, which matures the lining.
• If implantation does not occur, the corpus luteum regresses and estrogen and progesterone fall. Menstruation follows about 14 days after ovulation (Rosen's, p. 1419).
• Normal menses is predictable and cyclic. It stops through vasoconstriction, platelet plugging, endometrial repair and estrogen-driven re-epithelialisation.

3. Classification: PALM-COEIN (FIGO 2011)

• Polyp: often causes intermenstrual bleeding. Diagnose on saline infusion sonography or hysteroscopy. Treat with hysteroscopic polypectomy.
• Adenomyosis: the uterus is globular and tender, with dysmenorrhoea and HMB. MRI or TVS shows a thickened junctional zone. Hysterectomy is definitive; the LNG-IUS helps.
• Leiomyoma: submucosal fibroids bleed the most. Treatment is myomectomy, uterine artery embolisation, ulipristal or GnRH analogue pre-treatment, or hysterectomy.
• Malignancy and hyperplasia: endometrial hyperplasia with or without atypia, endometrial cancer, and cervical or other cancers.
• Coagulopathy:
  • Von Willebrand disease is the most common. ITP and platelet disorders are also seen.
  • Suspect it if HMB has been present since menarche, there is a family history, there is bruising or epistaxis, or the woman is on anticoagulants (Sabiston; Goldman-Cecil).
• Ovulatory dysfunction:
  • The cause is anovulation, with estrogen acting unopposed by progesterone. The endometrium proliferates and sheds irregularly.
  • Causes: PCOS, hypothyroidism, hyperprolactinaemia, obesity, stress, extreme exercise, and menarche or perimenopause.
  • Anovulatory bleeding tends to be less frequent and unpredictable, whereas organic lesions tend to bleed more frequently (Goldman-Cecil).
• Endometrial: primary disorder of local haemostasis or endometritis. This is a diagnosis of exclusion in a woman with regular cycles.
• Iatrogenic: IUDs, hormonal contraceptives (breakthrough bleeding), anticoagulants, tamoxifen, and antipsychotics that raise prolactin.
• Not yet classified: includes arteriovenous malformation and caesarean scar defect.

• DUB is bleeding with no structural cause. The commonest cause is anovulation, most often at the extremes of reproductive life (Robbins).
• Less common anovulatory causes: prolactinoma, granulosa cell tumour, PCOS, and obesity or malnutrition. A luteal phase defect is another possible cause (Robbins).
• Histology in anovulatory bleeding shows proliferative or disordered proliferative endometrium or hyperplasia, with no secretory change.

4. Epidemiology and age patterns

• AUB affects roughly 10 to 30% of reproductive-age women. About 20% of cases are adolescent post-menarchal bleeding due to an immature hypothalamic-pituitary-ovarian axis. About 50% are perimenopausal (Goldman-Cecil).
• Adolescent: anovulation and coagulopathy. Always think of bleeding disorders.
• Reproductive age: pregnancy complications (threatened, incomplete or missed miscarriage, ectopic), fibroids, polyps, PCOS, contraceptive effects, adenomyosis.
• Perimenopause (over 40): anovulation, but exclude hyperplasia and cancer.
• Postmenopause: atrophy is the commonest cause (Sabiston). Exclude endometrial carcinoma, which accounts for about 10% [std].

5. Approach to a patient with AUB

• Cycle pattern, LMP, volume (clots, flooding, pads per hour, nocturnal soaking, anaemia symptoms).
• Intermenstrual or postcoital bleeding, pain, contraception, drug history.
• Thyroid symptoms, hirsutism, galactorrhoea, weight change.
• Bleeding history (epistaxis, easy bruising, postpartum or dental bleeding), family history, last cervical smear.

• General: pallor, BMI, signs of thyroid disease or PCOS, bruising. Check vitals for haemodynamic status.
• Abdominal mass.
• Speculum: cervical polyp or growth, source of bleeding.
• Bimanual: uterine size, tenderness, adnexal mass.

1. Urine or serum hCG first, to rule out pregnancy.
2. CBC (anaemia, platelets) and ferritin.
3. TSH and prolactin; consider androgens and FSH or LH.
4. Coagulation screen (PT, aPTT, vWF antigen and activity, factor VIII) when history suggests it.
5. Cervical cancer screening and STI screening.
6. Transvaginal ultrasound is the first-line imaging test. It shows fibroids, adenomyosis, polyps, endometrial thickness and ovarian cysts.
7. Saline infusion sonography or hysteroscopy for focal lesions such as polyps and submucosal fibroids.
8. Endometrial sampling (Pipelle). Indications (Sabiston):
   • Age 45 or older with AUB.
   • Under 45 with unopposed estrogen risk (obesity, PCOS), persistent AUB or failure of medical treatment.
   • A family history of cancer (Lynch syndrome).
9. MRI for adenomyosis or fibroid mapping.

6. Management

A. Acute heavy bleeding [std]

• Resuscitate: IV access, fluids and blood, correct anaemia and coagulopathy.
• Tranexamic acid 1 g IV or orally every 8 hours.
• High-dose hormones:
  • IV conjugated equine estrogen 25 mg every 4 to 6 hours for up to 24 hours.
  • Or a multi-dose combined oral contraceptive (COC) regimen.
  • Or high-dose oral progestin such as medroxyprogesterone or norethisterone.
• Surgical: Foley balloon tamponade, hysteroscopy with D&C, uterine artery embolisation, and hysterectomy as a last resort.

B. Chronic AUB: medical (Goldman-Cecil; standard teaching)

• Correct anaemia with iron.
• Vitamin K or desmopressin may be used for bleeding disorders such as vWD.

C. Surgical (Sabiston Table 120.4)

• Endometrial ablation: for HMB when fertility is complete and there is no cavity distortion or malignancy.
• Hysteroscopic polypectomy for polyps.
• Myomectomy (fertility-sparing), uterine artery embolisation, or hysterectomy for fibroids.
• Hysterectomy for adenomyosis, for definitive cure, or for malignancy or atypical hyperplasia.

D. Cause-directed

• Hyperplasia without atypia: progestins or LNG-IUS with 3 to 6 monthly biopsy surveillance. Atypical hyperplasia: hysterectomy.
• PCOS: lifestyle and weight loss, COC or cyclic progestins, metformin.
• Hypothyroidism or hyperprolactinaemia: treat the underlying condition.
• Coagulopathy: involve a haematologist; TXA, desmopressin or factor replacement.

7. Postmenopausal bleeding (PMB)

• Causes: atrophic endometrium or vaginitis (commonest), polyps, hormone therapy, hyperplasia, endometrial carcinoma, cervical cancer.
• Work-up: TVS for endometrial thickness (4 mm or less is reassuring [std]). If it is more than 4 mm, or bleeding persists or recurs, do endometrial biopsy or hysteroscopy with biopsy.

8. Quick revision points

1. Always exclude pregnancy first.
2. PALM = structural; COEIN = non-structural.
3. Adolescent AUB: anovulation or coagulopathy. Perimenopausal AUB: anovulation, but exclude cancer.
4. Endometrial biopsy is needed at age 45 or older or with risk factors.
5. First-line medical treatments are LNG-IUS and tranexamic acid.
6. Postmenopausal bleeding needs evaluation to exclude cancer.

PART B: MISCARRIAGE (SPONTANEOUS ABORTION)

1. Definitions

• Miscarriage is spontaneous termination of pregnancy before 20 weeks of gestation. A fetal death after 20 weeks, or a fetus over 500 g, is classed as a stillbirth or premature birth (Rosen's, p. 3347). The WHO cut-off is 22 weeks or 500 g, and indian exam answers usually cite 20 weeks (or up to 28 weeks in older texts).
• Early pregnancy loss (EPL): a non-viable intrauterine pregnancy within the first 12 weeks and 6 days. This is either an empty gestational sac, or a sac containing an embryo with no cardiac activity (Rosen's).
• Recurrent pregnancy loss (RPL): 3 or more consecutive losses (older definition). ASRM and ESHRE now accept 2 or more.

2. Epidemiology and risk factors (Rosen's, p. 3347)

• Miscarriage is the most common serious complication of pregnancy. About 10% of recognised pregnancies end in miscarriage, and 80% of these occur in the first trimester.
• Embryonic and fetal loss after implantation occurs in up to one-third of detectable pregnancies.
• Risk factors:
  • Advanced maternal age (about fivefold higher risk over 40 compared with age 25 to 29) and paternal age.
  • Previous miscarriage.
  • Smoking, alcohol and caffeine.
  • Poorly controlled diabetes and thyroid disease.
  • Obesity, or a very low BMI.
  • Uterine anomalies and fibroids.
  • Vaginal bleeding in the current pregnancy.
• In diabetes, miscarriage is higher in type 2 (RR 1.28), but not significantly in type 1, suggesting poorer pre-conception control in T2DM (Creasy & Resnik's Maternal-Fetal Medicine).
• About 25% of pregnant women bleed in early pregnancy, and up to 50% of those miscarry. If cardiac activity is seen on ultrasound, the miscarriage risk falls to 3 to 6% (Rosen's).

3. Aetiology

4. Clinical classification (Rosen's, p. 3347 to 3348)

• Rosen's regards "missed abortion" as an obsolete term. It prefers anembryonic gestation, first or second trimester fetal death, and delayed miscarriage.
• Diagnostic ultrasound criteria for non-viability [std]:
  • CRL 7 mm or more with no cardiac activity.
  • Mean sac diameter 25 mm or more with no embryo.
  • No embryo with heartbeat 2 weeks after a scan that showed a gestational sac without a yolk sac.
• β-hCG landmarks on TVS: the discriminatory zone is about 1000 to 2000 mIU/mL; the gestational sac is seen at about 5 weeks; the yolk sac at about 6 weeks; cardiac motion at about 6 to 7 weeks (Rosen's Table 173.1). In a viable early pregnancy, hCG roughly doubles every 48 hours [std].

5. Clinical evaluation

• Vital signs: pallor, tachycardia, hypotension, fever.
• Abdomen: tenderness or peritonism (think ectopic).
• Speculum: source and amount of bleeding, open or closed os, tissue at the os.
• Bimanual: uterine size and tenderness, adnexal mass or tenderness.
• Do not probe the cervix in second or third-trimester bleeding, as the placenta may be low (Rosen's).

6. Management

Threatened miscarriage

• Reassurance, and avoid heavy activity. Bed rest has no proven benefit.
• Check blood group; give anti-D to Rh-negative women [std].
• Progesterone: in women with early bleeding and one or more previous miscarriages, the PRISM trial showed benefit with micronised vaginal progesterone 400 mg twice daily, mostly in women with 3 or more prior losses [std].
• Follow-up scan if bleeding persists. Return if bleeding increases or fever develops.

Inevitable / incomplete / missed miscarriage

1. Expectant: wait 1 to 2 weeks for spontaneous passage in a stable woman with no signs of infection.
2. Medical:
   • Misoprostol 800 µg vaginally (or 600 µg orally or sublingually), sometimes after mifepristone 200 mg orally.
   • Counsel on bleeding (up to 2 weeks), cramps, and the need for a repeat scan or urine pregnancy test at about 3 weeks.
   • Mifepristone is an antiprogestogen that sensitises the uterus to prostaglandin. Misoprostol is a PGE1 analogue.
3. Surgical:
   • Suction evacuation or manual vacuum aspiration (MVA) under local or general anaesthesia.
   • Indicated in haemodynamic instability, heavy bleeding, infection, or retained products with failed medical treatment.
   • Risks: uterine perforation, cervical injury, infection, and Asherman syndrome.
   • Send tissue for histopathology.

Complete miscarriage

• Confirm on scan, and arrange follow-up. No evacuation is needed.

Septic abortion (usually unsafe or induced)

• Features: fever, rigors, foul vaginal discharge, tender uterus, and possible peritonitis or shock.
• Management:
  • Resuscitate and use broad-spectrum IV antibiotics covering aerobes, anaerobes and Clostridium (for example, a cephalosporin or ampicillin with gentamicin and metronidazole).
  • Evacuate the uterus promptly after antibiotics are started.
  • Give tetanus prophylaxis, and manage shock in the ICU.
• Complications: haemorrhage, endotoxic shock, DIC, renal failure, pelvic abscess, peritonitis, Asherman syndrome, and infertility.
• About 47,000 women die each year from unsafe abortion; legal abortion is generally safe (Berek & Novak's).

7. Recurrent pregnancy loss (RPL)

• Parental karyotype (translocations) and genetic testing of products of conception.
• Antiphospholipid antibodies: lupus anticoagulant, anticardiolipin and anti-beta-2-glycoprotein I, positive on two occasions at least 12 weeks apart.
• Uterine assessment: 3D ultrasound, HSG, saline sonography or hysteroscopy, for septum, fibroids and adhesions.
• Endocrine: TSH, glucose or HbA1c, prolactin.
• Thrombophilia screening in selected cases.

• APS: low-dose aspirin plus prophylactic LMWH from a positive pregnancy test. This is the main treatment with proven benefit.
• Septate uterus: hysteroscopic septum resection. Asherman syndrome: hysteroscopic adhesiolysis.
• Parental balanced translocation: genetic counselling, with the option of PGT.
• Thyroid disease and diabetes: optimise control before conception.
• Unexplained RPL: supportive care with early scans and reassurance (the prognosis is good; about 65 to 75% have a successful next pregnancy). Progesterone from early pregnancy may help in women with RPL and bleeding.

8. Cervical incompetence (insufficiency)

• Painless cervical dilatation in the second trimester, followed by loss of the pregnancy. Typical history: successive losses at progressively earlier or similar gestations, with painless membrane bulging.
• Causes: congenital, cervical trauma (cone biopsy, LEEP, forced dilatation, obstetric tears), and DES exposure.
• Diagnosis: history, plus TVS cervical length below 25 mm before 24 weeks [std].
• Treatment: cerclage
  • McDonald (purse-string at the cervico-vaginal junction), done at 12 to 14 weeks.
  • Shirodkar (submucosal suture).
  • Indications: history-indicated, ultrasound-indicated, or emergency (rescue) cerclage.
  • Remove at 36 to 37 weeks, earlier if labour or PPROM starts.
  • Contraindications: infection, active bleeding, advanced dilatation with prolapsed membranes in some cases, and uterine contractions.
• Vaginal progesterone is an alternative for a short cervix.

9. Complications of miscarriage

10. Legal point (India): MTP Act

• Medical Termination of Pregnancy Act, amended in 2021 [std]:
  • Up to 20 weeks: one registered medical practitioner.
  • 20 to 24 weeks: two practitioners, for specified categories (such as rape survivors, minors, disabled women or changes in marital status).
  • Beyond 24 weeks: only for substantial fetal abnormalities, decided by a Medical Board.
• Please confirm against current law in your own jurisdiction.

11. Quick revision

1. Miscarriage is loss before 20 weeks (WHO: 22 weeks or 500 g).
2. The most common cause is a chromosomal abnormality (about 50 to 60%).
3. Threatened: closed os. Inevitable: open os, no tissue passed. Incomplete: open os, tissue partly passed. Complete: all passed, closed os. Missed: dead fetus retained, closed os.
4. Always exclude ectopic pregnancy.
5. Management: expectant, medical (mifepristone and misoprostol) or surgical (MVA or suction).
6. Give anti-D to Rh-negative women.
7. RPL: test for APS, parental karyotype, and uterine anomalies. Treat APS with aspirin plus heparin.
8. Cervical incompetence: painless second trimester loss, treated with cerclage.
9. Septic abortion: antibiotics first, then evacuation.