Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Vaginal Bleeding

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Vaginal Bleeding - Key Features

1. In any woman with vaginal bleeding, rule out pregnancy.

2. In pregnant patients with vaginal bleeding
a) Consider worrisome causes (e.g., ectopic pregnancy, abruption, abortion), and confirm or exclude the diagnosis through appropriate interpretation of test results.
b) Do not forget blood typing and screening, and offer rH immunoglobulin treatment, if appropriate.
c) Diagnose (and treat) hemodynamic instability.

First Trimester (20-40% of pregnancies) Second and Third Trimester
1) Implantation bleeding

2) Abnormal pregnancy (ectopic or molar)
3) Miscarriage (threatened, inevitable, incomplete, complete)
4) Uterine, Cervical, Vaginal pathology

1) Bloody show

2) Placenta previa
3) Placental Abruption
4) Uterine Rupture
5) Vasa previa


1st Trimester bleeding

HX:
Preg Hx
GTPAL, Dates/LMP, Ultrasound
Concerns with current or past pregnancies
Blood type/ Partners blood type
Bleeding Hx
Onset and Duration
Quantity – # of pads
Passing tissue or clots
RF: trauma, Intercourse, bleeding disorder, fibroid, pelvic surgery, PID, STD, IUD
PX:
ABC’s, Orthostatic Vital
Abdominal Exam- ? FHR
Pelvic Exam- look for source, is cervix open or closed, products of conception
Investigation
CBCD, lytes, BUN, Cr
Group and Screen
B-HCG
Transvaginal Ultrasound


Miscarriage Definition and Management

Definition Clinical Management
Threatened Bleeding through a closed os Cervix closed

Bleeding
+FHR

1) Watch and wait
Inevitable SA is imminent Cervix dilated

Increase cramping and bleeding
Tissue visualized in os

1) Watch and wait

2) Misoprostal

Incomplete Membrane ruptured and fetus passed

Retention of placental tissue

Uterus small but not well contracted

Cervix open
++ bleeding

1) Watch and wait

2) Misoprostal
3) D&C

Complete Complete passage of sac/gestational tissue Uterus small and contracted

Cervix closed
Scant vaginal bleeding

No management needed
Missed abortion Intrauterine death prior to 20 weeks with retention of pregnancy for prolonged period of time 1) watch and wait

2) Misoprostal
3) D&C

*** rh immunoglobulin if RH -


Management of Ectopic Pregnancy
1) Suspect if abdominal pain, vaginal pain and + b-hCG
2) Surgery if vitals unstable
3) Transvaginal ultrasound if stable (should see gestational sac 5.5-6 wks after LMP)
4) Methotrexate if : <3.5cm, unruptured, absent FHR, b-hCG <5000, no liver/renal/heme dz, willing and able to follow up. HCG is followed until undetectable

2nd and 3rd Trimester Bleed

Differential Diagnosis
Cervix/Vagina- polyps, CA, postcoital, laceration
Bloody show
Uterine Rupture
Placental


1) Abruption - placental separation
Presentation- bleeding plus abdominal/back pain, increased uterine tone, uterine irritability/contractions, +/- fetal distress/demise
RF include HTN, previous abruption, large uterus (macrosomia, polyhydramnios, multiple gestation), smoking, EtOH, cocaine, uterine anomaly, trauma
2) Placental Previa • Placenta over OS- Types: Complete or Partial previa. Marginal or Low lying
Presentation -Painless vaginal bleeding, uterus soft non-tender,+/- fetal distress
RF include history of placenta previa, multiple gestation, multiparity, increased maternal age, uterine anomalies including surgical scars
3) Vasa previa - rupture of fetal vessels- Painless vaginal bleeding and fetal distress


Physical Exam
Vitals- maternal and fetal
Abdominal exam including measurement of uterine size, Leopolds, increased uterine tone
Doppler for fetal heart NST
Sterile speculum-Amount of bleeding, tissue/clots, cervical dilatation, uterine and adnexal tenderness
** NO bimanual until previa ruled out with ultrasound
Investigations
CBC, blood type/type and screen, crossmatch- Rh status
Kleihaurer/Apt test- assess fetal blood
Fetal Ultrasound assess for abruption
Management
Maternal stabilization - ABC's, monitors, IV fluids, PRBCs if required
Continuous Fetal monitoring
Rhogam Rh negative -300mcg IM
Consider corticosteroids for fetal lung immaturity (24-34 weeks GA)- Betamethasone 12mg IM q24 hr x2
Abruption
<37 weeks - serial hemoglobin, deliver when hemorrhage dictates o
>37 weeks - stabilize and deliver
Placenta previa-Keep pregnancy intrauterine until the risk of delivery < risk of not delivering
Vasa previa- Emergency cesarean section


3. In a non-pregnant patient with vaginal bleeding:
a) Do an appropriate work-up and testing to diagnose worrisome causes (e.g., cancer), using an age-appropriate approach.
b) Diagnose (and treat) hemodynamic instability.
c) Manage hemodynamically stable but significant vaginal bleeding (e.g., with medical versus surgical treatment).

Abnormal Uterine Bleeding: any persistent change in menstrual period frequency, duration or amount +/- breakthrough bleeding
Dysfunctional Uterine Bleeding: excessively heavy, prolonged or frequent bleeding of uterine origin which is not due to pregnancy or to recognizable pelvic or systemic disease

Hx: RULE OUT PREGNANCY
Amt-Def:>80 ml, changing soaked pad >1 hr, changing pad overnight, postural hypotension

Ovulatory vs.Anovulatory

Ovulatory Anovulatory
Cyclical bleeding

Premenstrual symptoms
Midcycle pain
Dysmenorrhea

Irregular bleeding

Minimal pain
Higher risk of endometrial hyperplasia or cancer

Psychosocial issues-stress
Medication causing bleeding- Anticoagulants, ASA, Phenzothiazines, SSRI, TCA, Tamoxifen, Corticosteroids, Thyroxine, Contraception-OCP, DEPO, IUD Systemic causes- ie. Thyroid

PX:
Pap + swabs
Pelvic/bimanual exam

*detect genital tract pathology (fibroids. Polyps
* if abnormal consider transvaginal ultrasound


Investigations: CBC, ferritin, TSH
Coagulation work up- of FH/bleeding dyscrasia
Pelvic ultrasound
Endometrial biopsy

Endometrial Cancer Risk Factors
BMI >40
Age >40
DM
Anovulatory cycles/PCOS
Tamoxifen
FH of endometrial CA or colon CA

Management of Acute Bleeding

If stable: Hormonal contraceptive 2-4 pills per day for 7 days and then 1 pill/d for 2 weeks
If unstable: Send to emerg,
Conjugated equine estrogen (premarin) 25mg IV q 6 hr x 4 doses
Once bleeding has subsided oral hormonal therapy is continued for 2-3 weeks with conjugated estrogen 2.5 mg-10 mg daily along with progesterone (provera )10 mg for the last 10 days
Should be followed by cyclic hormonal contraceptive or cyclic progestin for 4-6 months
Gyne consult for surgical options- hysteroscopy, endometrial ablation, hysterectomy


4. In a post-menopausal woman with vaginal bleeding, investigate any new or changed vaginal bleeding in a timely manner (e.g., with endometrial biopsy testing, ultrasonography, computed tomography, a Pap test, and with a pelvic examination).

Post- Menopausal Vaginal Bleeding

* Most common cause in post-menopausal women is endometrial/vaginal atrophy
Ddx/Frequency:
Atrophic Vaginitis 59%
Endometrial polyp 12%
Endometrial hyperplasia 10%
Endometrial CA 10%
Hormonal Effect 7%
Cervical CA 2%
OTHER <1%


Hx Important Question
Amount/Frequency of blood loss
Medication: HRT, anticoagulants, ASA, Tamoxifen


PX
Vitals- Are they hemodynamically stable?
Pelvic Exam- atrophic/infectious vaginitis, cervical polyps, uterine size and contour
Pap and Swabs


Investigation
CBC, ferritin, TSH
Tranvaginal Ultrasound
* Sensitivity 96% for detecting endometrial CA
* If endometrial echo (EE) < 5 mm and symptoms resolve- WATCH
* If endometrial echo (EE) > 5 mm or symptoms persist- NEED ENDOMETRIAL biopsy
* Either endometrial biopsy, transvaginal US or both can be done to initially assess the endometrium- can base choice of first investigation upon patient preference, physician comfort with procedure, US availability


TX
Results of Biopsy
Normal- Symptoms resolve- watch
Hyperplasia without Atypia- Treat with Provera and repeat biopsy in 3-6 months
Hyperplasia with Atypia/Cancer- Gyne consult for surgery


TX for Vaginal Atrophy- Topical estrogen (creams, tablets, vaginal ring)

Study Guide

Vaginal Bleeding

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