PV BLEEDING

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