Hematometra Is a Disease That Prevents Normal Blood Flow
Franjic S
Published on: 2024-05-10
Abstract
Hematometra is a violation of the natural mechanism of blood removal from the uterus, due to which it begins to accumulate. In gynecology, this disease is rare. This pathological condition usually occurs after uterine scraping or childbirth. Difficulty in the outflow of blood from this organ is due to inadequate contraction, and also due to blockage of the cervical canal by polyps or remnants of the placenta.
Keywords
Hematometra; Abnormalities; Pain; Ultrasound; HealthIntroduction
Hematometra is a collection of blood in the body (cavity) of the uterus, resulting from the obstruction of the normal outflow tract [1]. This obstruction may result from congenital abnormalities, acquired cervical stenosis, iatrogenesis (dilation and curettage, endometrial ablation), or obstruction by neoplasia. Early reproductive and postmenopausal age most common.
Pathogenesis
Obstruction or atresia of the uterine outflow tract [1] (congenital malformation; most common are imperforate hymen and transverse vaginal septum, acquired causes; cervical stenosis from senile atrophy of the endocervix and endometrium, scarring by synechiae, scarring after surgery, endometrial ablation, radiation, cryocautery, electrocautery, neoplasia).
Symptoms
- Asymptomatic (especially in postmenopausal women) [1]
- Uterine enlargement (often soft and slightly tender)
- Dysmenorrhea, abnormal bleeding, amenorrhea and infertility in premenopausal women
- Cyclic abdominal pain
Diagnostic Approach
- Endocervical cancer [1]
- Pyometra
- Leiomyomata
- Ovarian neoplasia
- Cervical cancer, endometrial cancer, tubo-ovarian abscess, and endometriosis
Abnormalities
A properly functioning outflow tract (i.e., an obvious uterus, cervix, and vagina) may be an essential component for typical menstrual stream [2]. Anatomic anomalies at any level of the surge tract can meddled with ordinary menstrual stream and frequently result in amenorrhea. For illustration, uterine or cervical innate basic anomalies can cause obstacle and make menstrual stream incomprehensible or anomalous. Once in a while, sections of the Muellerian tube may come up short to create, coming about in anomalies such as imperforate hymen, lack of a vaginal opening, slips within the coherence of the vaginal canal, or an missing uterus, cervix, uterine cavity, or endometrium. Obstacles of menses may lead to excruciating distention due to a menstrual blood collection such as hematometra (blood within the uterus), hematocolpos (vagina), or hemoperitoneum (peritoneum). Affected women are genotypically and phenotypically typical females with working ovaries. Such variations from the norm are exceptional, but in women whose mothers were given diethylstilbestrol (DES) amid pregnancy ordinarily between the long time of 1938 and 1971. Women with a history of numerous cervical strategies such as dilation and curettage (D & C) or noteworthy endometrial contaminations are at hazard for scarring that will cause surge tract irregular uterine bleeding.
In case a woman presents with amenorrhea with no history of infection or injury and her pelvic examination and bimanual examination are ordinary, at that point an anomaly of the outpouring tract isn't likely.
Cyclic Pain
Cyclic pelvic pain taking after endometrial removal can be related to a central hematometra, a cornual hematometra, post-ablation tubal sterilization syndrome (PATSS) or endometriosis [3].
The diagnosis of PATSS can be difficult. Hematosalpinx may be unmistakable within the proximal tubal stump on the off chance that ultrasound imaging ponders are performed amid a woman's menses. Between menstrual cycles, in any case, the hematosalpinx may reduce essentially or may reabsorb inside and out and may not be unmistakable. T2-weighted MRI imaging can identify blood sequestered within the cornual and tubal locales. The determination ought to be suspected at whatever point a quiet with an earlier history of a tubal ligation presents after removal with new-onset one-sided or bilateral pelvic pain. The differential diagnosis will also incorporate a central or corneal hematometra. Central hematometra can happen when there's occlusion of the lower uterine section or cervix, with persistent working endometrium proximally. Cornual hematometra can happen when the proximal tubal sections and the distal endometrial canal are impeded, with persistence of working cornual endometrium. Adenomyosis can also be capable for post-ablation cyclic torment. More once in a while, adnexal abscesses or endometriosis have been detailed taking after removal, probably due to either break or fistula arrangement of the proximal tubal stump.
The first patients presenting with PATSS were overseen with endeavors at calming the surge hindrance hysteroscopically, or by laparoscopic salpingectomy. Be that as it may, numerous treatment failures have been detailed for salpingectomy, driving most specialists to suggest hysterectomy with salpingectomy as the treatment of choice. Separating PATSS from central hematometra is critical, since the last mentioned can be overseen by dilatation of the cervix and drainage of the bloodcollection. Separation from other substances showing as cyclic torment taking after removal is less critical from a viable angle, as most of these women will require hysterectomy.
Post-ablation pain disorder incorporates a number of conditions that result from discouraged menstrual bleeding after endometrial removal [4]. Warm damage to the endometrium from the removal comes about in intrauterine scarring and contracture that leads to obstruction of outflow. In spite of the fact that the objective of endometrial removal is to crush the complete endometrium to anticipate continuous dying, this is seldom achieved as prove by the less than 50% amenorrhea rate accomplished by these strategies. Persistent or recovering endometrium has been detailed in follow-up post-ablation MRI examinations in up to 95% of patients, proposing the nearness of persistent endometrial organs in most cases. Post-ablation pain disorder happens when determined or recovering endometrial cells drain coming about in caught blood behind intrauterine scar. This bleeding can result in hematometra at the corneal region, as seen in post-ablation tubal sterilization syndrome (PATSS) or inside the body of the uterus (central hematometra). Women with this disorder for the most part show with severe cyclic pelvic pain, with or without vaginal bleeding, after endometrial removal. These conditions can happen months to a long time after the removal strategy was performed.
Abortion
Dangers related with early abortion, including death, are relatively low when procedures are carried out beneath present day restorative conditions [5]. Legality is a vital prerequisite for such conditions to be present. In places where abortion is unlawful or restricted, related morbidity and mortality rates stay high. According to the World Health Organization, about half of all abortions that take put around the world are risky, leading to significant health and financial consequences for women, their families, and the countries in which they reside. Within the United States, abortion mortality rates have decreased impressively since the 1970s, to a great extent as a result of propels in strategy and end of numerous legitimate limitations. Hazard of passing increments with progressing gestational age. In any case, given the limited number of abortions that happen after the primary trimester and especially after 20 weeks of gestation, death from abortion is relatively rare within the United States. Compared to abortion, the chance of death related with live birth has been found to be approximately 14 times higher.
Serious and minor complications following lawful aspiration or D & E abortion are too rare. Possible complications (from most to least likely) incorporate disease, missed or incomplete abortion, cervical tear, uterine perforation, hemorrhage requiring transfusion, and hematometra. Overall, minor complications are evaluated to happen in less than 2.5% of abortions, and serious complications requiring hospitalization in less than 0.5%. In a precise review, other major complications requiring intervention, counting hemorrhage requiring transfusion and uterine perforation requiring repair, happened in less than 0.1% of cases. In common, these conditions are treatable and seldom lead to long-term morbidity or death.
Intrauterine Adhesions
The foremost frequent complaints of patients with intrauterine adhesions are changes in menstrual recurrence and character of menstrual flow (i.e., either amenorrhea or hypomenorrhea), infertility, and repeated pregnancy loss [6]. The extent of the alteration in the menstrual flow offers no understanding into the degree of intrauterine adhesions. A proposal of the determination is made by the patient's history, for illustration, hypomenorrhea or amenorrhea after intrauterine control regardless of type. An ordinary history evoked in a quiet with intrauterine adhesions is curettage after an occasion of pregnancy, at that point an arrangement of unconstrained menstrual cycles that diminish in concentrated taken after by amenorrhea. Amenorrhea and cyclic abdominal and pelvic pain may be introductory complaints when confined adhesions within the lower uterine fragment piece menstrual flow. The foremost dramatic clinical introductions are auxiliary to hindrance of menstrual flow and result within the advancement of hematometra requiring prompt assessment and drainage. The history in this circumstance is ordinarily one of a cessation of menses with continuous cyclic abdominal and pelvic pain suggestive of serious dysmenorrhea. The pain at first is restricted only to the time of anticipated menses but gets to be dynamically more serious and involves increasingly of the month. In this circumstance, crisis assessment may be required. As it were a little sum of fundamentally set grips is vital to result in this clinical picture.
Menstrual changes are not prerequisites to the diagnosis. The extent of the intrauterine adhesions connects ineffectively with the extent of changes within the menstrual pattern. Patients with extreme intrauterine attachments may proceed with standard month-to-month menses, depending on the degree of work of the remaining endometrium. On the other hand, patients with gentle attachments may complain of stamped changes in their menstrual pattern and impressive reduction within the sum of flow. Around 13% of patients have cyclic menses, and 72% are totally asymptomatic. The causes of this differential reaction are obscure. Restricted data from MRI (Magnetic Resonance Imaging) proposes that alter within the function and responsiveness of endometrium encompassing but not a portion of the intrauterine adhesions may be included. In an arrangement of cases of amenorrhea related with intrauterine adhesions, MRI uncovered endometrial and junctional signals of low escalated all through the cavity, suggesting a dysfunctional endometrium. This design held on in spite of delayed high-dose estrogen stimulation. These discoveries propose that in zones free of adhesion, endometrial harm of adequate escalated and profundity may exist and avoid recovery of endometrium in reaction to hormonal stimulation. These discoveries back the concept that occasions contributory to intrauterine attachment arrangement may happen on a continuum. Extraordinary harm to regions of the endometrium and basalis may result in coalescence of the contradicting uterine walls and eventual organization into intrauterine adhesions. In other areas, harm to the basalis may be of adequate concentrated to avoid recovery of working endometrium but not so serious as to contribute to adhesion arrangement or obliteration of the cavity. These zones may show up free of adhesions on HSG (hysterosalpingography) or hysteroscopy but may be without the capacity to reply to hormonal stimulation. Other surrounding zones may be gently harmed, with recovery of ordinarily working endometrium contributing to month-to-month menses.
Ultrasound
In spite of the fact that the information are constrained, ultrasound evaluation of the endometrial cavity may be valuable for the determination of intrauterine adhesions [6]. Grips show up as thick, exceedingly echogenic structures within the region of the endometrial stripe and, with serious intrauterine adhesions, totally supplant the endometrial stripe. Transvaginal ultrasound may moreover be utilized as implies of diagnosing and surveying the degree of intrauterine adhesions. In one consider of 77 women, adhesions were diagnosed with an affectability of 91% and a specificity of 100%. In this study, transvaginal sonography was useful in diagnosing and classifying intrauterine adhesions. Preoperative assessment of endometrial pattern by transvaginal sonography may moreover give a few knowledge with respect to outcome after surgical repair in patients with serious intrauterine adhesions. Patients with minimal endometrium seen on transvaginal sonography amid the final luteal stage are at hazard of having serious adhesions or cavity obliteration. In any case, those patients with a clearly characterized, well-developed endometrium on ultrasound may have gentle adhesions or adhesions confined to the lower uterine segment. These patients are in the foremost favorable category and ordinarily continue ordinary monthly cycle after hysteroscopy. Transvaginal ultrasound evaluation of the endometrial design too licenses recognizable proof of patients who may require preoperative concealment to encourage hysteroscopic lysis of adhesions. In case the endometrium is thickened in a few ranges adjoining to the adhesions, endometrial debris may occlude the agent field and concealment may be useful. Ultrasound can moreover illustrate hematometra in patients in whom adhesions piece the departure of menstrual stream or may be valuable in recognizing regions of loculation. Ultrasound assessment is an essential preoperative assessment to evaluate the endometrial stripe and rule-out any areas of hematometra.
Most uterine anomalies can be precisely characterized with as of now accessible imaging methods counting hysterosalpingography, ultrasonography, and MRI [7]. Transvaginal ultrasound or hydrosonography is delicate sufficient to recognize the appearance of the endometrium during the proliferative and secretory stages of the menstrual cycle and can clearly survey the forms, cavity size and shape, structural changes, and by and large estimate of the uterus. Transvaginal ultrasound can regularly recognize between a bicornuate and septate or subseptate uterus, while on hysterosalpingography they frequently see comparative. Transvaginal ultrasound can as a rule separate a little uterine horn from an ovarian mass. Ultrasound is valuable in finding hematometra or hematocolpos and presence of ovaries, and for assessing the presence of kidneys.
Hysterosalpingography and hysteroscopy are moreover valuable procedures for the assessment of uterine anomalies. On hysterosalpingography, the endometrial depth of a unicornuate uterus shows up as an oblong-shaped form, rather than an ordinary triangular shape, and as it were one fallopian tube emerges from the cavity. A uterine didelphys yields a copied endocervical canal and two oblong-shaped endometrial cavities. A fragmented combination of the Mullerian ducts comes about in a bicornuate, V-shaped endometrial cavity.
Magnetic resonance imaging is considered by numerous as the gold standard for diagnosing uterine irregularities. Exact estimation of the uterine fundus distance across can recognize an ordinary, bicornuate, didelphys or septate uterus. Uterine contours, nearness of endometrial tissue in a uterine horn or diameter and length of a septum can be assessed.
Endometrial Carcinoma
Abnormal bleeding happens in roughly 80% of patients and is the foremost critical and early side effect of endometrial carcinoma [8]. An anomalous vaginal release, particularly after menopause or discontinuous spotting, is detailed by a few patients. Amid the premenopausal a long time, the bleeding is more often than not portrayed as intemperate stream at the time of feminine cycle. Be that as it may, dying may happen as intermenstrual spotting or premenstrual and postmenstrual bleeding. Roughly 5-10% of patients with postmenopausal bleeding have underlying cancer, but the likelihood increments with age and depends on fundamental chance variables. Roughly 10% of patients complain of lower abdominal issues and pain secondary to uterine compressions caused by detritus and blood trapped behind a stenotic cervical os (hematometra). In case the uterine contents gotten to be contaminated, a sore creates and sepsis may happen.
Physical examination is more often than not unremarkable but may uncover therapeutic issues related with progressed age. Speculum examination may affirm the nearness of bleeding, but since it may be minimal and intermittent, blood might not be displayed. Atrophic vaginitis is habitually recognized in these elderly women, but postmenopausal bleeding ought to never be attributed to atrophy without a histologic examining of the endometrium to run the show out endometrial carcinoma. Bimanual and rectovaginal examination of the uterus within the early stages of the disease will be typical unless hematometra or pyometra is present. In case the cancer is broad at the time of presentation, the uterus may be enlarged and may be misdiagnosed as a benign condition such as leiomyomata. In advanced cases, the uterus may be fixed and immobile from parametrial extension.
Vaginal, vulvar, or inguinal-femoral lymph node metastases are once in a while identified in early disease but are not exceptional in progressed cases or with repeat taking after treatment. Ovarian metastases may cause marked enlargement of these organs.
Conclusion
Hematometra is a disease in which blood accumulates in the uterus due to obstruction of some part of the genital tract or spasm of the cervix, which prevents normal blood flow. Blood accumulates in the uterus and exerts strong pressure on the walls, causing pain. Hematomas can be caused by malignant tumors in the cervical canal or in the vagina, cervical stenosis or radiation therapy. Neglecting treatment can be fatal.
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