This document provides guidance on managing abnormal vaginal bleeding in the emergency department. It outlines how to assess patients presenting with vaginal bleeding, including determining if they are pregnant and stable. Common causes of vaginal bleeding are discussed for different age groups and pregnancy statuses, such as miscarriage, ectopic pregnancy, and issues later in pregnancy like placenta previa. Recommendations are provided on investigations, treatment options, and discharge criteria depending on the identified cause. Pelvic exams are not recommended for those in the third trimester due to risk.

1. ED MANAGEMENT OF
PV BLEEDING
CME JUNE 2017

2. ➤ Common ED presentation
- 20-40% of pregnancies have 1st trimester bleeding
➤ Wide range of differential diagnoses
➤ Can be life-threatening
➤ Distressing
INTRODUCTION

3. Assessment of patient
Important causes
Management/Disposition

4. ASSESSMENT

5. TWO IMPORTANT QUESTIONS
Stable or unstable ?
Pregnant or not ?

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

7. EXAMINATION
➤ Observations
➤ General appearance
➤ Abdominal examination
➤ Pelvic examination

8. INVESTIGATIONS
➤ Urine bHCG
➤ Serum/Quantitative bHCG
➤ Bloods/Group&Hold
➤ Check rhesus status
➤ USS

9. CAUSES OF PV
BLEEDING

10. Abnormal PV bleeding
Reproductive
age
Pregnant
<20 weeks
EctopicMiscarriage
Pre-menarchal
➤ Vulvovaginiti
s
➤ Trauma
➤ Sexual abuse
Non-pregnant
➤ Abnormal uterine
bleeding
➤ Structural causes
➤ Non-structural
➤ PID
➤ Ovarian cyst rupture
Post-menopausal
➤ Malignancy
>20 weeks
➤ Placenta previa
➤ Placental
abruption

11. Abnormal PV bleeding
Reproductive
age
Pregnant
<20 weeks
EctopicMiscarriage
Pre-menarchal
➤ Vulvovaginiti
s
➤ Trauma
➤ Sexual abuse
Non-pregnant
➤ Abnormal uterine
bleeding
➤ Structural causes
➤ Non-structural
➤ PID
➤ Ovarian cyst rupture
Post-menopausal
➤ Malignancy
>20 weeks
➤ Placenta previa
➤ Placental
abruption

12. Abnormal PV bleeding
Reproductive
age
Pregnant
<20 weeks
EctopicMiscarriage
Pre-menarchal
➤ Vulvovaginiti
s
➤ Trauma
➤ Sexual abuse
Non-pregnant
➤ Abnormal uterine
bleeding
➤ Structural causes
➤ Non-structural
➤ PID
➤ Ovarian cyst rupture
Post-menopausal
➤ Malignancy
>20 weeks
➤ Placenta previa
➤ Placental
abruption

13. STRUCTURAL CAUSES
➤ Polyps
➤ Adenomyosis
➤ Fibroids
➤ Malignancy

14. NON-STRUCTURAL CAUSES
➤ Coagulopathy
➤ Ovulatory dysfunction
➤ Endometrial dysfunction
➤ Iatrogenic

15. MANAGEMENT AND DISPOSITION
Pharmacological options

17. MANAGEMENT AND DISPOSITION
Pharmacological options
Caution with VTE risk
Outpatient follow up with USS to identify structural causes +/-
gynaecology follow up

18. Abnormal PV bleeding
Reproductive
age
Pregnant
<20 weeks
EctopicMiscarriage
Pre-menarchal
➤ Vulvovaginiti
s
➤ Trauma
➤ Sexual abuse
Non-pregnant
➤ Abnormal uterine
bleeding
➤ Structural causes
➤ Non-structural
➤ PID
➤ Ovarian cyst rupture
Post-menopausal
➤ Malignancy
>20 weeks
➤ Placenta previa
➤ Placental
abruption

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

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

27. Inevitable

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

29. Inevitable
Incomplete

30. INCOMPLETE MISCARRIAGE
Part of the products of conception is retained in the uterus
➤ Persistant cramps and heavy PV bleeding

31. Inevitable
Incomplete
Complete

32. COMPLETE MISCARRIAGE
All products of conception expelled
➤ Cramps and PV bleeding stop
➤ Cervical os closed

33. Inevitable
Incomplete
Complete
Missed

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

36. CLINICAL PICTURE
➤ History
- Bleeding
- Abdominal pain
- Amenorrhoea
➤ Examination
- Lower abdominal tenderness/mass
- Shock

37. DIAGNOSIS
➤ TV USS
➤ TV USS + Discriminatory bHCG

39. Abnormal PV bleeding
Reproductive
age
Pre-menarchal Post-menopausal
Pregnant Non-pregnant
>20 weeks<20 weeks
EctopicMiscarriage
➤ Vulvovaginiti
s
➤ Trauma
➤ Sexual abuse
➤ Abnormal uterine
bleeding
➤ Structural causes
➤ Non-structural
➤ PID
➤ Ovarian cyst rupture
➤ Malignancy
➤ Placenta previa
➤ Placental
abruption

40. DO NOT PERFORM A PELVIC
EXAMINATION ON ANY PATIENT
WITH PV BLEEDING WHO IS IN THE
THIRD TRIMESTER OF THEIR
PREGNANCY

41. PLACENTA PREVIA
Placental tissue extending over the cervical os
➤ History
- Painless PV bleeding
➤ Examination
- Soft uterus

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

43. MANAGEMENT
OBSTETRIC EMERGENCY
➤ Resuscitation
➤ Consider USS if position of placenta unknown
➤ Often needs urgent caesarian

44. LEARNING
POINTS

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.

47. THANK-YOU