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Abdomenul acut n ginecologie. Hemoragia n
ginecologieAsist. univ. dr. Bogdan Doroftei
Thursday, December 30, 2010
Abdomenul acut
Durerea acut: este intens, caracterizat prin instalare brusc, creterea rapid n intensitate i durata scurtDurerea ciclic - dismenoreea este asociat cu ciclul menstrualDurerea pelvin cronic este durerea cu durat mai mare de 6 luni
Thursday, December 30, 2010
Durerea acut
Instalarea rapid a durerii este sugestiv pentru peforaia unui organ cavitar sau pentru un proces ischemicDurerea colicativ sunt asociate cu contracia muscular sau obstrucia unui viscer cavitar, precum intestinul sau uterulDurerea perceput la nivelul ntregului abdomen sugereaz o reacie generalizat la prezena unui fluid iritant n interiorul cavitii peritoneale
Thursday, December 30, 2010
etiologia durerii acute
Periombilical
Apendicita - forma de debut Obstrucia intestinului subire Gastroenterita Ischemia de mezenter Ruptura unui anevrism aortic abdominal Disecia unui anevrism aortic abdominal
Thursday, December 30, 2010
Flancul drept: Apendicita Colon iritabil Tumorile ovariene Torsiunea de ovar Sarcina ectopic Boala inflamatorie pelvin Abcesul tubo-ovarian Pielonefrita Abcesul perinefritic Urolitiaza Procese neoplazice gastro-intestinale Diverticulite situate pe colonul ascendent Ileocolita Gastroenterita Hernia
etiologia durerii acute
Thursday, December 30, 2010
Suprapubic
Colonul iritabil Tumorile ovariene Torsiunea de ovar Sarcina ectopic Boala inflamatorie pelvin Abcesul tubo-ovarian Ovarian tumor Dismenoreea Diverticulita Cistita Nefrolitiaza
etiologia durerii acute
Thursday, December 30, 2010
etiologia durerii acuteFlancul stng abdominal
Colon iritabil Tumora de ovar Torsiunea de ovar Sarcina ectopic Boala inflamatorie pelvin Abcesul tubo-ovarian Pielonefrita Abcesul perinefritic Nefrolitiaza Diverticul sigmoidian Ileocolit Gastroenterit Hernia Tumori neoplazice gastrointestinale
Thursday, December 30, 2010
Difuze
GastroenetritaOcluzia intestinalPeritonitaIschemia de mezenterColon iritabilCetoacidoza diabeticPorfiria UremiaHipercalcemia Sickle cell crisis Vasculite Intoxicaia cu metale greleSevrajul dup consumul de opiacee Febra familial mediteranean Angioedemul ereditar
etiologia durerii acute
Thursday, December 30, 2010
Diagnostic
1. Istoric
2. Examenul fizic
Semne vitale
Examenul abdomenului
Examenul pelvin
3. Teste de laborator
4. Radioimagistica
5. Laparoscopia exploratorie
Thursday, December 30, 2010
Istoricdebutul dureriicircumstanele apariiei dureriiCaracterul durerii: colicativ, difuz, simptomatologia asociatCondiii ginecologice anterioare: APF si APPDisuria, hematuria, polakiuria orienteaz diagnosticul spre etiologia urinarAmenoreea, scurgerile vaginale, dispareunia. hemoragiile vaginale orienteaz spre cauze ginecologiceVrsturile: imp ca moment al apariiei: n abdomenul acut chirurgical apar DUP instalarea durerii ca mecanism reflex determinat de iritarea vagului. Se nsoeste de greaDac vrsturile apar nainte de instalarea durerii e mai puin probabil s fie o cauz de abdomen acut chirurgical
Thursday, December 30, 2010
Examenul fizic Semne vitale:
expresia feei transpiraii paloare gradul de agitaietemperatur: subfebrilitate - apendicit, diverticulit
febr: BIP, Peritonit, pielonefritpuls cu dif >30b/min. intre poz ortostatic si decubit - hipovolemietensiune arterial dif > 20 mmHg intre poz ortostatic si decubit la un interval de 1 min. - hipopvolemieAtenie la boli neurologice sau medicaie hipotensoare care pot duce la confuzie n stabilirea diagnosticului
Thursday, December 30, 2010
examenul abdomenului Inspecia abdomenului: c icatr ic i anter ioare laparotomie/laparoscopie - risc de ocluzie intestinal / hernie la nivelul inciziei, aderene. Cianoz cutanat periombilical - SEU
Distensia abdominal mai frecvent n ocluzia intestinal, perforaia unui organ abdominal sau ascit Ascultaia abdomenului - zgomote specifice n ocluzia intestinal.
Palparea abdomenului pe fiecare cadran cu accentuare pe zona indicat de pacient Iritaia peritoneal - aprare muscular sau abdomen de lemn datorit reflexului de aprare involuntar i a spasmului muchilor abdominali.
Thursday, December 30, 2010
Examinarea ginecologic
Secreia vaginal purulent - BIPHemoragia vaginal - complicaiile sarcinii, traumatisme n aria genital, tumori benigne sau maligne ale ovarului, uterului (col) vaginului.
Sarcina, adenomioza, leiomiomul uterin sunt responsabile de creterea n volum a uterului i de modificarea consistenei acestuia.Mobilizarea cervixului urmat de durere se ntlnete mai frecvent n sindromul de iritaie peritoneal ( BIP, apendicit, diverticulit, hemoragie intraabdominal).
Mase anexiale dureroase reflect sarcina ectopic sau abces tubo-ovarian, chist ovarian torsionat, rupt sau hemoragie intrachistic. ATENIE! Se poate confunda cu abces apendicular sau diverticul. Tueul rectal- informaii suplimentare despre sursa i mrimea unor eventuale mase anexiale sau posibilitatea unei patologii colo-rectale
Thursday, December 30, 2010
Teste de laborator
hemoleucograma complet cu determinarea Hb, Ht, Leucocite, formula leucocitarVSH -nespecific, adesea este singurul test anormal n BIP subacutSumar urinTest sarcinCuldocenteza
Thursday, December 30, 2010
imagistic
Eco pelvin transabdominal/ endovaginalRx abd pe gol/ subst de contrastCT /RMN
Thursday, December 30, 2010
Laparoscopia diagnostic
Contraindicaii: Tumori pelvine > 10 cmperitonitileusocluzie intestinalcicatrice median postlaparotomie ( peritonite, ocluzii intestinale, procese neoplazice)oc hipovolemic
Thursday, December 30, 2010
Ruperea sau pierderea coninutului unui chist ovarianchistul folicular este cel mai frecvent implicatmittelschmertz chist de corp luteal hemoragicteratomul chistic - dermoidchistadenoameleendometriomul
Thursday, December 30, 2010
un chist ovarian care NU torsioneaz, dar care crete rapid n dimensiuni, se infecteaz sau pierde din coninut nu determin durere acutchist luteinic rupt - simptomatologie ca n sarcina ectopic - hemoperitoneu, durere instalat brusc, sincopendometriomul sau chistul dermoid nu va fi nsoit de hemoperitoneu, cantitatea de snge fiind mai micsensibilitate abdominal semnificativ asociat cu sensibilitate de rebound datorat iritaiei peritonealeabdomen moderat destinsformaiune pelvin dac nu este complet ruptverific Ht/culdocentez
Ruperea sau pierderea coninutului unui chist ovarian -
Thursday, December 30, 2010
hemoperitoneu - tratament chirurgical laparoscopic sau clasicCuldocenteza: snge proaspt - corp luteal; snge cu aspect chocolatiu - endometriom; lichid uleios, sebaceu - chist dermoid; lichid purulent - BIP sau abces tubo-ovarianAntibioticeAntiinflamatorii
Ruperea sau pierderea coninutului unui chist ovarian -
Thursday, December 30, 2010
Torsiunea de ovarinstalarea rapid a durerii pelvine acuteteratomul chistic benign cel mai frecvent se poate torsionadurere sever i constantinstalarea durerii coincide cu ridicarea unor greuti, a unui efort fizic deosebit sau contact sexualse nsoete de grea, vrsaturi, anxietateabdomen sensibil la palpare palparea - prezena unei mase pelvine marifebr, leucocitoz
Thursday, December 30, 2010
Torsiunea de ovar
Chistectomie dac esutul nu este infarctizatOvariectomie dac este infarctizat
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Chistectomie
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ovariectomie
Clamping the meso-ovarium
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Pedicle ligation.
Thursday, December 30, 2010
Chistecomia laparoscopica
Ovarian incision.
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Cyst dissection.
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Cyst wall removal.
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Thursday, December 30, 2010
Thursday, December 30, 2010
Salpingo-ooforita acutaNeisseria gonorrhea i Chlamydia trachomatisAvortul septic, endometrita, colonizare ascendentinstalare acut a durerii ce crete n intensitate cu micareafebrsecreie vaginal purulentvrsturisensibilitate abdominalsensibilitatea la mobilizarea coluluisensibilitate anexial bilateralVSH mrit, leucocitozCuldocentez - lichid purulent, fetidtest pozitiv la antigene Chlamydiene din col
Thursday, December 30, 2010
Criterii de spitalizare:abces tubo-ovarian suspectprezena unui DIU, diagnostic incertgrea/ vrsturi ce mpiedic tratament per ossemne peritoneale lipsa ameliorrii dup 48 ore tratament cu antibiotice
Salpingo-ooforita acuta
Thursday, December 30, 2010
Abcesul tubo-ovarianmai frecvent bilateraledurer i febr persistent mai mult de 7 zileabcesul tubo-ovarian rupt - URGEN - oc endotoxinic gram negativ cu potenial letalmase bilaterale fixe, ferme, intens dureroasepot fi fixate la fundul de sac ecografic se stabilete diagnosticultratament cu asociere de antibiotice ivabces rupt- peritonit - tahicardie, sensibilitate n toate cele 4 cadrane, hipotensiunea i oliguria
Thursday, December 30, 2010
Leiomiomul uterin degenerat sau torsionat
Thursday, December 30, 2010
Endometrioza
Thursday, December 30, 2010
Sindromul de Hiperstimulare ovarian
n urma procedurilor de FIVDurere abdominal Grea, vrsturi, stare alterat, dispneeAscit, hidrotorax, hidropericardoligurie, hemoconcentraietromboze venoase profunde
Thursday, December 30, 2010
Sindromul de Hiperstimulare ovarian
Thursday, December 30, 2010
Hemoragia n ginecologie
Menorrhagia is defined as prolonged or heavy cyclic menstruation. Objectively, menses lasting longer than 7 days or exceeding 80 mL of blood loss
Metrorrhagia describes intermenstrual bleeding.
Frequently women may complain of both patterns, menometrorrhagia
Some women, there is diminished flow or shortening of menses, hypomenorrhea.
Normal menstruation typically occurs every 28 days 7 days. Cycles with intervals longer than 35 days describe a state of oligomenorrhea.
Withdrawal bleeding refers to the predictable bleeding that often results from abrupt progestin cessation.
Thursday, December 30, 2010
Differential Diagnosis of Abnormal BleedingDysfunctional uterine bleeding
Anovulatory
Perimenarchealimmature hypothalamic-pituitary-ovarian axis
Perimenopausalinsensitive ovarian follicles
Endocrinopathiessee systemic causes
Drugshypothalamic depressants, steroids
Ovulatory
Organic lesions
Pregnancy-associated causesimplantation spotting, abortion, ectopic pregnancy, gestational trophoblastic disease, postabortal or postpartum infection
Anatomic uterine lesions
Neoplasmleiomyoma, polyp, endometrial hyperplasia, cancer
Atrophic endometrium
Infectionsexually transmitted disease, tuberculosis
Mechanical causesintrauterine device, perforation
Arteriovenous malformation
Partial outflow obstructioncongenital mllerian defect, Asherman syndrome Thursday, December 30, 2010
Anatomic nonuterine lesions Ovarian lesionshormonally functional neoplasm
Fallopian tube lesionssalpingitis, cancer Cervical and vaginal lesionscancer, polyp, infection, atrophic vaginitis, foreign body, trauma
Systemic abnormalitiesExogenous hormone administrationsex steroids, corticosteroids
CoagulopathiesHepatic failure
Chronic renal failureEndocrinopathieshypothyroidism, hyperthyroidism, adrenal disorders, diabetes mellitus,
hypothalamic-pituitary disorders, polycystic ovarian syndrome, obesity
Thursday, December 30, 2010
Simptomatologia
Menorrhagia and Metrorrhagia
Postcoital Bleeding endocervical polyps, cervicitis, and less commonly, endometrial polyps. In the cases of cervicitis, Chlamydia trachomatis is a frequent cause. Bax and associates (2002) found that the relative risk of chlamydial infection in women with postcoital bleeding was 2.6 times higher than that of a control group without bleeding. From cervical or other genital tract neoplasia.
Pelvic Pain Dysmenorrhea frequently develops concurrently with abnormal bleeding caused by leiomyomas polyps, adenomyosis, infections, and pregnancy complications. Because of the role of prostaglandins in both menorrhagia and dysmenorrhea, it seems logical that painful cramping would commonly accompany abnormal bleeding
Thursday, December 30, 2010
Diagnostic
Diagnostic algorithm to identify endometrial pathology in patients with abnormal uterine bleeding. D&C = dilatation and curettage; EMB = endometrial biopsy; SIS = saline-infusion sonography; TVS = transvaginal sonography.aEndometrium bilayer thickness measurements are used for postmenopausal women.bSIS or hysteroscopy per physician preference.cAdequate diagnosis and clinical management should follow.
Thursday, December 30, 2010
Diagnostic algorithm to identify endometrial pathology in patients with abnormal uterine bleeding and with risk factors for endometrial cancer.D&C = dilatation and curettage; EMB = endometrial biopsy; SIS = saline-infusion sonography; TVS = transvaginal sonography.aTVS or EMB per physician preference.bEndometrium bilayer >5 mm (in postmenopausal women) or obvious pathology seen.cSIS or hysteroscopy per physician preference.dAdequate diagnosis and clinical management should follow.
Thursday, December 30, 2010
Laboratory Evaluation
HEMATOLOGIC AND -HCG TESTING
hemogram
urine or serum levels of human chorionic gonadotropin (-hCG)
Screening for coagulation disorders should be considered in women with menorrhagia and no other obvious causes. This is particularly true for adolescents with menorrhagia. Evaluation typically includes partial thromboplastin time, prothrombin time, bleeding time, platelet count, and may include special testing for von Willebrand disease (von Willebrand Disease).
INFECTIONScervicitis commonly causes intermenstrual or postcoital spotting (Chlamydia trachomatis and Neisseria gonorrhoeae). Cervicitis secondary to herpes simplex virus (HSV) infection may also cause bleeding (Paavonen, 1988).
Thursday, December 30, 2010
CYTOLOGIC EXAMINATION
Both cervical and endometrial cancers can cause abnormal bleeding and evidence for these tumors can often be found with Pap smear screening. The most frequent abnormal cytologic results involve squamous cell pathology and may reflect cervicitis, intraepithelial neoplasia, or cancer. Less commonly, atypical glandular or endometrial cells may be found.
ENDOMETRIAL BIOPSY
sampling and histologic evaluation of the endometrium in women with abnormal bleeding may disclose infection or neoplastic lesions such as endometrial hyperplasia, cancer, polyps, or gestational trophoblastic neoplasia
Laboratory Evaluation
Thursday, December 30, 2010
During biopsy, the Pipelle is first directed to the uterine fundus (A). The stylette of the Pipelle is retracted to create suction within the cylinder. (B). The Pipelle is then drawn to the internal cervical os and advanced back to the fundus. The Pipelle is gently spun during its advancement and retraction to allow thorough sampling of all endometrial surfaces.
Thursday, December 30, 2010
Transvaginal sonography
With its improved resolution, this technology is chosen by many instead of endometrial biopsy as a first-line tool to assess abnormal bleeding. If abnormal bleeding stems from myometrial pathology such as leiomyomas or adenomyosis, sonography offers anatomic information regarding the myometrium that is not afforded by hysteroscopy or endometrial biopsy. In addition, transvaginal sonography (TVS) compared with these other two offers greater patient comfort and comparable detection of endometrial hyperplasia and cancer.
Thursday, December 30, 2010
Endometrial thickness
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SALINE-INFUSION SONOGRAPHY
Thursday, December 30, 2010
SALINE-INFUSION SONOGRAPHY
Saline-infusion sonography ( S I S ) h a s a l s o b e e n c o m p a r e d w i t h hysteroscopy to detect uter ine cav i tary foca l lesions. De Kroon and co-workers (2003) performed a meta-analysis of 24 studies and reported SIS to e q u a l t h e d i a g n o s t i c accuracy of hysteroscopy. Importantly, neither hysteroscopy nor SIS can reliably discriminate between benign and malignant focal lesions.
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Endometrial polyps h a d o n l y o n e a rt e r i a l s u p p l y, whereas submucosal l e i o m y o m a s generally received b l o o d fl o w f r o m s e v e r a l v e s s e l s ar is ing from the inner myometrium
TRANSVAGINAL COLOR DOPPLER SONOGRAPHY
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Hysteroscopy
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Hysteroscopy
A: A submucous myoma prolapses through the cervix and is grasped with the tenaculum. B: The base of the myoma has been clamped, and a ligature has been placed on the pedicle. C: The myoma has been removed and measures approximately 4 cm across.
Thursday, December 30, 2010
endometrial polypoid hyperplasia.
Hysteroscopy
Thursday, December 30, 2010
An endometrial polyp in a woman who had received tamoxifen treatment for breast cancer. The endometrium has been modified by the tamoxifen treatment.
Hysteroscopy
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The endometrium shows extensive atrophy, which accounts for abnormal bleeding.
Hysteroscopy
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Abnormal vascular pattern and vegetations associated with adenocarcinoma endometrium arising from the posterior wall of the uterus.
Hysteroscopy
Thursday, December 30, 2010
AINSacid mefenamic 500mg x3/zi , 5 zile din prima zi a CMNaproxen 550mg in ziua 1 a CM apoi 275mg/ziIbufrofen 500mg/zi la menstruaieFlurbiprofen 100 mg x2 /zi 5 zile ncepnd cu ziua 1 a CM
Meclofenamate 100mg x3 /zi 3 zile ncepnd cu ziua 1 a CM
tratamentul medical al menoragiilor
Thursday, December 30, 2010
tratamentul medical al menoragiilor
Contraceptive orale 1cp/zi din ziua 1 a CM, timp de 21 zileacid tranexamic 1g x 4/zi timp de 5 zile din prima zi a CM Androgeni - Danazol 100mg sau 200mg/zi sau GestrinonaGnRH agonist 3,75mg/luna im doza depot, maxim 6 luniNorethindrone 5mg x 3 /zi din ziua 5-a pn n ziua 26 a CM ( HUD ovulatorie) sau 5mg x 2 /zi din ziua 15-a a CM pn n ziua 26 a CM (HUD anovulatorii)Mirena - DIU cu levonorgestrel Estrogen n doze mari pt a controla HUD acut - Premarin 2,5mg x4/zi pn la oprirea hemoragiei, apoi COC
Thursday, December 30, 2010
Tratamentul chirurgical
Chiuretajul hemostatic i biopsicProceduri de distrucie a endometruluiHisterectomia
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D&C
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D&C
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Thursday, December 30, 2010
D&C
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D&C
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Second-Generation Endometrial Ablation Technologies
Hot liquid balloonsThermaChoice I, II, and IIICavaterm and Cavaterm plusThermablate Hydrothermablation Cryoablation (Her option) Microwave endometrial ablation
Impedance controlled ablation (NovaSure)
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ThermaChoice III Uterine Balloon Therapy System AND Hysteroscopic termal ablation
Thursday, December 30, 2010
Impedance-controlled electrocoagulation AND Cryoablation
Thursday, December 30, 2010
Absolute Contraindications for Endometrial Ablation
Genital tract malignancyWomen wishing to preserve their fertilityPregnancyExpectation of amenorrheaAcute pelvic infectionPrior uterine surgeryclassical cesarean delivery, transmural myomectomy.
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Histerectomia
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Histerctomia
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Histerctomia
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Histerctomia
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Histerctomia
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Hemoragia datorat unor procese tumorale
Leiomiomul (fibromul ) uterinAnomalii ale ductului mullerian - septuri vaginale sau uterine care determin hemoragii intermenstruale prin acumularea i evacuarea ntrziat a sngelui menstrualMalformaii arterio-venoase la nivelul uterinPolip endometrialPolip endocervicalEndometrita cronic
Thursday, December 30, 2010
Insuficiena renal sever- dializ se nsoete de amenoree, infertilitate, hipoestrogenemie. Uneori pot apare menoragii.Tratamentul presupune administraea de doze mari de medroxiprogesteron acetat pt a induce atrofia endometruluiCOC pot fi adminstrate doar dac nu se suspicioneaz HTAInhibitori de sintez ai prostaglandinelor sunt contrainicai deoarece determin spasm arterial renaldac hemoragia nu poate fi controlat se practic histerectomia
Hemoragia datorat unor boli sistemice
Thursday, December 30, 2010
Insuficiena hepatic60% cazuri la pacientele pt transplant hepaticmetabolismul hepatic interfer cu metabolismul hormonilor sexuali, determinnd hiperestrogenemie - hemoragieInsuficiena hepatic determin i tulburri de coagulare prin deficit de proteine implicate n coagulare, trombocitopenie
Thursday, December 30, 2010
Boli tiroidiene
Amenoree sau Menometroragie Dozare TSHHipertiroidia se nsoete de hipomenoree/amenoree. 5% din cazuri se asociaz cu menometroragieHipotiroidia - anovulaie, amenoree, HUD cu anovulaie i tulburari ai factorilor de coagulare
Thursday, December 30, 2010
Coagulopatii
testing for bleeding disorders in: (1) adolescents with severe menorrhagia, (2) women with significant menorrhagia without another identifiable cause, and (3) preoperatively, prior to hysterectomy planned for severe bleeding.
creening evaluation of bleeding disorders in general has included a prothrombin time (PT), partial thromboplastin time (PTT), platelet count, and bleeding time. More commonly identified coagulopathies include von Willebrand disease (vWD) and other disorders of platelet function. Deficiencies of factor VII and IX (hemophilia A and B) or other factor deficiencies are more rarely involved.
Thursday, December 30, 2010
von Willebrand DiseaseIn women with abnormal bleeding and normal pelvic anatomy, rates of vWD were found to be 13 percent (Shankar, 2004). The disorder is more common in Caucasian than in African-American women (Miller, 2003).
Patients with vWD commonly complain of menorrhagia, and rates of 60 to 70 percent have been noted (Kadir, 1998, 1999; Lak, 2000). Heavy menstruation begins with menarche in these patients.
Importantly, vWF levels may be higher during the luteal phase, and thus samples should be obtained prior to day 7 of the menstrual cycle (Kadir, 1999; Lee, 2005).
Treatments for women with menorrhagia and vWD include desmopressin, plasma concentrates, hormonal contraception, antifibrinolytics, and surgery. Combination oral contraceptive pills have been noted to arrest uterine hemorrhage in 88 percent of women (Foster, 1995). Also, Kingman and co-workers (2004) reported that the LNG-IUS effectively decreased blood loss and induced amenorrhea in 56 percent of women with inherited bleeding disorders. Preliminary success has been found with endometrial ablation for women with vWD-related menorrhagia (El-Nashar, 2007; Rubin, 2004).
Thursday, December 30, 2010
Coagulation factor Deficiencies
Hemophilia A and B are inherited X-linked deficiencies of factor VIII or IX. Women carriers of the gene, however, can have decreased levels of factor VIII or IX. In some cases, these are low enough to cause mild hemophilia (Mannucci, 2001; Siegel, 2005).
Deficiencies of other coagulation factors are usually inherited as autosomal recessive traits and are rare. This group includes dysfibrinogenemia, hypofibrinogenemia, prothrombin deficiency, and deficiency of factors V, VII, X, XI, and XIII. Treatment of these disorders is by factor replacement (Mannucci, 2004b).
Thursday, December 30, 2010
Thrombocitopenia
Trombocitele variaz ca numr pe parcursul ciclului menstrual.
Cresc dup ovulaie i scad odat cu apariia menstruaiei.La unele femei aceste variaii se nsoesc de hemoragie genital.
Thursday, December 30, 2010