Vaginal Bleeding in a Child

Surgery depends on the cause, e.g. myomectomy or hysterectomy for fibroids (below), or hysterectomy for persistent excessive bleeding not responding to drug treatment. N.B. a small submucous fibroid may lead to heavy bleeding and may be resected by hysteroscope. Endometrial ablation can be considered in some units for bleeding from a normal uterus – i.e. when the uterus is of normal size and no specific cause is found. If there is marked dysmenorrhoea there is less satisfaction with ablation. Many different types of ablation exist. Pregnancy after ablation is contra-indicated, and specified as such in consent. Uterine artery embolisation may be offered in some units. Pregnancy after is cautiously allowed. Catheterisation and occlusion of both uterines is achieved via the femoral artery. A watery blood stained discharge follows, which is very rarely associated with overwhelming sepsis. MANAGEMENT OF MULTIFIBROID UTERUS Drug treatment (as for excessive vaginal bleeding) may control haemorrhage sufficiently to avert hysterectomy, at least in the short term. 1. Do not force a hysterectomy an unwilling patient 2. Consider myomectomy. Consent for a myomectomy must include specific mention of proceeding to hysterectomy if there are intraoperative problems 3. Consider alternatives: Uterine artery embolization(UAE) or High Intensity Focused Ultrasound(HIFU) for suitable patients who want to preserve their fertility. UAE may shrink the uterus by 50%. Pregnancy Following UAE may have complications(IUGR, prem labour, placenta accreta). This should enter consent. HIFU has not to date been used much on the larger uterus(the current limit is 18 weeks size). Always discuss with a consultant. 4. Where fertility is an issue, consider other causes. N.B. if, for a person with bleeding, there is a delay while awaiting an operation or a procedure and that person is not maintained on progestagens and haematinics, when the procedure is due there will be anaemia and it will be cancelled.