Rosen & Barkin's 5-Minute Emergency Medicine Consult (750 page)

• 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
    

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

• Light headedness
  
• Fatigue
  
• Weakness
  
• Thirst
  
• Duration of bleeding
  
• Quantity:
  
  • Average tampon holds ∼5 mL
    
  • Average pad holds ∼5–15 mL
    
• Last menstrual period
  
• Home pregnancy tests
  
• Prior ectopic pregnancy
  
• Passage of clots or tissue
  
• Menstrual history
  
• Family history
  
• Trauma
  

• 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
  

• 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 β-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
    
  • β-HCG if concern for retained tissue
    

• 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
  

• 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
      

• 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

• 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
    

• 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
      

• 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 β-HCG greater than institutional discriminatory zone:
  
  • Cannot exclude ectopic pregnancy
    
  • If hemodynamically stable with little bleeding, repeat measurement of β-HCG and outpatient obstetric follow-up within 48 hr
    
  • Strict return parameters
    
• US indeterminate for IUP or ectopic with β-HCG level less than institutional discriminatory zone:
  
  • Patient stable with low risk for ectopic pregnancy may be discharged
    
  • Repeat measurement of β-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
  

• 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 μg IM if <12 wk pregnant
  
• RhoGAM 300 μg IM if >12 wk pregnant