Abdominal Pain and Vaginal
Bleeding
HPI:
C.L. is a 46 yo F G5P4 who presents with 5 days of increased
vaginal bleeding and lower abdominal pain. The bleeding was
spotty at first, but has increased over the past few days and is
heavier than her normal period. She has passed some nickelsized blood clots. The lower abdominal pain started yesterday, is
suprapubic and dull in nature without radiation. She has 6/10
pain in the ED.
Her LMP was 2 weeks ago, was heavier than usual and lasted 4
days, but her cycle was normal before that. She denies any
other vaginal discharge, dyspareunia or dysuria. She uses ‘the
patch’ faithfully and has annual OB/GYN exams. She had some
‘weird cells’ on her last visit, but further tests were normal. She
has a remote history of Chlamydia, but was ‘treated for that a
long time ago’ and is in a stable monogamous relationship. C.L.
feels safe at home and denies any smoking history, but does
consume alcohol regularly ‘to unwind’.
What else would you like to know?
Current Medications: Ortho Evra, Vitamin D and
Calcium, occasional Tylenol
PMHx: G5P4, 1 spontaneous abortion at 12 weeks,
remote history of Chlamydia, childhood asthma
SocHx: non smoking, drinks alcohol regularly, no other
drug use
FamHx: no bleeding disorders or h/o ovarian, cervical
or breast cancers.
Mother – 65, living has CAD and HTN
Father – deceased from MI at 62yo
Siblings – 2 sisters, 30 and 35 who are healthy
ROS:
Gen: mild fatigue for the last 2 months
HEENT: occasional headaches, no visual changes
CV: denies chest pain, palpitations
Resp: denies dyspnea, cough
GI: no N/V/D, lower abdominal pain for 2 days, normal
stools, no changes to appetite
GU: vaginal bleeding x5 days, LMP 2 weeks ago, heavier
than normal, denies dysuria, hematuria, dyspareunia,
other vaginal discharge
Skin: no rashes
Neuro: denies syncope, weakness
Physical Exam:
Vitals: 110/65, 95, T=37.5, 98% on RA
Gen: well-appearing, obese female in NAD
HEENT: PERRL, EOMI, NCAT, no cervical lymphadenopathy, normal
thyroid
CV: RRR, no r/m/g, good peripheral perfusion
Pulm: CTA, regular respirations, equal expansion
Abd: mild suprapubic tenderness, non-distended, normal bowel sounds
GU: normal external genitalia, moderate blood in vaginal vault coming
from normal appearing multiparous cervical os, no clots, negative for
cervical motion and adnexal tenderness, enlarged uterus with a smooth,
rounded mass about 4 cm in diameter is palpated just below the uterine
fundus, slightly left of midline
Skin: normal, no rashes or lesions
Neuro: normal sensation, no focal deficits
Ext: normal strength and ROM
What is your Differential Diagnosis?
DDx:
•
•
•
•
•
•
•
•
•
Adenomyosis
Pregnancy
Ovarian tumor
Endometrial polyp
Endometrial cancer
Leiomyosarcoma
Menorrhagia
Dysmenorrhea
Perimenopausal
What Labs/Imaging would you order next?
Labs:
-UPT
-UA
-CBC
-Iron studies
-PT/INR, PTT
-Wet prep
-GC RNA
Imaging:
- Abdominal Ultrasound
- Pelvic Ultrasound
Lab results:
-UPT - negative
-Wet prep - normal
-GC RNA sent – results
pending (will take 1-2 days
for results)
Urinalysis
Specimen
Mid stream
Color
Yellow
Appearance
Clear
SpGr
1.010
pH
6.5
Protein
None
Glucose
Negative
Ketones
Negative
Blood
1+
WBCs/hpf
3
RBCs/hpf
5
Bacteria
None
Epithelial Cells/hpf
None
Granular casts
None
Waxy casts
None
Lab Results (continued):
-CBC
9.5
8.0
300
-PT: 11
-PTT: 30 seconds
MCV 68
MCHC 33
-Iron studies
Iron: 33
TIBC: 475
Ferritin: 19
Transferrin Saturation: 7
Abdominal Ultrasound Imaging result:
What is your diagnosis?
Leiomyoma
Leiomyomas (Uterine Fibroids)
• Common cause of lower abdominal pain
• Estrogen-dependent, uterine smooth muscle
tumors
• About 50% of women have leiomyomas, but only
50% are symptomatic
• They may be submucosal, intramural or subserosal
• They may outgrow their blood supply and
degenerate or if on a pedicle can twist and become
torsed.
• Leiomyomas make the uterus asymmetric and
enlarged and may be palpated during the physical
exam
Management:
Initially
-pain control
-transfusion if Hgb <9
-patient will need iron supplementation
Long term
-GnRH agonists may reduce the volume of leiomyomas, but is a
temporary result and reserved for pre-surgical use
- Uterine embolization – IVR releases polyvinyl alcohol particles
into uterine arteries causing fibroids to undergo ischemic
necrosis. This procedure has unknown effects on future child
bearing.
- Myomectomy – removal of the uterine fibroids, for those who
may still wish to bear children, however, fibroids may recur.
- Hysterectomy – removal of uterus
Types of Leiomyomas
http://www.med.unc.edu/obgyn/specialty-services/advanced-laparoscopy-pelvic-pain/uncfibroid-center
Leiomyoma - Gross Pathology
Leiomyoma -Microscopic
Normal myometrium is at the left, and the neoplasm is well-differentiated so that the
leiomyoma at the right hardly appears different. Bundles of smooth muscle are interlacing in the
tumor mass.
http://library.med.utah.edu/WebPath/FEMHTML/FEM030.html
Abdominal Ultrasound - Leiomyoma
MRI - Leiomyoma
References:
1.
2.
3.
4.
Lukens TW. Chapter 100. Abdominal and Pelvic Pain in the Nonpregnant Female.
In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds.
Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York:
McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6363195.
Accessed December 2, 2012.
Zeiger Roni F, McGraw-Hill's Diagnosaurus 2.0:
http://www.accessmedicine.com/diag.aspx.
Evans P. Chapter 33. Vaginal Bleeding. In: South-Paul JE, Matheny SC, Lewis EL,
eds. CURRENT Diagnosis & Treatment in Family Medicine. 3rd ed. New York:
McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=8154144.
Accessed December 2, 2012.
Shu-Huei Shen, Fiona Fennessy, Nathan McDannold, Ferenc Jolesz, Clare Tempany,
Image-Guided Thermal Therapy of Uterine Fibroids, Seminars in Ultrasound, CT
and MRI, Volume 30, Issue 2, April 2009, Pages 91-104, ISSN 0887-2171,
10.1053/j.sult.2008.12.002.
(http://www.sciencedirect.com/science/article/pii/S0887217108001194)