Uterine Artery Embolization

Uterine Artery Embolization
Presentation by:Dennis DeSimone, MIV
Virginia College of Osteopathic Medicine

Background
* Menorrhagia is a very common gynecologic complaint
* The complaint of heavy menstrual bleeding accounts for nearly 30% of all hysterectomies
Uterine Fibroids - a source of significant uterine bleeding
* Surgical management has been the standard of treatment in menorrhagia due to organic causes
o Dilatation and curettage
o Transcervical resection of the endometrium
o Endometrial ablation
o Uterine balloon therapy
o HydroThermAblator
o Hysterectomy
* Modern gynecology dictates the trend toward conservative therapy
o Cost containment
o Patient’s desire to preserve their uterus
o Evidence that nearly 50% of uterine pathology findings from hysterectomies for menorrhagia are free of disease and histopathologic abnormalities.
* Uterine artery embolization
* A relatively new approach to treating fibroid tumors.

significant improvement
* Tumors shrink by 50%
* Uterus shrinks by 40%
* Main risks:
o Pain
o Secondary
amenorrhea

Uterine artery embolization
Before and after
Methods
Results
Conclusions

* UAE has a low MAJOR complication rate
* Hospital stay, time off from work, and time until resumption of normal activities for UAE patients is reduced
* Short term minor complications of the procedure include hematoma, pain, nausea
* UAE may be a reasonable alternative to hysterectomy
References

Uterine Artery Embolization.ppt

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Menstrual Disorders

Menstrual Disorders
Presentation by:Oguchi A. Nwosu M.D.
Assistant Profressor
Emory Family Medicine Dept.

Menstrual Cycle
Definitions
* Menorrhagia Excessive (>80ml) uterine bleeding Prolonged (>7days) regular
* DUB Abnormal Bleeding, no obvious organic cause usually anovulatory
* Oligomenorrhea Uterine bleeding occurring at intervals between 35 days and 6 months
* Amenorrhea No menses x at least 6 months

Metrorragia, Menometrorrhagia, Polymenorrhea
Ovulatory vs Anovulatory cycles
Oligo or Amenorrhea +/- Menorrhagia
DUB
-Defn: Excessively heavy, prolonged or frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic disease
-Diagnosis of exclusion
- Anovulatory
-Usually extremes of reproductive life and in pts with PCOS

DUB pathophysiology
* Disturbance in the HPO axis thus changes in length of menstrual cycle
* No progesterone withdrawal from an estrogen-primed endometrium
* Endometrium builds up with erratic bleeding as it breaks down.

DUB management
– sample endometrium
Usually followed by OCP or progestin
Menorrhagia

-Heavy vaginal bleeding that is not DUB
-Usually secondary to distortion of uterine cavity- heavy with or without prolongation (anatomic).
Uterus unable to contract down on open venous sinuses in the zona basalis
-Other causes organic, endocrinologic, hemostatic and iatrogenic
-Usually ovulatory

Menorrhagia, Management
sample endometrium
Other tests as INDICATED by HX and PE
Endometrial evaluation of menorrhagia
Endometrial Biopsy
Procedure of choice (detection and cost)
Menorrhagia, medical management
* NSAID’s, 1st line, 5 days, decrease prostaglandins
* Danazol, Androgen and prog. competitor , amenorrhea in 4-6 weeks, androgenic side effects
* OCP’s, esp. if contraception desired, up to 60% dec. supp. HP axis
* Continous OCP’s
* Oral continous progestins (day 5 to 26), most prescribed, antiestrogen, downregulates endormetrium
* Levonorgestrel IUD (Mirena), High satisfaction rate that approaches surgical techniques
* GnRH agonists, Inhibit FSH and LH release– hypogonadism, bone
* Conjugated estrogens for acute bleeding
* Other treatments as indicated e.g. DDAVP for coagulation defects

Menorrhagia, surgical management
Amenorrhea, physiologic causes
Primary Amenorrhea
-Vaginal agenesis
-Androgen insensitivity syndrome
-Turners syndrome
Amenorrhea, causes
Amenorrhea, management
Evaluation of Secondary Amenorrhea
Causes of Amenorrhea
Hyperprolactinemia
Antipsychotics
Antidepressants
Antihypertensives
Histamine H2 receptor blockers
Opiates, cocaine
Empty sella syndrome
Pituitary adenoma
Hypergonadotropic hypogonadism
Gonadal dysgenesis
Turner's syndrome*
Other*
Postmenopausal ovarian failure
Premature ovarian failure
Autoimmune
Chemotherapy
Galactosemia
Genetic
17-hydroxylase deficiency syndrome
Idiopathic
Mumps
Pelvic radiation
Hypogonadotropic hypogonadism
Anorexia or bulimia nervosa
Central nervous system tumor
Constitutional delay of growth and puberty*
Chronic illness
Chronic liver disease
Chronic renal insufficiency
Diabetes
Immunodeficiency
Inflammatory bowel disease
Thyroid disease
Severe depression or psychosocial stressors
Cranial radiation
Hypogonadotropic hypogonadism
Excessive exercise
Excessive weight loss or malnutrition
Hypothalamic or pituitary destruction
Kallmann syndrome*
Sheehan's syndrome
Normogonadotropic
Congenital
Androgen insensitivity syndrome*
Müllerian agenesis*
Hyperandrogenic anovulation
Acromegaly
Androgen-secreting tumor (ovarian or adrenal)
Cushing's disease
Exogenous androgens
Nonclassic congenital adrenal hyperplasia
Polycystic ovary syndrome
Thyroid disease
Outflow tract obstruction
Asherman's syndrome
Cervical stenosis
Imperforate hymen*
Transverse vaginal septum*
Other
Pregnancy
Thyroid disease
*-Causes of primary amenorrhea only.

Abnormal Menstruation
Here’s what you need to remember!!
* Always R/O pregnancy, check pap
* Try to differentiate anovulatory from ovulatory bleeding
* Good history and physical is key( this applies to amenorrhea as well)
* Do a focused work up based on your H & P rather than a random set of studies
* In amenorrhea, where no indication of cause based on H & P, follow the stepwise algorithm for diagnosis
* Know the INDICATIONS for endometrial sampling
References

Menstrual Disorders.ppt

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Respiratory Distress in Newborn

Respiratory Distress in Newborn
Presentation lecture by:Leena Mane and Rhea Mane


Case study:

* A male infant weighing 3000 g (6 lb 10 oz) is born at 36 weeks' gestation, with normal Apgar scores and an unremarkable initial examination. At 48 hours of age he is noted to have dusky episodes while feeding, and does not feed well. On repeat examination the child is tachypneic, with subcostal retractions. Lung sounds are clear and there is no heart murmur.

What Next ?
Tests & labs…

* Pulse oximetry on room air is 82%.
* Arterial blood gases on 100% oxygen show a pCO2 of 26 mm Hg (N 27-40), a pO2 of 66 mm Hg (N 83-108),
* blood pH of 7.50 mg/dL (N 7.35-7.45), and a base excess of -2 mmol/L (N -10 to -2).
* Hemoglobin- 22.0g/dl (N13.0- 20.0)
* Hematocrit- 66 % (N 42- 66)
* WBC- 19,000/mm3 (N9000-30,000)
* Blood cultures- Pending.
* Chest X-ray- Increased vascular marking, Large thymus.


Most likely diagnosis
* 1- Transient tachypnea of newborn
* 2- Congenital heart disease
* 3- Hyaline membrane disease
* 4- Neonatal sepsis
* 5- Hyperviscosity syndrome

Transient Tachypnea of Newborn
* Most common cause of respiratory distress.
* 40% cases.
* Residual fluid in fetal lung tissues.
* Risk factors- maternal asthma, c- section, male sex, macrosomia, maternal diabetes

TTN

* Tachypnea immediately after birth or within two hours, with other predictable signs of respiratory distress.
* Symptoms can last few hours to two days.
* Chest radiography shows diffuse parenchymal infiltrates, a “ wet silhouette” around heart, or intralobar fluid accumulation

X-ray
Fluid in the fissure
Respiratory Distress Syndrome
RDS
Meconium Aspiration Syndrome
Infections
Other causes-
Congenital Heart disease
Hyperoxia Test
Treatment
Transient Tachypnea of Newborn
Respiratory distress Syndrome
Meconium Aspiration Syndrome
Algorithm
Evaluation
Treatment

Respiratory Distress in Newborn.ppt

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