Downloaded 331 times
Uploaded bySCGH ED CME
PV Bleeding
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.
More Related Content
More from SCGH ED CME
PV Bleeding
- 1. ED MANAGEMENT OF PVBLEEDING CME JUNE 2017
- 2. ➤ Common EDpresentation - 20-40% of pregnancies have 1st trimester bleeding ➤ Wide range of differential diagnoses ➤ Can be life-threatening ➤ Distressing INTRODUCTION
- 3. Assessment of patient Importantcauses Management/Disposition
- 4.
- 5. TWO IMPORTANT QUESTIONS Stableor unstable ? Pregnant or not ?
- 6. HISTORY ➤ Amount orvolume of bleeding and duration ➤ Relation to menstrual cycle ➤ Normal cycle ➤ Other symptoms ➤ Gynae/Obstetric history including IVF ➤ PMH/FH ➤ Drugs
- 7. EXAMINATION ➤ Observations ➤ Generalappearance ➤ Abdominal examination ➤ Pelvic examination
- 8. INVESTIGATIONS ➤ Urine bHCG ➤Serum/Quantitative bHCG ➤ Bloods/Group&Hold ➤ Check rhesus status ➤ USS
- 9.
- 10. Abnormal PV bleeding Reproductive age Pregnant <20weeks 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 <20weeks 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 <20weeks 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.
- 17. MANAGEMENT AND DISPOSITION Pharmacologicaloptions Caution with VTE risk Outpatient follow up with USS to identify structural causes +/- gynaecology follow up
- 18. Abnormal PV bleeding Reproductive age Pregnant <20weeks 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 ➤ Checkrhesus 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 ➤ Levelsincrease 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 intrauterinepregnancy 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 beforethe 20th week of gestation ➤ 8-20% of pregnancies ➤ Most common in 1st trimester ➤ Risk factors include - advancing maternal age, previous miscarriage and smoking
- 27.
- 28. INEVITABLE MISCARRIAGE Spontaneous miscarriagethan can’t be stopped ➤ Persistant lower abdominal cramps and heavy PV bleeding ➤ Cervical os open ➤ Products of conception often visible
- 29.
- 30. INCOMPLETE MISCARRIAGE Part ofthe products of conception is retained in the uterus ➤ Persistant cramps and heavy PV bleeding
- 31.
- 32. COMPLETE MISCARRIAGE All productsof conception expelled ➤ Cramps and PV bleeding stop ➤ Cervical os closed
- 33.
- 34. MISSED MISCARRIAGE Foetal demisepicked up on USS ➤ Products of conception retained ➤ Sometimes get an asymptomatic brownish discharge
- 35. ECTOPIC Ectopic pregnancy occurswhen 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-menarchalPost-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 PERFORMA PELVIC EXAMINATION ON ANY PATIENT WITH PV BLEEDING WHO IS IN THE THIRD TRIMESTER OF THEIR PREGNANCY
- 41. PLACENTA PREVIA Placental tissueextending over the cervical os ➤ History - Painless PV bleeding ➤ Examination - Soft uterus
- 42. PLACENTAL ABRUPTION Bleeding betweenthe 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.
- 45. ➤ A patientwith 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.