High-risk factors for massive haemorrhage in medical abortion patients with missed miscarriage.

BACKGROUND: Recently, the incidence of missed miscarriage has gradually increased, and medical abortion is a common method to terminate a pregnancy. In the process of medical abortion, massive vaginal bleeding takes place, leading to emergency surgical haemostasis. Emergency surgery may produce infection and organ damage. Our study aimed to investigate the high-risk factors for massive haemorrhage during a medical abortion. METHODS: A total of 1062 missed miscarriage patients who underwent medical abortion participated in this retrospective study. According to the amount of bleeding, the patients were divided into a massive haemorrhage group and a control group. By comparing the general conditions of the two groups, such as fertility history, uterine surgery history, uterine fibroids, etc., the high-risk factors for massive haemorrhage during medical abortion were identified. RESULTS: Relative to the control group, the massive haemorrhage group exhibited a higher proportion of patients with a previous artificial abortion (51.9% vs. 38.1%, P = 0.001). Additionally, the massive haemorrhage group had a lower percentage of first-time pregnant women (32.1% vs. 40.4%) and a higher proportion of women with shorter pregnancy intervals (44.9% vs. 33.1%, P = 0.03). Furthermore, there were notable differences between the two groups regarding maximum fibroid size, the duration of amenorrhea, and gestational week (P < 0.05). CONCLUSION: In this study, we determined that a history of artificial abortion and an amenorrhea duration of > 11 weeks represented high-risk factors for massive vaginal bleeding during medical abortion in missed miscarriage patients.

Risk factors for atypical hyperplasia or endometrial cancer in premenopausal women aged ≤ 45 years with abnormal uterine bleeding.

OBJECTIVES: To assess the prevalence and risk factors for atypical hyperplasia (AH) or endometrial cancer (EC) in premenopausal women aged ≤ 45 years with abnormal uterine bleeding (AUB). METHODS: This was a retrospective study of premenopausal patients aged 18 to 45 years who underwent hysteroscopy, dilation and curettage, or pipelle sampling at Inha University Hospital, South Korea, from 2014 to 2023. We used multivariable logistic regression analysis to identify risk factors and calculate the predicted probabilities of AH or EC with various combinations of these factors. RESULTS: Of 821 patients included in the study, 6.0 % were diagnosed with AH or EC. The significant risk factors identified were nulliparity (odds ratio (OR): 4.75, 95 % confidence interval (CI): 2.11-10.70), PCOS (OR: 2.72, 95 % CI: 1.34-5.52), and multiple polyps (OR: 2.33, 95 % CI: 1.23-4.41). The predicted probabilities of developing AH or EC increased with the number of risk factors present, ranging from 1 % to 33.6 %. CONCLUSIONS: The predicted probabilities within combinations of risk factors may be considered helpful in making better clinical decisions regarding endometrial sampling for patients ≤ 45 years with AUB.

COVID-19 vaccination and postmenopausal bleeding: a retrospective cohort study.

OBJECTIVE: COVID-19 vaccination has been related to menstrual irregularities; however, the effect on postmenopausal women is unknown. The aim of this study was to analyze the prevalence of postmenopausal bleeding (PMB) after COVID-19 vaccination. METHODS: A retrospective study was conducted in the Department of Gynecology in Hospital del Mar. Consecutive postmenopausal women with data available and endometrial biopsy were included between February 2021 and January 2022. Patients were stratified between COVID-19 vaccinated and unvaccinated groups. PMB after 30 days from last vaccine dose was considered unrelated to vaccine. Endometrial pathology diagnoses were stratified into benign or malignant. Univariable and multivariable of regression analysis on variables potentially associated with PMB was performed. RESULTS: A total of 381 patients were included, 91 in the vaccinated group and 290 in the unvaccinated group. Prevalence of PMB in the vaccinated group was 75.8% compared to 59.0% in the unvaccinated group (p < 0.005). No increase in endometrial malignant pathology was observed among the vaccinated group (p = 0.189). Multivariable analysis that correlates factors associated with PMB suggests COVID-19 vaccine and malignant endometrial biopsy as independent risk variables. CONCLUSIONS: A higher prevalence of PMB was associated with COVID-19 vaccine. Endometrial histological results showed no association with COVID-19 vaccination, but endometrial biopsy should be performed for PMB.

Determinants of feto-maternal outcomes of antepartum hemorrhage among women who gave birth in Awi zone public hospitals, Ethiopia. A case-control study.

BACKGROUND: Antepartum hemorrhage continues to be a major cause of maternal and perinatal morbidity and mortality in developing countries including Ethiopia and it complicates 2-5% of all pregnancies with an increased rate of maternal and perinatal morbidity and even mortality. Despite many activities, still, poor fetomaternal outcomes of antepartum hemorrhage are still there. Moreover, studies around the current study area emphasize the magnitude and associated factors for antepartum hemorrhage rather than its feto-maternal outcomes. Thus, there is a need to identify the determinants associated with the fetomaternal outcomes of antepartum hemorrhage to guide midwives and obstetricians in the early diagnosis and treatment. METHOD: An institution-based case-control study was conducted in four-year delivery charts diagnosed with antepartum hemorrhage from April 2, 2022, to May 12, 2022, at Awi Zone public hospitals. To see the association between dependent and independent variables logistic regression model along with a 95% confidence interval (CI) and a p-value of <0.05 were used. RESULT: No antenatal care follow-up (AOR: 2.5, 95% CI 1.49-4.2), rural residence (AOR: 1.706, 95%CI 1.09-2.66), delay to seek care >12 hours (AOR: 2.57, 95% CI: 1.57-4.23) and advanced maternal age (AOR: 3.43, 95% CI 1.784-6.59) were significant factors associated with feto-maternal outcomes of antepartum Hemorrhage. CONCLUSION: This study revealed that rural residence, delay in seeking the care of more than 12 hours, not having antenatal care follow up and advanced maternal age were significant factors associated with feto-maternal outcomes of Antepartum hemorrhage. RECOMMENDATION: The findings of our study suggest the need for health education about the importance of antenatal care follow-up which is the ideal entry point for health promotion and early detection of complications, especially for rural residents.

Fetomaternal Outcome in Antepartum Hemorrhage After 34 Weeks of Gestation.

BACKGROUND: Antepartum hemorrhage is defined as any bleeding from or into the genital tract during pregnancy, after the period of viability until delivery of the fetus. APH complicates 2-5% of pregnancies and is a primary cause of perinatal and maternal mortality globally. Aim of this study is to evaluate maternal and perinatal outcome in patients with APH at a tertiary care hospital. METHODS: The present study was a cross sectional study conducted in Obstetrics and Gynaecology department of Paropakar Maternity and Women's Hospital, during a period of 5 months from December 2022 to April 2023. 50 cases of APH were enrolled with gestational age ≥ 34 weeks of gestation. RESULTS: Incidence of APH after 34 weeks of gestation was 0.51%. The most common type of APH was abruption placenta (44%) followed by placenta previa (32%) and undetermined (24%). The age range of 26 to 30 years old accounted for the highest number of APH patients i.e., 21(42%). In placenta previa, 75% and in abruption placenta 63.64% were multigravida. APH was presented mostly between 37-40 weeks. Around 26% of the patients had anemia at the time of admission. Most common mode of delivery was cesarean section (82%). Most common maternal complications were PPH (40%), blood transfusion (28%), DIC (4%), cesarean hysterectomy (4%). Low birth weight and preterm were the most common causes of fetal complications. Maternal mortality was 2% and perinatal mortality was 18% overall. CONCLUSIONS: APH is primary cause of maternal and perinatal morbidity and mortality. In our study, an abruption placenta was the most frequent cause of APH. Cesarean section was the most commonly used mode of delivery. PPH with blood transfusion was the most prevalent maternal complication, while fetal complications included low birth weight and preterm..

Association of caesarean scar defect with risk of abnormal uterine bleeding: results from meta-analysis.

OBJECTIVE: To investigate the association between caesarean scar defects and abnormal uterine bleeding through systematic literature review. METHODS: PubMed, Web of Science, Cochrane Library and Embase databases were searched based on PRISMA 2020 to include studies exploring abnormal uterine bleeding in women with caesarean scar defects. The combined relative risk (RR) of uterine bleeding, combined prevalence of abnormal uterine bleeding and combined RR of intermenstrual uterine bleeding were calculated using a fixed- or random-effects model. RESULTS: Ten studies involving 1,183 women with caesarean scar defects met the inclusion criteria for this study. Compared with women without caesarean scar defects, those with caesarean scar defects had a higher risk of abnormal uterine bleeding (RR: 3.22, 95% CI: 1.83-5.66) and intermenstrual bleeding (RR: 2.93, 95% CI: 1.91-4.50). The prevalence of abnormal uterine bleeding was approximately 0.46 (95% CI: 0.27-0.64), and across populations, women with a previous caesarean section who had undergone imaging specifically for gynaecological disease had a significantly higher prevalence of abnormal uterine bleeding (0.77, 95% CI: 0.65-0.89) than those with at least one caesarean Sect. (0.25, 95% CI: 0.10-0.39). CONCLUSION: A significant association was observed between caesarean scar defects and abnormal uterine bleeding, with the former being a risk factor for the latter. However, previous studies have differed in the definition of caesarean scar defects and abnormal uterine bleeding, and more high-quality studies are needed to further investigate the relevant definitions and study results in the future.

Abnormal uterine bleeding and its associated factors among reproductive-age women who visit the gynecology ward in Dilla University General Hospital, Southern Ethiopia, 2022.

BACKGROUND: Abnormal uterine bleeding, a frequent gynecological problem among women of reproductive age, significantly affects their health and quality of life. Despite its problem, research on its extent and contributing factors in Ethiopia is scarce. Hence, this study is designed to determine the magnitude and factors associated with abnormal uterine bleeding among women visiting Dilla University General Hospital, Dilla, Ethiopia. METHODS: A cross-sectional study design was conducted with 380 women of reproductive age at Dilla University General Hospital. A systematic sampling method was employed to select the participants for the study. A structured interview administered questionnaire and checklist were used to collect the data. Stata V.14 software was used for cleaning, coding, ensuring completeness and accuracy, and further analysis. Bivariate and multivariable logistic regression analyses were used. Finally, the variables that have a p-value of < 0.05 were considered statistically significant. RESULTS: In this study, the magnitude of abnormal uterine bleeding was 24.21% (95% CI, 20.14-28.79). History of sexually transmitted disease [AOR = 1.44, 95% CI: (1.33, 4.75)], history of anemia [AOR = 3.92, 95% CI: (1.20, 12.74)]., history of alcohol consumption [AOR = 2.49, 95% CI: (1.22, 5.06)], and perceived stress level [AOR = 1.30, 95% CI: (1.15, 1.69)] were found to be significantly associated with abnormal uterine bleeding. CONCLUSIONS: The magnitude of abnormal uterine bleeding was 24.2% in the study setting. Factors such as a history of sexually transmitted disease, anemia, alcohol consumption, and perceived stress level were identified as significant risk factors for abnormal uterine bleeding. Addressing these factors is crucial for management. Further research and interventions targeting these risks are needed to enhance health outcomes. The study provides valuable insights for future interventions.

Regional practice variation in hysterectomy and the implementation of less invasive surgical procedures: A register-based study in the Netherlands.

INTRODUCTION: Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource-intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice. MATERIAL AND METHODS: We completed a register-based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case-mix adjustment. Crude and case-mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions. RESULTS: Overall, 14 186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (ß = 0.11; P = 0.21) and therapeutic hysteroscopy rates (ß = 0.14; P = 0.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (ß = 0.10; P = 0.34) and negatively associated with both embolization rates (ß = -0.08; P = 0.08) and myomectomy rates (ß = -0.03; P = 0.82). CONCLUSIONS: Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association.

Prevalence of Lower Urinary Tract Symptoms in Women Planning to Undergo Hysterectomy for Uterine Leiomyoma and Abnormal Uterine Bleeding.

Introduction: Leiomyomas are associated with lower urinary tract symptoms (LUTS), but more specific characterization of their impact on LUTS is needed. Methods: This is a retrospective cohort study of 202 participants (101 per group) who underwent hysterectomy for leiomyomas versus abnormal uterine bleeding nonclassified (AUB-N) from July 2015 to May 2019. Baseline demographics, leiomyoma characteristics, and presence of baseline LUTS were collected. The main objective was to compare the prevalence of LUTS between these two groups. Secondary objectives were to analyze the association between leiomyoma characteristics and the prevalence of LUTS. Results: There was no difference in baseline prevalence of LUTS between the hysterectomy for leiomyoma versus AUB-N groups (42.6% vs. 45.5%, p = 0.67). When examining the entire study cohort of participants, irrespective of hysterectomy indication, leiomyoma size >6 cm was associated with an increased prevalence of LUTS when compared with leiomyoma <6 cm (64.9% vs. 40.4%, p = 0.02), and specifically difficulty passing urine (p = 0.02), nocturia (p = 0.04), and urinary frequency (p = 0.04). When controlling for age, body mass index, parity, chronic pelvic pain, and diabetes, leiomyomas >6 cm remained significantly associated with the presence of LUTS (odds ratio 3.1, 95% confidence interval = 1.2-8.3) when compared with leiomyoma <6 cm. Presence of >1 leiomyoma was associated with urinary frequency (67.9% vs. 32.1%, p = 0.02) when compared with ≤1 leiomyoma. Anterior location and uterine volume were not associated with a difference in LUTS. Conclusion: LUTS are prevalent in those planning hysterectomy for leiomyoma and AUB-N. Leiomyomas >6 cm are associated with the presence of LUTS. Future studies should evaluate change in LUTS following hysterectomy for leiomyomas.

The Incidence of Cervical Intraepithelial Neoplasia or Cervical Cancer in Women Referred With Postcoital Bleeding.

OBJECTIVES: The incidence of cervical cancer among patients with postcoital bleeding (PCB) was the primary objective of this study. Furthermore, the proportion of cervical intraepithelial neoplasia requiring treatment and the correlation between PCB and the presence of high-risk human papillomavirus (HPV) was determined. Lastly, the study aimed to identify risk factors among the referred women. METHODS: A retrospective cohort study was conducted at a university hospital in Denmark between January 1, 2017 and December 31, 2019. Women referred with PCB were identified with the ICD diagnosis codes "DN930 Postcoital and contact bleeding" and "DN930B Contact bleeding." Demographic and paraclinical data were extracted from the journals and the supportive systems: Patoweb and the Danish Microbiology Database. RESULTS: A total of 789 women were included in this study, with only 0.25% ( n = 2) diagnosed with cervical cancer and 2.5% ( n = 20) diagnosed with cervical intraepithelial neoplasia II-III and adenocarcinoma in situ. Human papillomavirus testing was only conducted in a minority of cases, and a low incidence of high-risk human papilloma virus was detected in the 22 cases, n = 5. CONCLUSIONS: A very low incidence of cervical cancer and high-grade cervical intraepithelial neoplasia reported among women referred with PCB. Prognostic factors as body mass index, smoking, and HPV vaccination status may predict the risk of cervical cancer. Selection criteria like primary testing for hrHPV and cytology as cotests before referral to colposcopy may reduce the number of unnecessary colposcopies.

Rate and risk factors of inadequate endometrial tissues after endometrial sampling among Bhutanese women at the national referral hospital of Bhutan: a cross-sectional study.

INTRODUCTION: Women presenting with abnormal uterine bleeding needs careful and thorough assessment including ultrasound examination of endometrium and histopathological assessment of the endometrial tissues. The objective of this cross-sectional study was to determine the rate and the factors associated with inadequate endometrial tissues after endometrial sampling using MedGyn® pipette among Bhutanese women at the colposcopy clinic, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Bhutan. METHODS: This cross-sectional study was conducted at the colposcopy clinic, JDWNRH, Thimphu between October, 2021 and March, 2022. Women included in this study underwent endometrial sampling using MedGyn® pipette without anesthesia as an office procedure. Data were collected using an interviewer-administered questionnaire and results extracted into a structured pro forma. The histopathology reports were extracted from the Department of Pathology and Laboratory Medicine, JDWNRH using the unique Bhutanese citizenship identity card number of the study participants. RESULTS: Inadequate endometrial tissues were noted in 27% (33 out of 122 cases). Among 89 patients with an adequate endometrial tissue, histologic results were normal in 30 (33.7%), benign pathology in 22 (24.7%), atrophy in 10 (8.2%), and hyperplasia in 27 (30.3%). In a univariate analysis, menopausal state (OR 1.6, 95% CI 0.708-3.765), overweight and obese (OR 1.6 95% CI 0.640-3.945), unemployed (OR 1.7, 95% CI 0.674-1.140), nulliparous (OR 1.7, 95% CI 0.183-15.816), primipara (OR 5.1, 95% CI 0.635-40.905) and use of hormonal contraception (OR 2.1, 95% CI 0.449-10.049) were associated with increased risk of inadequate endometrial tissues. On multivariate regression analysis, nulliparity (OR 1.1, 95% CI 0.101-12.061), overweight and obesity (OR 1.4, 95% CI 0.490-3.917), use of hormonal contraceptives (OR 2.2, 95% CI 0.347-13.889), and junior surgeons (OR 1.1, 95%CI 0.463-2.443) were found to be associated with inadequate endometrial tissues. However, the above associations were not statistically significant (p > 0.05). CONCLUSION: The rate of inadequate endometrial tissue following endometrial sampling using MedGyn® pipette was 27.0%. Factors associated with an increased risk of inadequate endometrial tissue after endometrial sampling were menopausal state, overweight and obese, unemployed, nulliparous, primipara and use of hormonal contraception.

Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men.

PURPOSE: While it is common for menstrual cycles to cease within the initial 6 months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition. METHODS: In this case-control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6 months. RESULTS: A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019). CONCLUSION: Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.

Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females.

BACKGROUND: Adolescent heavy menstrual bleeding(HMB), menorrhagia or abnormal uterine bleeding commonly occur in adolescent women. The differential diagnosis can be challenging. The pneumonic: PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified), is commonly used but it does not stratify as to the likelihood of a disorder. We have sought to develop a probability-based differential diagnosis for Adolescent HMB, menorrhagia or abnormal uterine bleeding. METHODS: A comprehensive literature search was conducted using PubMed, EMBASE, and SCOPUS databases. Case series describing adolescents from 10-19 years of age with HMB, menorrhagia or abnormal uterine bleeding was acceptable if: more than 10 patients were included; editorials, case reports, and secondary sources such as review articles, or book chapters were excluded. No language filter was used, but an English abstract was required. The etiology of HMB, menorrhagia or abnormal uterine bleeding, and the country of origin was extracted from articles that met inclusion criteria. Cumulative rate estimates were determined by Bayesian probability modeling. RESULTS: Seventeen full text articles were reviewed in detail; 2,770 patients were included. The most frequent causes of HMB were Ovarian Uterine Disorders (23.7%; 95% CredI 22-25.5%), Coagulation Disorders (19.4%; 95% CredI 17.8-21.1%), and Platelet Disorders (6.23%; 95% CredI 5.27-7.27%) with 45.9% (95% CredI 43.8-47.%9) of the cases of indeterminate origin. CONCLUSIONS: The leading causes of HMB in healthy adolescent females were varied. The sub-analysis identified distinct etiologies, suggesting that multiple factors must be considered in the evaluation of HMB. While PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) provides us with a comprehensive picture of the possible causes of HMB in females, this systematic review assigns probabilities to the etiologies of HMB in adolescent females, providing physicians with a more focused and efficient pathway to diagnosis.

Postmenopausal bleeding after COVID-19 vaccination.

BACKGROUND: There is a growing literature base regarding menstrual changes following COVID-19 vaccination among premenopausal people. However, relatively little is known about uterine bleeding in postmenopausal people following COVID-19 vaccination. OBJECTIVE: This study aimed to examine trends in incident postmenopausal bleeding diagnoses over time before and after COVID-19 vaccine introduction, and to describe cases of new-onset postmenopausal bleeding after COVID-19 vaccination. STUDY DESIGN: For postmenopausal bleeding incidence calculations, monthly population-level cohorts consisted of female Kaiser Permanente Northwest members aged ≥45 years. Those diagnosed with incident postmenopausal bleeding in the electronic medical record were included in monthly numerators. Members with preexisting postmenopausal bleeding or abnormal uterine bleeding, or who were at increased risk of bleeding due to other health conditions, were excluded from monthly calculations. We used segmented regression analysis to estimate changes in the incidence of postmenopausal bleeding diagnoses from 2018 through 2021 in Kaiser Permanente Northwest members meeting the inclusion criteria, stratified by COVID-19 vaccination status in 2021. In addition, we identified all members with ≥1 COVID-19 vaccination between December 14, 2020 and August 14, 2021, who had an incident postmenopausal bleeding diagnosis within 60 days of vaccination. COVID-19 vaccination, diagnostic procedures, and presumed bleeding etiology were assessed through chart review and described. A temporal scan statistic was run on all cases without clear bleeding etiology. RESULTS: In a population of 75,530 to 82,693 individuals per month, there was no statistically significant difference in the rate of incident postmenopausal bleeding diagnoses before and after COVID-19 vaccine introduction (P=.59). A total of 104 individuals had incident postmenopausal bleeding diagnosed within 60 days following COVID-19 vaccination; 76% of cases (79/104) were confirmed as postvaccination postmenopausal bleeding after chart review. Median time from vaccination to bleeding onset was 21 days (range: 2-54 days). Among the 56 postmenopausal bleeding cases with a provider-attributed etiology, the common causes of bleeding were uterine or cervical lesions (50% [28/56]), hormone replacement therapy (13% [7/56]), and proliferative endometrium (13% [7/56]). Among the 23 cases without a clear etiology, there was no statistically significant clustering of postmenopausal bleeding onset following vaccination. CONCLUSION: Within this integrated health system, introduction of COVID-19 vaccines was not associated with an increase in incident postmenopausal bleeding diagnoses. Diagnosis of postmenopausal bleeding in the 60 days following receipt of a COVID-19 vaccination was rare.

Abnormal uterine bleeding in reproductive age: a comparative analysis between the five Brazilian geographic regions.

OBJECTIVE: This study aimed to comparatively evaluate the presence of abnormal uterine bleeding and associated factors among women from the five official Brazilian geographic regions. METHODS: This is a cross-sectional, population-based, multicenter study of reproductive-age women from the five regions of Brazil. All participants answered questionnaires containing personal and socioeconomic data and information on uterine bleeding (self-perception and objective data). RESULTS: A total of 1,761 Brazilian women were included, 724 from the Southeast, 408 from the Northeast, 221 from the South, 213 from the North, and 195 from the Central-West. Considering women's self-perception, the prevalence of abnormal uterine bleeding was 37.56% in the North region, 39.46% in the Northeast, 21.54% in the Central-West, 29.56% in the Southeast, and 25.34% in the South (p<0.001). Abnormal uterine bleeding was more prevalent in the North and Northeast, where women had lower purchasing power, became pregnant more often, and were the only ones financially responsible for supporting the family more often (p<0.001). The menstrual cycle lasted <24 days in less than 20% of the women in all regions (p=NS). Among these, approximately 8 out of 10 women had never undergone treatment in four out of the five regions evaluated. More than half of the evaluated women reported a worsening of their quality of life during bleeding. CONCLUSION: The prevalence of abnormal uterine bleeding in Brazilian women was higher in the North and Northeast, followed by the Southeast, South, and Central-West regions. There was a worsening of quality of life during menstruation regardless of the woman's self-perception of abnormal uterine bleeding. Such results can direct the actions of health managers toward a better approach to abnormal bleeding.

Presentation trends, characteristics and outcomes for women with early pregnancy bleeding in the emergency department: A 10-year data linkage study.

BACKGROUND: Women present to the emergency department (ED) with pregnancy complications including bleeding. They seek investigations, treatment and clear discharge and referral pathways. AIMS: The aim was to identify trends, characteristics, ED care and discharge pathways for women who present to the ED with early pregnancy bleeding. METHODS: Retrospective data (from 2011 to 2020) were extracted from a regional health district's databank. Data were processed, and deterministic linking was used to produce a final data set. Descriptive statistics were used to identify trends and characteristics. Linear and logistic regression models were used to identify factors that influence health service use, outcomes and discharge pathways. RESULTS: Over the 10 years, there have been almost 15 000 presentations to the ED for early pregnancy bleeding, from approximately 10 000 women, 0.97% of all ED presentations. The frequency of presentations increased by 19.6% over the study period. The average age of women who presented to the ED was 29.1 years, which increased from 28.5 years (2011) to 29.3 (2020). The median length of stay was less than 4 h, and most women were treated and discharged from the ED. One-third of presentations received neither ultrasound nor pathology, but health service costs increased by 330% from 2014 to 2020. CONCLUSIONS: Maternal age is increasing, as is the frequency of ED presentations for early pregnancy bleeding, and both factors increase demands on the ED. Findings from this study may inform strategies to improve current care models and improve quality and safety practices within the ED.

Transfusion and hematologic indices in cases of stillbirth due to placental abruption.

BACKGROUND: Stillbirth because of placental abruption is often associated with maternal hemorrhage and coagulopathy. OBJECTIVE: This study aimed to describe blood product requirements, hematologic indices, and the overall clinical picture of patients experiencing abruption demise. STUDY DESIGN: This retrospective cohort included patients with abruption demise at an urban hospital from 2010 to 2020. Outcome data from patients who delivered stillborn infants ≥500 g or with gestational age of ≥24 weeks were included. Abruption was a clinical diagnosis made by a multidisciplinary stillbirth review committee. The overall number and type of blood products given were analyzed. Patients with a stillbirth who required blood transfusion were compared with those that did not. In addition, the hematologic indices of these 2 populations were analyzed and compared with one another. Finally, the overall clinical characteristics of the 2 populations were analyzed. The analysis of data included chi-square, t test, and logistic and negative binomial regression models. RESULTS: Of 128,252 deliveries, 615 patients (0.48%) experienced a stillbirth, with 76 cases (12%) caused by abruption. Of note, 42 patients (55.2%) required blood transfusion; all received either packed red blood cells or whole blood with a median 3.5 units (2.0-5.5) received. The total units ranged from 1 to 59, with 12 of 42 patients (29%) requiring ≥10 units. Maternal age, gestational age, and mode of delivery were not different, with most (61/76 [80%]) delivering vaginally. Hematocrit level on arrival (odds ratio, 0.80; 95% confidence interval, 0.68-0.91; P=.002) and vaginal bleeding on arrival (odds ratio, 3.73; 95% confidence interval, 1.15-13.40; P=.033) were associated with blood transfusion, as was a diagnosis of preeclampsia (odds ratio, 8.40; 95% confidence interval, 2.49-33.41; P=.001). Those that required a blood transfusion often presented with lower hematologic indices and were more likely to develop disseminated intravascular coagulation (28% vs 0%; P<.001). CONCLUSION: Most patients experiencing stillbirth because of abruption required blood transfusion, with almost 1 in 3 of those patients consuming ≥10 units of blood products. Hematocrit level on arrival, vaginal bleeding, and preeclampsia were all predictors of the need for blood transfusion. Those requiring blood transfusion were more likely to develop disseminated intravascular coagulation. Blood transfusion should be prioritized when abruption demise is suspected.

Abnormal uterine bleeding in anticoagulated patients by drug class: outcomes and management.

BACKGROUND: Although abnormal uterine bleeding is a known adverse effect of anticoagulant drugs, true rates have not been widely studied. Society-backed recommendations and guidelines do not yet exist for prevention and management of abnormal uterine bleeding among anticoagulated patients. OBJECTIVE: This study aimed to describe the incidence of new-onset abnormal uterine bleeding among patients receiving therapeutic anticoagulation by anticoagulant class, and to evaluate gynecologic treatment patterns. STUDY DESIGN: We conducted an institutional review board-waived retrospective chart review of female patients aged 18 to 55 years and prescribed therapeutic anticoagulants, including vitamin-K antagonists, low-molecular-weight heparins, and direct oral anticoagulants, in an urban hospital network from January 2015 through January 2020. We excluded patients with antecedent abnormal uterine bleeding and menopause. Associations between abnormal uterine bleeding, anticoagulant class, and other covariates were evaluated with Pearson chi-square and analysis-of-variance tests. The primary outcome, abnormal uterine bleeding odds by anticoagulant class, was modeled with logistic regression. Age, antiplatelet therapy, body mass index, and race were included in our multivariable model. Secondary outcomes included emergency department visits and treatment patterns. RESULTS: Of the 2479 patients who met the inclusion criteria, 645 were diagnosed with abnormal uterine bleeding after initiating therapeutic anticoagulation. After adjusting for age, race, body mass index, and concurrent use of antiplatelet therapy, those receiving all 3 classes of anticoagulants had higher odds of experiencing abnormal uterine bleeding (adjusted odds ratio, 2.63; confidence interval, 1.70-4.08; P<.001), whereas those taking only direct oral anticoagulants had the lowest odds (adjusted odds ratio, 0.70; confidence interval, 0.51-0.97; P=.032), with vitamin-K antagonists as the reference group. Race other than White was associated with higher odds of abnormal uterine bleeding, as was lower age. The most common hormone therapies used among patients with abnormal uterine bleeding were levonorgestrel intrauterine devices (7.6%; 49/645) and oral progestins (7.6%; 49/645). Sixty-eight patients (10.5%; 68/645) had an emergency department visit for abnormal uterine bleeding; 29.5% (190/645) of patients received a blood transfusion; 12.2% (79/645) began any pharmacologic therapy for bleeding; and 18.8% (121/645) underwent any gynecologic procedure. CONCLUSION: Abnormal uterine bleeding occurs frequently among patients on therapeutic anticoagulation. Incidence in this sample varied considerably by anticoagulant class and race; use of single-agent direct oral anticoagulation carried the lowest risk. Important sequelae such as bleeding-related emergency department visits, blood transfusions, and gynecologic procedures were common. Balancing bleeding and clotting risk in patients on therapeutic anticoagulation requires a nuanced approach and should involve collaborative management between hematologists and gynecologists.

Quantifying the risk of ectopic pregnancy with a transient diagnosis of pregnancy of unknown location.

OBJECTIVE: To quantify the risk of ectopic pregnancy among a transient diagnosis of pregnancy of unknown location (PUL). METHODS: Retrospective cohort study between August 2016 and November 2020. The final cohort included 244 patients with 255 PULs who presented with vaginal bleeding and/or abdominal pain, positive serum quantitative ß-human chorionic gonadotropin, and negative transvaginal ultrasound, with a subsequent definitive diagnosis. Two-way analysis of variance was used with significance set at P < 0.050. Bonferroni-corrected significance values were used in post hoc analysis. Multinominal logistic regression was used to predict adjusted risk for pregnancy outcome. RESULTS: Definitive diagnosis consisted of 101 (39%) intrauterine pregnancies, 33 (13%) ectopic pregnancies, and 121 (48%) resolved PULs or resolved/treated persisting PULs. A total 68% of the PULs subsequently became nonviable. Vaginal bleeding was associated with increased risk of nonuterine pregnancies. CONCLUSION: A total of 13% of PULs were subsequently diagnosed as ectopic pregnancies, which is higher than the 2% to 3% risk of an ectopic pregnancy in the general reproductive population. A total of 68% of PULs were subsequently nonviable, which is higher than the 31% early pregnancy loss rate in the general reproductive population. This study quantitatively confirms that a transient diagnosis of a PUL increases the odds for ectopic pregnancy and early pregnancy loss.