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Vaginal Bleeding, Emergency Medicine

Basics

Description

- 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

- 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

- Later pregnancy: - Type and Rh - Fetal heart tones - US indications: - No fetal heart tones - No documented IUP - Unknown placental lie

- If US reveals an ectopic pregnancy: - Methotrexate according to standards at treating institution - Definitive treatment is surgery

- Incomplete abortion: - Obstetric consultation is required - Dilation and curettage vs. expectant management

- Molar pregnancy: - Chemotherapy - Very responsive in early stages of disease

- Uterine inversion: - Prevent by avoiding strong traction on umbilical cord after delivery - Replace uterus immediately - Occasionally requires operative management

  • 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 pregnantMenstrual 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, septicMolar pregnancyTrauma
  • Later pregnancy:Placenta previaPlacental abruptionMolar pregnancyLaborTrauma
  • Immediate postpartum period:Postpartum hemorrhageUterine inversionRetained placentaEndometritis

NONPREGNANT PATIENTS

  • Dysfunctional uterine bleeding (DUB)
  • Structural abnormalities:Uterine fibroidsCervical/endometrial polypsPelvic tumors
  • Atrophic endometrium:Most common cause of postmenopausal bleeding
  • Rare for systemic disorders to present solely with vaginal bleeding:Von Willebrand diseaseIdiopathic thrombocytopenic purpura
  • Trauma
  • Foreign bodies
  • Infections

Diagnosis

Signs and Symptoms

History

  • Light headedness
  • Fatigue
  • Weakness
  • Thirst
  • Duration of bleeding
  • Quantity:Average tampon holds ’ Ό5 mLAverage 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 bleedingEvidence of traumaCervical 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 bleedingAssess whether cervical os open or closedDelay pelvic exam pending US result in late pregnancy:Evaluate for placenta previaDefer 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 RhUS to confirm intrauterine pregnancy (IUP)Quantitative ²-human chorionic gonadotropin (HCG)HematocritType and cross-match:Ectopic pregnancyLow hematocrit levelsHemodynamic instabilityUA
  • Later pregnancy:Type and RhFetal heart tonesUS indications:No fetal heart tonesNo documented IUPUnknown placental lieHematocrit if significant bleedingType and cross-match if placenta previa/abruption or low hematocrit levelsDIC panel if placental abruption:Platelets, PT, PTT, Fibrinogen, fibrin split products
  • Early postpartum:US for retained productsHematocrit 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/mLTransvaginal 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 resuscitationConjugated estrogens (Premarin) 25 mg IV slowly over 10 " 15 min q4 " 6h until bleeding stops for uncontrolled menorrhagia:

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 institutionDefinitive 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 pregnancyIf hemodynamically stable with little bleeding, repeat measurement of ²-HCG and outpatient obstetric follow-up within 48 hrStrict 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 dischargedRepeat measurement of ²-HCG level and obstetric follow-up within 48 hrPatient may still have an ectopic pregnancy
  • Complete abortion:Discharge patient if stable without significant ongoing bleeding
  • Incomplete abortion:Obstetric consultation is requiredDilation and curettage vs. expectant management
  • Missed abortion:Expectant management initially
  • Septic abortion:IV antibiotics and admission
  • Molar pregnancy:ChemotherapyVery responsive in early stages of disease

LATER PREGNANCY

  • Placenta previa:Obstetric consultation for possible admission
  • Placental abruption:Induction of labor if largeCan lead to fetal/maternal deathMay require cesarean section

IMMEDIATE POSTPARTUM

  • Uterine inversion:Prevent by avoiding strong traction on umbilical cord after deliveryReplace uterus immediatelyOccasionally requires operative management
  • Postpartum hemorrhage:Extraction of placenta if retainedHysterectomy if uncontrolled life-threatening bleeding

EARLY POSTPARTUM

  • Retained tissue:
  • Endometritis:

NONPREGNANT

  • Menses:NSAIDs and supportive care
  • DUB:<35 " 40 yr of age:If known anovulatory DUB:Medroxyprogesterone (Provera) " warn patient about withdrawal bleedingOral contraceptive pill daily for 7 daysPatients >35 " 40 yr of age:US for any masses palpated during physical examGynecologic referralUterine sampling necessary before initiation of hormonal treatmentEvaluate 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 USLevels 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Vaginal Bleeding in Pregnancy
  • Threatened Abortion
  • Placental Abruption
  • Placenta Previa
  • Ectopic Pregnancy

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)