Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Vaginal Bleeding
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) |
1) Bloody show 2) Placenta 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 |
1) Watch and wait |
| Inevitable | SA is imminent | Cervix dilated Increase cramping and bleeding |
1) Watch and wait 2) Misoprostal |
| Incomplete | Membrane ruptured and fetus passed Retention of placental tissue |
Uterus small but not well contracted Cervix open |
1) Watch and wait 2) Misoprostal |
| Complete | Complete passage of sac/gestational tissue | Uterus small and contracted Cervix closed |
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 |
- *** 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 |
Irregular bleeding Minimal pain |
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)