High blood pressure in pregnancy may cause intrauterine growth retardation, increased perinatal mortality etc. Pregnant women with hypertension are also at risk of development of medical problems like preeclampsia and abruptio placenta. To prevent the complications of hypertension, women with chronic hypertension should be thoroughly evaluated for to identify the remediable causes of hypertension and also to prevent adverse effects of anti hypertensive drugs during pregnancy.

Treatment of hypertension:

Pregnancy is an extraordinary situation and requires meticulous care in treating high blood pressure. The normally prescribed drugs for hypertension (ACE inhibitors like enalapril, angiotensin-receptor blockers like losratan) can not be used due to fear of development of fetal abnormality. The most commonly use antihypertensive drugs during pregnancy are alpha-Methyldopa, labetalol, and nifedipine, which have very little if any effect on growing fetus and considered safe during pregnancy. If the hypertension is due to pregnancy it will normalize after delivery.

Renal function should be evaluated to find out the chance of developing preeclampsia and to treat and manage early, should preeclampsia develop.

During pregnancy the cardiac output (which the quantity of blood heart has to pump every minute) increases by approximately 40% and the heart rate or pulse rate increases by approximately 10 beats per minute mainly during the last three months of pregnancy. But despite the increase in heart rate the increase in cardiac output is mainly due to increase in stroke volume, which is the amount of blood heart pumps out in every heart beat.

During second trimester of pregnancy there is reduction in the vascular resistance and there is reduction in blood pressure in normal pregnant women. Blood pressure is the result of cardiac output and degree of vascular resistance and if there is reduction in the vascular resistance, blood pressure falls. That is the reason blood pressure of 140/90 mm of Hg is considered very high during pregnancy (mainly during second trimester), whereas the same pressure is considered only the beginning of high blood pressure in general population. High perinatal (4 weeks before delivery to 4 weeks after delivery is the perinatal period) mortality and morbidity is associated even at blood pressure of 140/90 mm of Hg.

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Marked physiological changes occur during pregnancy (e.g. marked increase in cardiac output and workload of heart, which is as much as 40% increase) and the mother’s body need to adapt to these physiological changes appropriately to have a good outcome of pregnancy. Medical disorders which interfere with physiological adaptations of pregnancy can increase the risk of a poor outcome of pregnancy and pregnancy may sometimes aggravate the preexisting medical disorder in a woman.

The medical disorders which can occur during pregnancy are preeclampsia (development of hypertension and presence of protein in urine after 20 weeks of pregnancy or gestation) which occurs in approximately 5-7% of all pregnancies, eclampsia, gestational hypertension, aggravation of existing essential hypertension, cardiovascular disorders (like mitral stenosis, mitral and aortic regurgitation etc.), renal disorders, pulmonary hypertension, pulmonary embolism, deep vein thrombosis, hormonal disorders (like diabetes, gestational diabetes, hypothyroidism or hyperthyroidism), blood disorders, neurological disorders, gastrointestinal disorders and liver diseases. The pregnant women are also prone to develop certain bacterial (urinary tract infection, which is very common medical problem during pregnancy) and viral infections (cytomegalovirus infection, rubella, herpes, HIV infection etc.).

Conservative General Measures:

If the bleeding due to menorrhagia is not heavy and consequent anemia is not serious or hemoglobin is normal, the patient should be observed for few months, as in many cases there is spontaneous cure (recovery from menorrhagia) and it should be awaited. If the patient’s menorrhagia is severe there is always some degree of anemia. In this juncture the complete hemogram test should be done instead of doing only hemoglobin estimation. As a conservative measure oral iron preparation should be given to the patient and response to the oral iron checked by serial blood count and hemoglobin estimation (generally at least twice a month, if possible every week). If patient is not responding to iron satisfactorily due to any cause (may be due to iron intolerance, failure to utilize the oral iron etc.), she should be given parenteral iron preparation till anemia is fully corrected and body iron stores become normal. The patient should be reassured and bed rest and sedatives given, which plays important role in conservative management of menorrhagia. If anemia is severe, blood transfusion may be required.

Role of NSAIDs in menorrhagia:

The NSAID (non steroidal anti inflammatory drug) used is mefenamic acid 500 mg three times a day with full stomach. This is given for 5-6 days during menstruation in menorrhagia cases of ovulatory cycles, menorrhagia associated with IUCD, and post sterilization menorrhagia. The common side effects of mefenamic acid are nausea, vomiting, headache, dyspepsia, hemolytic anemia etc.

Role of antifibrinolytic drugs:

The drug which was tried with varying result in menorrhagia is epsilon-amino-caproic acid at the dose of 1-3 grams four times a day for 6-7 days. The side effects that are encountered with epsilon-amino-caproic acid are nausea, vomiting, headache, intracranial thrombosis etc.

Menorrhagia is a presenting symptom in many endocrine diseases. In patients with hyperthyroidism, menorrhagia is a frequent symptom, especially in early stage of the disease. In advance stage of hyperthyroidism patients usually have amenorrhea (absence of menstruation). In hypothyroidism menorrhagia is generally seen in the advanced stage of the disease. Menorrhagia is a common symptom in myxedema (disease of hormonal disturbance), especially in women above 40 years of age. In acromegaly (due to excess production of growth hormone in adults) menorrhagia can be a symptom in early stage and in the late stage usually there is amenorrhea.

Iatrogenic causes of menorrhagia:

Menorrhagia may also develop due to use of estrogen for prolonged period for non gynecological condition (especially use of synthetic estrogen prescribed by dermatologists, for relief of symptoms which is not a gynecological problem). The use may be for long duration and at a dose that may be of high. Estrogen is also frequently prescribed by many doctors for menopausal symptoms, and this prescription (of estrogen) may itself cause menorrhagia. Both of the above instances can be regarded as iatrogenic (caused by doctor’s prescription or hospital acquired).

IUCD as a cause of menorrhagia:

IUCD (intrauterine contraceptive device, used as a method of contraception by women), can also cause menorrhagia as seen in recent times. In fairly large percentage of women using IUCD develop menorrhagia in first few periods after insertion of IUCD and in some women the device has to be withdrawn due to continuation of menorrhagia for long duration.

In approximately 15% of cases of tubectomy (sterilization operation in women in which part of Fallopian tube is removed and both ends are ligated to prevent re-canalization) also menorrhagia is seen although the cause is not clear.

]]> http://www.womenhealthguide.net/causes-of-menorrhagia-endocrine-disturbance-iucd/feed/ http://www.womenhealthguide.net/causes-of-menorrhagia-local-cause-in-pelvis/ http://www.womenhealthguide.net/causes-of-menorrhagia-local-cause-in-pelvis/#comments Sat, 25 Jul 2009 12:00:53 +0000 drjupitor http://www.womenhealthguide.net/?p=211 Local pathology in the female pelvis is a common cause of menorrhagia, along with other causes of menorrhagia such as due to general diseases and due to some endocrine disturbance.

In large percentage of cases of menorrhagia the cause is some local pathology in the pelvis. One of the classic examples of local disease in pelvis causing menorrhagia is ‘myoma’ and menorrhagia is the characteristic symptom of myomas. Myomatous polypi are found often during diagnostic curettage while investigating the cause of menorrhagia, so are endometrial polypi found sometimes during investigation of menorrhagia. Inflammation of pelvic area like salpingo-oophoritis (inflammation of ovary and Fallopian tube) also can cause menorrhagia by causing hyperemia.

First menstrual period after childbirth and abortion may be excessive because the uterus is enlarged and not involuted properly. Retroversion of uterus also the menstrual bleeding may be in excess. The symptoms of chocolate cyst may also sometime be menorrhagia, which is also may be due to hyperemia induced by the presence of chocolate cyst. Endometriosis generally does not cause menorrhagia, unless the tumor is estrogenic like granulosa cell tumor.

Symmetrical enlargement of uterus (equal to eight to ten weeks of pregnancy), which is generally due to hyperplasia of uterine musculature, may also be the cause of menorrhagia, as is seen in the pelvic examination of patients. The symmetrical enlargement of uterus is due to excessive estrogen stimulation as seen in adenomyosis. Tuberculosis of emdometrium also presents as menorrhagia in the early stage of disease.

]]> http://www.womenhealthguide.net/causes-of-menorrhagia-local-cause-in-pelvis/feed/ http://www.womenhealthguide.net/menorrhagia/ http://www.womenhealthguide.net/menorrhagia/#comments Tue, 23 Jun 2009 00:42:49 +0000 drjupitor http://www.womenhealthguide.net/?p=209 Normal blood loss during menstrual cycle is about 50-80 ml and usually do not exceed 100 ml. Menorrhagia is excess menstrual bleeding for longer duration without any alteration in the menstrual cycle i.e. menstrual cycle is unaltered but duration of menstrual bleeding and quantity of menstrual blood loss is increased. Menorrhagia is not a disease itself but a symptom.

The underlying cause of menorrhagia is difficult to detect. But the causes of menorrhagia can be grouped as (a) causes due to general diseases (b) due to local cause in pelvis (c) due to endocrine disturbance and (d) hormonal causes.

Diagnosis of menorrhagia:

1. Finding out the cause of menorrhagia may be very difficult. The patient of menorrhagia must be investigated carefully due to the difficulty in detection of the underlying cause of menorrhagia and its symptoms. History of the patient should be taken carefully to find out the onset, duration, quantity of blood loss, the character of blood and the cyclical feature of menstrual cycle. Any preceding history like recent delivery, abortion or IUCD (intra-uterine contraceptive device) should be elicited.
2. A full gynecological examination should be done, which should include thyroid profile, blood count and bi-manual pelvic examination.
3. A diagnostic curettage should be done to obtain samples for histological examination.
4. Ultrasound examination of should be done to exclude extra uterine pathology.
5. Instead of all the above investigations, if nothing comes out as the cause of menorrhagia, a hysterosalphingogram should be done and it may reveal some cause like polyp, fibroid etc.

The contraceptive methods can be broadly categorized into two:

(1) spacing methods.

(2) terminal sterilization.

Spacing methods can be further divided and sub-divided into the following:

(1) Barrier methods (they are subdivided into physical barrier, chemical barrier and combined barrier).

(2) IUCDs intra-uterine contraceptive devices.

(3) Hormonal methods.

(4) post-conceptional methods.

(5) Miscellaneous.

Terminal methods can be divided into male sterilization and female sterilization. Male sterilization is called vasectomy and female sterilization is called tubectomy. The male sterilization or vasectomy is much cheaper, easier and has lesser side effects than tubectomy. But much more tubectomies are done every year in compare to vasectomy. One great advantage of male sterilization or vasectomy is that it is easily reversible and when the vasectomized male want to bear child again the vas deference can be easily re-canalized and it is highly successful and without any side effects. In case of tubectomy the re-canalization can be successful, but it has many potentially fatal consequences like tubal pregnancy.

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