PV bleeding refers to bleeding from the vagina. It can be normal menstruation or abnormal. Abnormal PV bleeding has many potential causes and requires assessment of whether the patient is stable, pregnant, and if pregnant, how far along. Important questions are the amount of bleeding, relation to menstrual cycle, symptoms, medical history, and examination. Differential diagnoses include issues like polyps, fibroids, pregnancy complications, or coagulation disorders. Management depends on the diagnosis and may include Rh immunoglobulin, monitoring, procedures, or resuscitation.

1. DR. TOUSIF SHEIKH

2.  PV BLEEDING IS A REFERS TO BLEEDING FROM
THE VAGINA.

3. NORMAL BLEEDING PV
ABNORMAL BLEEDING PV

4.  -Normal menstruation occurs as the
endometrium sloughs from the uterus, with
consequent bleeding.
 -The flow lasts for three to five days; in
some cases as short as one day, or as long as
eight days.
 - Normal blood loss is around 30 mls per
cycle; the normal range is up to 80 mls per
cycle.

5.  ➤ Common OPD/IPD presentation - 20-40% of
pregnancies have 1st trimester bleeding
 ➤ Wide range of differential diagnoses

 ➤ Can be life-threatening
 ➤ Distressing

6. 1
•Assessment of patient
2
•IMPORTANT CAUSE
3
•MANAGEMENT

8. TWO IMPORTANT QUESTIONS
STABLE OR NOT
PREGNANT OR NOT

9.  Amount or volume of bleeding and duration
 ➤ Relation to menstrual cycle
 ➤ Normal cycle
 ➤ Other symptoms
 ➤ Gynae/Obstetric history including IVF
 ➤ PMH/FH
 ➤ Drugs

10.  ➤ General appearance
 ➤ Observations
 ➤ Abdominal examination
 ➤ Pelvic examination
 TPR/BP

12.  Urine bHCG
 ➤ Bloods/Group & Hold

 ➤ Check rhesus status
 ➤ USG

17.  ➤ Polyps
 ➤ Adenomyosis
 ➤ Fibroids
 ➤ Malignancy

18.  ➤ Coagulopathy
 ➤ Ovulatory dysfunction
 ➤ Endometrial dysfunction
 ➤ Iatrogenic

20.  ➤ Move to rhesus
 ➤ Good IV access x2
 ➤ FBC, UEC, CrossMatch
 ➤ Urgent bedside USS
 ➤ Resuscitate with fluid+/- blood products
 ➤ Consider cervical shock
 ➤ Urgent obs & gynae input

22.  ➤ 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

23.  ➤ Viable intrauterine pregnancy or
threatened miscarriage
 ➤ Miscarriage
 ➤ Ectopic
 ➤ Pregnancy of unknown location

24.  PV bleeding +/- abdominal cramping with a
viable fetus 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

25.  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

26.  Spontaneous miscarriage than can’t be
stopped
 ➤ Persistent lower abdominal cramps and
heavy PV bleeding
 ➤ Cervical os open
 ➤ Products of conception often visible

27.  Part of the products of conception is
retained in the uterus.
 ➤ Persistent cramps and heavy PV bleeding

28.  Inevitable
 Incomplete
 Complete

29.  All products of conception expelled
 ➤ Cramps and PV bleeding stop
 ➤ Cervical os closed

30.  Foetal demise picked up on USG
 ➤ Products of conception retained
 ➤ Sometimes get an asymptomatic brownish
discharge

31.  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

32.  ➤ History - Bleeding - Abdominal pain –
Amenorrhea
 ➤ Examination - Lower abdominal
tenderness/mass - Shock

33.  ➤ TV USG
 ➤ TV USG + Discriminatory bHCG

36.  Antepartum haemorrhage
 - is bleeding from the vagina during
pregnancy from twenty four weeks . -medical
attention should be sought immediately, as if
it is left untreated it can lead to death of the
mother and/or fetus - Bleeding without pain
is most frequently bloody show, which is
benign; however, it may also be placenta
previa (in which both the mother and fetus
are in danger). -Painful APH is most
frequently placental abruption (which may
also lead to adverse fetal and/or maternal
outcomes).

37.  Placental tissue extending over the cervical os
 ➤ History - Painless PV bleeding
 ➤ Examination - Soft uterus

40.  Post-partum Haemorrhage
 (PPH) - Primary post-partum haemorrhage is
loss of blood estimated to be >500ml, from
the genital tract, within 24 hours of delivery.
- Secondary PPH is defined as abnormal
bleeding from the genital tract, from 24
hours after delivery until 6 weeks post-
partum.

43.  ➤ 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
 ➤ALWAYS REPLACE LOST BLOOD.

44. DR. TOUSIF SHEIKH