This document provides guidance on managing cases of abnormal vaginal bleeding that present to the emergency department. It outlines key steps for assessment including determining if the patient is stable or unstable, and whether they are pregnant or not. Common causes of vaginal bleeding are discussed for different age groups and stages of pregnancy, such as miscarriage, ectopic pregnancy, and complications in later pregnancy like placenta previa. Recommendations are provided on investigations, treatment approaches, and discharge criteria depending on the identified cause. Special precautions are also noted for high-risk situations.
2. ➤ Common ED presentation
- 20-40% of pregnancies have 1st trimester bleeding
➤ Wide range of differential diagnoses
➤ Can be life-threatening
➤ Distressing
INTRODUCTION
6. HISTORY
➤ Amount or volume of bleeding and duration
➤ Relation to menstrual cycle
➤ Normal cycle
➤ Other symptoms
➤ Gynae/Obstetric history including IVF
➤ PMH/FH
➤ Drugs
19. UNSTABLE PV BLEEDING
➤ Move to resus
➤ Good IV access x2
➤ FBC, UEC, Crossmatch
➤ Urgent bedside USS
➤ Resuscitate with fluid+/- blood products
➤ Consider cervical shock
➤ Urgent obs & gynae input
20. RHESUS STATUS
➤ Check rhesus status for all pregnant patients
➤ Rhesus negative
- RhD immunoglobulin 250 units IM <20 weeks
- RhD immunoglobulin 625 units IM >20 weeks
- Unclear role if <12 weeks
➤ Prevents maternal formation of antibodies from
isoimmunisation
21. QUANTITATIVE BHCG
➤ Levels increase at least 66% every 48hrs in the first 10 weeks
➤ Serial measurements are more useful
- Falling bHCG consistent with non-viable pregnancy
➤ No discrimination between miscarriage/ectopic
➤ Discriminatory zone is usually >1500 - BHCG level at which
gestational sac visible on TV USS
22. TRANS VAGINAL USS
➤ Most useful tool for determining pregnancy location
- Sensitivity ~98% and specificity 100% for IUP
- Sensitivity ~85% and specificity ~99% for ectopic
23.
24. ➤ Viable intrauterine pregnancy or threatened miscarriage
➤ Miscarriage
➤ Ectopic
➤ Pregnancy of unknown location
25. THREATENED MISCARRIAGE
PV bleeding +/- abdominal cramping with a viable foetus inside
the uterine cavity with a closed cervix
➤ Can affect up to 20% of pregnancies <20 weeks
➤ 17% go on to have further complications
Management
➤ RhD immunoglobulin if rhesus -ve
➤ Discharge with advice
➤ Follow up in EPAS clinic
26. MISCARRIAGE
Pregnancy loss before the 20th week of gestation
➤ 8-20% of pregnancies
➤ Most common in 1st trimester
➤ Risk factors include - advancing maternal age, previous
miscarriage and smoking
28. INEVITABLE MISCARRIAGE
Spontaneous miscarriage than can’t be stopped
➤ Persistant lower abdominal cramps and heavy PV bleeding
➤ Cervical os open
➤ Products of conception often visible
34. MISSED MISCARRIAGE
Foetal demise picked up on USS
➤ Products of conception retained
➤ Sometimes get an asymptomatic brownish discharge
35. ECTOPIC
Ectopic pregnancy occurs when the developing blastocyst
becomes implanted at a site other than the endometrium of the
uterine cavity
➤ 1-2% of pregnancies but 6-16% of pregnancies that present to
ED with symptoms
➤ High morbidity and mortality - 10-15% of all pregnancy deaths
➤ Risk factors include previous ectopics, previous tubal surgery,
previous PID & smoking
42. PLACENTAL ABRUPTION
Bleeding between the placenta and the uterus lining that causes
partial or complete detachment of the placenta
Risk factors include previous abruption, abdominal trauma, cocaine,
pre-eclampsia and hypertension
➤ History
- PV bleeding with abdominal pain
- Uterine contractions
➤ Examination
- Firm, tender uterus
45. ➤ A patient with PV bleeding is pregnant until proven otherwise
➤ Don’t do a PV examination on a patient with PV bleeding who
is in the third trimester of pregnancy
➤ Don’t forget Rhesus status
➤ All the information you could ever possibly need is online
46. REFERENCES
KEMH clinical guidelines - http://www.kemh.health.wa.gov.au/development/manuals/
SCGH clinical guidelines - management of 1st trimester pain and bleeding -
http://scghed.com/2015/11/scgh-early-pregnancy-guideline-102015/
eTG Complete - Menstrual disorders - https://tgldcdp-tg-org-
au.smhslibresources.health.wa.gov.au/viewTopic?topicfile=menstrual-
disorders&guidelineName=Endocrinology#toc_d1e84
Approach to vaginal bleeding in the emergency department - https://www-uptodate-
com.smhslibresources.health.wa.gov.au/contents/approach-to-vaginal-bleeding-in-the-emergency-
department?source=search_result&search=vaginal%20bleeding&selectedTitle=1~150
Diagnosis and management - Emergency Medicine - Seventh Edition. Anthony FT Brown and
Michael D Cadogan. CRC Press.
