1. Vaginal Bleeding in OPD Dr. Dianne M.P. Graham M.D. Vaginal Bleeding in the ER Sept 2014 2

2. Basic Questions 1. Is the patient hemodynamically stable? 2. Is the patient pregnant?  If YES, is it first trimester or late stage?  If NO, what diagnoses are appropriate for this age? Vaginal Bleeding in the ER Sept 2014 3

3. Initial Assessment Vaginal Bleeding in the ER Sept 2014 4

4. Patient Bleeding History Volume & Duration?  Number of pads/cloths changed in last 24 hrs.?  Note: Heavy bleeding requires change min. every 3 hrs.  How saturated were cloths?  Presence of clots? Vaginal Bleeding in the ER Sept 2014 5

5. Patient Bleeding History Timing?  Did bleeding begin at scheduled onset of period?  Did bleeding begin prematurely or late?  Was menstrual period missed? Vaginal Bleeding in the ER Sept 2014 6

6. Patient Bleeding History Pregnant?  Unprotected sexual intercourse?  Method of contraception?  Date of last menstrual period?  Any change in frequency of periods?  Have periods been lighter than usual? (Possible ectopic pregnancy) Vaginal Bleeding in the ER Sept 2014 7

7. Patient Bleeding History Associated Symptoms?  Fever or chills?  Suggests pelvic inflammatory disease, UTI or septic abortion  Urinary symptoms?  Possible hemorrhagic cystitis  Any pain?  Onset?  Location?  Duration?  What aggravates or relieves it? Vaginal Bleeding in the ER Sept 2014 8

8. Patient Bleeding History Current Medication?  On oral contraceptive pill?  On anticoagulants?  On hormone replacement? Vaginal Bleeding in the ER Sept 2014 9

9. Patient Bleeding History Multiple Site Bleeding?  Mucous membranes?  Easy bruising?  Prolonged heavy periods?  Family history of bleeding?  Recent pregnancy with Hypertension and/or Toxemia? Vaginal Bleeding in the ER Sept 2014 10

10. Patient Bleeding History Any Unrelated Symptoms?  Weight gain, fatigue, cold intolerance, constipation, hair loss? (hypothyroidism)  Obesity, hirsutism & irregular menses? (polycystic ovary disease)  Headaches, visual changes? (pituitary tumor) Vaginal Bleeding in the ER Sept 2014 11

11. Physical Examination Vaginal Bleeding in the ER Sept 2014 12

12. Physical Examination Purpose  Uncovers evidence of significant blood loss  Identifies underlying causes of genital tract bleeding  Provides vital signs to assess hemodynamic instability Vaginal Bleeding in the ER Sept 2014 13

13. Life Threatening Indicators ANY OF THE FOLLOWING:  Systolic Blood Pressure <90 mm Hg  Pulse >110  Soaking Pads or Cloth every 15 min. or less  Unconscious Vaginal Bleeding in the ER Sept 2014 14

14. Life Threatening Emergency Management  Airway  Intubate if Unconscious  Breathing  Oxygen 5L /min.  Circulation  Obtain 2 large-bore IV’s - #16 or #18 gauge  IV NS or Ringer’s Lactate Vaginal Bleeding in the ER Sept 2014 15

15. Physical Examination Observations  Anemia  Pale skin or conjunctivae  Bleeding disorders  Mucosa, hemorrhage, purpura or petechiae Vaginal Bleeding in the ER Sept 2014 16

16. Abdominal Exam  Abdominal mass?  Localized abdominal tenderness?  Peritoneal signs?  Pelvic Inflammatory Disease (P.I.D)  Ruptured ectopic pregnancy  Hemorrhagic ovarian cyst Vaginal Bleeding in the ER Sept 2014 17

17. Pelvic Exam  The pelvic exam is NOT performed in the third trimester of pregnancy  Risk of causing separation of placenta previa Vaginal Bleeding in the ER Sept 2014 18

18. Pelvic Exam  Site of bleeding?  Volume of bleeding?  Trauma?  Products of conception?  Uterine size & surface contours?  Adnexal mass or tenderness? Vaginal Bleeding in the ER Sept 2014 19

19. Investigations Vaginal Bleeding in the ER Sept 2014 20

20. Investigations Pregnancy Tests  Urine pregnancy test (hCG)  Quantitative serum hCG level  If urine hCG is positive or if urine hCG is negative but you suspect pregnancy  Symptomatic patients with hCG levels <1000 mIU/L are 4 times more likely to have an ectopic pregnancy Vaginal Bleeding in the ER Sept 2014 21

21. Investigations Pelvic Ultrasound (US)  Vaginal US exam follows a positive pregnancy test  Vaginal US can identify intrauterine pregnancy by 35 days since Last Menstrual Period (LMP)  US excellent to identify placenta previa in 3 rd trimester  US less useful in non-pregnant patients with painless Vaginal Bleeding Vaginal Bleeding in the ER Sept 2014 22

22. Investigations Additional Tests for Vaginal Bleeding  Blood type & cross match in severe bleeding  Blood type & screen for less severe bleeding  CBC with Hematocrit  Platelets, INR, PTT if coagulopathy suspected  Cervical/vaginal cultures if infection suspected Vaginal Bleeding in the ER Sept 2014 23

23. Life Threatening Causes of Genital Tract Bleeding Early Pregnancy Vaginal Bleeding in the ER Sept 2014 24

24. Early Pregnancy Patient Bleeding Management  Perform Pelvic Exam  Pelvic US (to rule out ectopic pregnancy)  Obtain Quantitative Serum hCG (If available) Vaginal Bleeding in the ER Sept 2014 25

25. Life Threatening Causes Early Pregnancy Ruptured Ectopic Pregnancy  Symptoms 6 to 8 weeks after last normal period  Beware LMP “Much lighter than normal”  Normal pregnancy symptoms  Breast tenderness, nausea, frequent urination  Abdominal pain  Bleeding  Symptoms - unremarkable to profound shock Vaginal Bleeding in the ER Sept 2014 26

26. Life Threatening Causes Early Pregnancy Septic Abortion  Symptoms  Fever & chills  Foul discharge  History of attempted abortion (Common cause of mortality in younger women) Vaginal Bleeding in the ER Sept 2014 27

27. Life Threatening Causes of Genital Tract Bleeding Third Trimester Vaginal Bleeding in the ER Sept 2014 28

28. Life Threatening Causes 3 rd Trimester Placental Abruption  Painful bleeding  Uterine contractions  Uterine tenderness  US not always useful  Monitor vital signs Amount of visible bleeding does not always indicate severity of abruption Vaginal Bleeding in the ER Sept 2014 29

29. Life Threatening Causes 3 rd Trimester Placenta Previa  Painless vaginal bleeding  Ultrasound useful  DO NOT perform pelvic exam Vaginal Bleeding in the ER Sept 2014 30

30. Life Threatening Causes of Genital Tract Bleeding Post Partum Vaginal Bleeding in the ER Sept 2014 31

31. Life Threatening Causes Post Partum Hemorrhage Major cause of maternal death in developing countries  Occurs 0 to 3 months after delivery  Bleeding > 500 ml after delivery  Any blood loss with hemodynamically unstable woman Vaginal Bleeding in the ER Sept 2014 32

32. Life Threatening Causes Post Partum Hemorrhage (PPH) 4 “T’s” for PPH 1. Tone - Uterine atony 2. Tissue – Retarded placenta or clots 3. Trauma – Tears of vagina, cervix, uterus or uterine rupture 4. Thrombin – pre-existing coagulopathy, or acquired coagulopathy such as pregnancy induced hypertension & HELLP Syndrome (HELLP=High Elevated Liver enzymes and Low Platelets) Vaginal Bleeding in the ER Sept 2014 33

33. Life Threatening Causes of Genital Tract Bleeding Non Pregnant Patient Vaginal Bleeding in the ER Sept 2014 34

34. Life Threatening Causes Non Pregnant Patient  Acute Severe Menorrhagia  Genital Trauma (including sexual & physical abuse) Vaginal Bleeding in the ER Sept 2014 35

35. Non-Life Threatening Causes Non Pregnant Patient  Spontaneous abortion  Ruptured ovarian cyst  Infection - Pelvic Inflammatory Disease (PID)  Foreign bodies  Coagulation disorders  Gynecological cancers  Endometrial cancer, vaginal or cervical cancer Vaginal Bleeding in the ER Sept 2014 36

36. Vaginal Bleeding Pre Menopausal Women Common Causes  Dysfunctional uterine bleeding  Estrogen/progesterone imbalance  Uterine or endometrial polyps  Infection (PID)  Endocrine dysfunction (Thyroid, Pituitary) Vaginal Bleeding in the ER Sept 2014 37

37. Vaginal Bleeding Post Menopausal Women Common Causes  Cancers  Especially in > 35 years of age  Vaginal cancers Vaginal Bleeding in the ER Sept 2014 38

38. CAUTION Ensure bleeding is from the vagina!  Other possible sources:  Urinary Tract  Hemorrhagic cystitis  Cancer  Lower gastro intestinal bleeding  Hemorrhoids  Inflammatory bowel disease Vaginal Bleeding in the ER Sept 2014 39

39. Non Life Threatening Causes of Genital Tract Bleeding Pregnant Patient Vaginal Bleeding in the ER Sept 2014 40

40. Early Pregnancy Bleeding Pelvic Exam  Tenderness and or Mass in Pelvic Area  Possible Ectopic Pregnancy or Ovarian Cyst  Cervix Open, No Tissue  Complete Abortion  Cervix Open with Tissue  Incomplete Abortion  Cervix Closed With Bleeding  Threatened Abortion Vaginal Bleeding in the ER Sept 2014 41

41. Ectopic Pregnancy Action Plan  Urgent Gyn Consultation  Confirm Blood Type & Cross Match  Confirm 2 large bore IV’s in Place  Monitor Vital Signs Closely Vaginal Bleeding in the ER Sept 2014 42

42. Late Pregnancy Bleeding  DO NOT perform Pelvic Exam  OB Consultation  Do Blood Type & Screen  Do CBC  Differential Diagnosis:  Placental abruption  Placenta Previa  Trauma or abuse  Early labour Vaginal Bleeding in the ER Sept 2014 43

43. Non-Pregnant Patients  Peri or Postmenopausal  Key Concern - Endometrial Cancer  Action – Refer to Gynecologist for endometrial biopsy & follow up Vaginal Bleeding in the ER Sept 2014 44

44. Non-Pregnant Patients  Premenopausal  Key Concerns – PID, Ovarian Torsion, Ruptured Ovarian Cyst, Dysfunctional Uterine Bleeding  Action – Appropriate treatment &/or referral Vaginal Bleeding in the ER Sept 2014 45

45. Non-Pregnant Patients  Premenarchal  Key Concerns – Bleeding Disorder, Thyroid, Trauma or Sexual Assault  Action – Treat Causes & Pediatric Follow Up Vaginal Bleeding in the ER Sept 2014 46