Vaginal Bleeding, Emergency Medicine

Basics

Description

Common presenting complaint to EDs
Most cases have benign etiology
Some patients may have potentially life-threatening conditions
Key principles in evaluating women with vaginal bleeding:
- Any woman capable of childbearing might be pregnant
- Menstrual and sexual histories do not rule out pregnancy

Etiology

PREGNANCY RELATED

Early pregnancy:
- Ectopic pregnancy (occurs in 2% of pregnancies)
- Abortion:
  - Threatened, incomplete, complete, missed, inevitable, septic
- Molar pregnancy
- Trauma
Later pregnancy:
- Placenta previa
- Placental abruption
- Molar pregnancy
- Labor
- Trauma
Immediate postpartum period:
- Postpartum hemorrhage
- Uterine inversion
- Retained placenta
- Endometritis

NONPREGNANT PATIENTS

Dysfunctional uterine bleeding (DUB)
Structural abnormalities:
- Uterine fibroids
- Cervical/endometrial polyps
- Pelvic tumors
Atrophic endometrium:
- Most common cause of postmenopausal bleeding
Rare for systemic disorders to present solely with vaginal bleeding:
- Von Willebrand disease
- Idiopathic thrombocytopenic purpura
Trauma
Foreign bodies
Infections

Diagnosis

Signs and Symptoms

History

Light headedness
Fatigue
Weakness
Thirst
Duration of bleeding
Quantity:
- Average tampon holds ’ Ό5 mL
- Average pad holds ’ Ό5 " 15 mL
Last menstrual period
Home pregnancy tests
Prior ectopic pregnancy
Passage of clots or tissue
Menstrual history
Family history
Trauma

Physical Exam

Vital signs
Cardiopulmonary exam
Abdominal exam (gravid uterus, masses)
Pelvic exam:
- Source of bleeding
- Evidence of trauma
- Cervical os open or closed
Change in mental status may occur with significant blood loss and/or hypotension

Essential Workup

Qualitative pregnancy test:
- Point-of-care urine-based pregnancy test preferred
Pelvic exam:
- Essential for all women with vaginal bleeding
- Assess whether cervical os open or closed
- Delay pelvic exam pending US result in late pregnancy:
  - Evaluate for placenta previa
- Defer exam if patient is near term with possible rupture of fetal membranes
Pregnancy test mandatory for all patients with childbearing potential
Early pregnancy:
- Blood type and Rh
- US to confirm intrauterine pregnancy (IUP)
- Quantitative ²-human chorionic gonadotropin (HCG)
- Hematocrit
- Type and cross-match:
  - Ectopic pregnancy
  - Low hematocrit levels
  - Hemodynamic instability
- UA
Later pregnancy:
- Type and Rh
- Fetal heart tones
- US indications:
  - No fetal heart tones
  - No documented IUP
  - Unknown placental lie
- Hematocrit if significant bleeding
- Type and cross-match if placenta previa/abruption or low hematocrit levels
- DIC panel if placental abruption:
  - Platelets, PT, PTT, Fibrinogen, fibrin split products
Early postpartum:
- US for retained products
- Hematocrit
- ²-HCG if concern for retained tissue

Diagnosis Tests & Interpretation

Lab

Qualitative and/or quantitative HCG
Hematocrit for women with significant bleeding
Type and Rh
Platelet count for suspected thrombocytopenia
PT/PTT for suspected coagulopathy
Send any passed tissue or clot for pathology evaluation

Imaging

Bedside US may be indicated based on presentation, pregnancy status, and other considerations:
US and discriminatory zone:
- Transabdominal US:
  - Should detect gestational sac if HCG >6,500 mIU/mL
- Transvaginal US:
  - Should detect gestational sac if HCG >1,000 " 1,500 mIU/mL

Differential Diagnosis

DUB
Ectopic pregnancy
Menorrhagia
Menometrorrhagia
Threatened miscarriage
Placental abruption
Placenta previa
Postpartum hemorrhage
Leiomyoma
Pelvic masses and tumors
Postcoital bleeding
Traumatic injury
Thyroid dysfunction
Bleeding disorders

Treatment

Pre-Hospital

Establish IV 0.9% NS with 1 " 2 L fluid bolus for significant bleeding or hypotension
Administer high-flow oxygen in pregnant or unstable patients
In later pregnancy:
- Place patient in left lateral recumbent position to prevent occlusion

Initial Stabilization/Therapy

Manage airway and resuscitate as indicated
Place cardiac/pulse oximeter monitors
Oxygen for significant bleeding or unstable patient
Establish 2 large-bore IVlines and initiate fluid bolus (1 " 2 L) for hypotensive patients
Type and cross-match:
- Transfuse blood if continued hypotension from blood loss despite IV fluid resuscitation
- Conjugated estrogens (Premarin) 25 mg IV slowly over 10 " 15 min q4 " 6h until bleeding stops for uncontrolled menorrhagia:
  - Not to exceed 4 doses

Ed Treatment/Procedures

If unstable with surgical condition, arrange for transfer of the patient to the OR as soon as possible
RhoGAM for vaginal bleeding, pregnancy, and Rh-negative mother

EARLY PREGNANCY

If US reveals an ectopic pregnancy:
- Methotrexate according to standards at treating institution
- Definitive treatment is surgery
If US reveals an IUP without concerns of heterotopic pregnancy (1/2,600 " 1/30,000):
- Discharge patient with arranged obstetric follow-up with precautions for a threatened miscarriage
US indeterminate for IUP or ectopic with ²-HCG greater than institutional discriminatory zone:
- Cannot exclude ectopic pregnancy
- If hemodynamically stable with little bleeding, repeat measurement of ²-HCG and outpatient obstetric follow-up within 48 hr
- Strict return parameters
US indeterminate for IUP or ectopic with ²-HCG level less than institutional discriminatory zone:
- Patient stable with low risk for ectopic pregnancy may be discharged
- Repeat measurement of ²-HCG level and obstetric follow-up within 48 hr
- Patient may still have an ectopic pregnancy
Complete abortion:
- Discharge patient if stable without significant ongoing bleeding
Incomplete abortion:
- Obstetric consultation is required
- Dilation and curettage vs. expectant management
Missed abortion:
- Expectant management initially
Septic abortion:
- IV antibiotics and admission
Molar pregnancy:
- Chemotherapy
- Very responsive in early stages of disease

LATER PREGNANCY

Placenta previa:
- Obstetric consultation for possible admission
Placental abruption:
- Induction of labor if large
- Can lead to fetal/maternal death
- May require cesarean section

IMMEDIATE POSTPARTUM

Uterine inversion:
- Prevent by avoiding strong traction on umbilical cord after delivery
- Replace uterus immediately
- Occasionally requires operative management
Postpartum hemorrhage:
- Extraction of placenta if retained
- Hysterectomy if uncontrolled life-threatening bleeding

EARLY POSTPARTUM

Retained tissue:
- Dilation and curettage
Endometritis:
- IV antibiotics

NONPREGNANT

Menses:
- NSAIDs and supportive care
DUB:
- <35 " 40 yr of age:
  - If known anovulatory DUB:
  - Medroxyprogesterone (Provera) " warn patient about withdrawal bleeding
  - Oral contraceptive pill daily for 7 days
- Patients >35 " 40 yr of age:
  - US for any masses palpated during physical exam
  - Gynecologic referral
  - Uterine sampling necessary before initiation of hormonal treatment
  - Evaluate for endometrial cancer

STRUCTURAL ABNORMALITIES

Pap smear/biopsy for cervical lesions
US for workup of pelvic masses
Fibroids or uterine tumors
Conservative management or lumpectomy/hysterectomy

Medication

Conjugated estrogens 25 mg IV slowly over 10 " 15 min q6h until bleeding stops(not to exceed 4 doses)
- If no response after 1 " 2 doses re-evaluation needed
Known anovulatory DUB:
- Medroxyprogesterone 10 mg PO per day for 1st 10 days of menstrual cycle (warn patient about withdrawal bleeding)
- Norethindrone and ethinyl estradiol (Ortho-Novum) 1/35 BID for 7 days
MICRhoGAM 50 Όg IM if <12 wk pregnant
RhoGAM 300 Όg IM if >12 wk pregnant

Follow-Up

Disposition

Admission Criteria

Ectopic pregnancy not meeting methotrexate discharge criteria
Uterine inversion
Septic abortion
Placental abruption
Postpartum hemorrhage
Endometritis
Unstable DUB
Newly diagnosed molar pregnancy

Discharge Criteria

Stable vital signs
Confirmed IUP
Ectopic pregnancy meeting institutional methotrexate discharge criteria
Pregnant patient with low risk for ectopic pregnancy:
- No findings of IUP on US
- Levels of ²-HCG below discriminatory zone
Nonpregnant patients with vaginal bleeding that are hemodynamically stable

Issues for Referral
Obstetric/gynecologic referral

Follow-Up Recommendations

Obstetric referral within 48 hr for 1st-trimester vaginal bleeding without identified IUP
OB/GYN referral for patients with menorrhagia for continued evaluation, workup, and treatment

Patient Education

Ectopic precautions: Return immediately for increasing abdominal pain, vaginal bleeding more than 1 pad per hr for 3 " 4 hr, fever >100.4 °F, syncope, or dizziness. Patients should not be left alone until the diagnosis of ectopic pregnancy can be safely ruled out. Family and friends should also be instructed on the warning signs and symptoms of ruptured/bleeding ectopic pregnancies.

Pearls and Pitfalls

Pregnancy test for all women of reproductive age
If there is 1st-trimester vaginal bleeding, evaluate for ectopic pregnancy

Additional Reading

Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008;35:219 " 234.
McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin North Am. 2008;88:265 " 283.
Oyelese Y, Scorza WE, Mastrolia R, et al. Postpartum hemorrhage. Obstet Gynecol Clin North Am. 2007;34:421 " 241.
Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician. 2007;75:1119 " 1206.
Tsai MC, Goldstein SR. Office diagnosis and management of abnormal uterine bleeding. Clin Obstet Gynecol. 2012;55:635 " 650.

Codes

ICD9

623.8 Other specified noninflammatory disorders of vagina
640.90 Unspecified hemorrhage in early pregnancy, unspecified as to episode of care or not applicable
641.80 Other antepartum hemorrhage, unspecified as to episode of care or not applicable
641.80 Other antepartum hemorrhage, unspecified as to episode of care or not applicable
626.8 Other disorders of menstruation and other abnormal bleeding from female genital tract
634.90 Spontaneous abortion, without mention of complication, unspecified
627.1 Postmenopausal bleeding
633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
615.9 Unspecified inflammatory disease of uterus
640.00 Threatened abortion, unspecified as to episode of care
641.10 Hemorrhage from placenta previa, unspecified as to episode of care or not applicable
641.20 Premature separation of placenta, unspecified as to episode of care or not applicable
666.00 Third-stage postpartum hemorrhage, unspecified as to episode of care or not applicable

ICD10

O20.9 Hemorrhage in early pregnancy, unspecified
O46.90 Antepartum hemorrhage, unspecified, unspecified trimester
N93.9 Abnormal uterine and vaginal bleeding, unspecified
O46.90 Antepartum hemorrhage, unspecified, unspecified trimester
N93.8 Other specified abnormal uterine and vaginal bleeding
O03.9 Complete or unspecified spontaneous abortion without complication
N95.0 Postmenopausal bleeding
O00.9 Ectopic pregnancy, unspecified
N71.9 Inflammatory disease of uterus, unspecified
O20.0 Threatened abortion
O44.10 Placenta previa with hemorrhage, unspecified trimester
O45.90 Premature separation of placenta, unsp, unsp trimester
O72.0 Third-stage hemorrhage

SNOMED

289530006 bleeding from vagina (finding)
34842007 Antepartum hemorrhage (disorder)
25825004 hemorrhage in early pregnancy (disorder)
34842007 Antepartum hemorrhage (disorder)
17369002 Miscarriage (disorder)
19155002 Dysfunctional uterine bleeding (finding)
34801009 Ectopic pregnancy (disorder)
76742009 Postmenopausal bleeding (finding)
109894007 Retained placenta (disorder)
198903000 Placenta previa with hemorrhage
415105001 placental abruption (disorder)
54048003 Threatened abortion (disorder)
78623009 Endometritis (disorder)

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