Vaginal Bleeding / AUB

1. In any woman with vaginal bleeding, rule out pregnancy.

2. In pregnant patients with vaginal bleeding

   1. Consider worrisome causes (e.g., ectopic pregnancy, abruption, abortion), and confirm or exclude the diagnosis through appropriate interpretation of test results.

   2. Do not forget blood typing and screening, and offer Rh immunoglobulin treatment, if appropriate.

   3. Diagnose (and treat) hemodynamic instability.

3. In a non-pregnant patient with vaginal bleeding:

   1. Do an appropriate work-up and testing to diagnose worrisome causes (e.g., cancer), using an age-appropriate approach.

   2. Diagnose (and treat) hemodynamic instability.

   3. Manage hemodynamically stable but significant vaginal bleeding (e.g., with medical versus surgical treatment).

4. In a post-menopausal woman with vaginal bleeding, investigate any new or changed vaginal bleeding in a timely manner (e.g., with endometrial biopsy testing, ultrasonography, computed tomography, a Pap test, and with a pelvic examination).

Abnormal Uterine Bleeding (AUB)

• Definitions

  • Volume

    • Heavy (ovulatory, interferes with QOL)

  • Regularity (Normal variation is 2-20 days)

    • Irregular (>20 day bleed-free intervals within 90 days)

    • Absent/amenorrhea (No bleed in 90 days)

  • Frequency (Normal 24-38 days)

    • Infrequent (>38d)

    • Frequent (<24d)

  • Duration (Normal 3-8 days)

    • Prolonged (>8d)

    • Shortened (<3d)

  • Irregular, non-menstrual

    • Intermenstrual bleeding (light/short between normal menstrual periods)

    • Post-coital

    • Premenstrual/post-menstrual spotting

  • Outside reproductive age

    • Post-menopausal

    • Precocious (<9y)

  • Acute (not pregnant requires immediate intervention)

  • Chronic (>6 months)

DDx

• Pregnancy (Ectopic)

• Trauma

• Infection

• Systemic (Hypothyroid, Hyperprolactinemia, Cushing's, PCOS, Adrenal, Hypothalamic suppression - stress)

• Iatrogenic / Medication (anticoagulants, hyperprolactinemia - antipsychotics, antidepressants)

• AUB

  • PALM (structural)

    • Polyp

    • Adenomyosis

    • Leiomyoma (Submucosal, Other)

    • Malignancy/hyperplasia

  • COEIN (nonstructural)

    • Coagulopathy

    • Ovulatory dysfunction

    • Endometrial

    • Iatrogenic

    • Not yet classified

Pregnancy

• Remember to give anti-D Ig (Rhogam 300mcg IM) for Rh (D)-neg patient to protect against isoimmunization

First Trimester

• DDx

  • Implantation bleed

  • Abnormal pregnant (Ectopic/molar)

  • Abortion (threatened, inevitable, incomplete, complete, missed, septic)

  • Non-Obstetrical (Uterine, Cervical Vaginal Pathology)

• On exam

  • Vitals (r/o hemodynamic instability, fever)

  • Abdominal exam (r/o surgical abdomen)

  • Speculum

    • Source of bleeding (Vagina/Cervical/Uterine)

    • Cervical os (r/o cervical dilation)

  • Bedside ultrasound (r/o free fluid, confirm IUP)

• Investigations

  • CBC

  • Blood type

  • Serial b-hCG

    • Rising b-hCG >35% over 48h consistent with viable IUP (but ectopic may also display rising hCG)

    • hCG <35% over 48h suggest ectopic or abnormal IUP

  • Abdominal Ultrasound

    • IUP if b-hCG >6000 IU/L

  • Transvaginal Ultrasound

    • Gestational sac and yolk sac at 5w gestation

    • Cardiac activity at 6w gestation

    • IUP if b-hCG >2000 IU/L

      • Absence of IUP does not always ectopic (eg. early multiple gestation)

• Treatment

  • See pregnancy termination

  • If excessive bleeding

    • Tranexamic acid 1g IV over 10-20 mins

    • Misoprostol 800mcg SL/PO/PR/(avoid PV if excessive bleeding), then 400mcg q3h PRN

    • Vasopressin injected on anterior lip of cervix (see paracervical block)

  • If incomplete abortion, consider dilation & aspiration

    • Prophylactic antibiotics (eg. Azithromycin 500mg PO x1 or Doxycycline 200mg PO x1)

    • If cervix is not open, dilate PRN

    • Clean cervix with proviodine or diluted chlorhexidine (10mL in 1L sterile NS)

    • Paracervical block

      • Inject 2mL Lidocaine orXylocaine 1% where tenaculum is placed

      • Inject in two or more injection points with total 10-20mL (eg. 2 and 10 o'clock at the cervico-vaginal junction)

        • Avoid 3 and 9 o'clock due to vessels

        • Can add vasopressin (3-5 units) in syringe to reduce bleeding

        • If bleeding from puncture site, can use silver nitrate PRN

    • Consider procedural sedation (eg. Fentanyl 100mcg IV and Midazolam 2mg IV, and increase PRN)

      • Monitoring PRN

    • Ideally place in knee stirrups

    • Place tenaculum

    • Insert cannula on MVA (manual vaccuum aspirator)

      • Cannula must be large enough to aspirate the products (usually corresponds to the number of weeks rounded up - eg. 9 weeks = 9mm cannula)

      • Click/Push on both sides of the aspirator to engage the vaccuum system

      • Pull on plunger to create vaccuum

      • Once inside the uterus, unclick aspirator

    • Ideally two aspirations

      • Ensure to rotate and to avoid going past fundus

      • Stop when uterus feels empty (less bleeding, 'orange peel feeling')

    • For Rh negative, consider Rh Ig PRN

Second and Third Trimester

• DDx

  • Bloody show (onset 72h prior to labor, PPROM)

  • Placenta previa (20%)

    • Touching/covering internal os (low-lying is within 2cm)

    • Risk: Previous placenta previa, previous C/S, uterine surgery, advanced age, multiparity, smoking/cocaine, multiple gestation, in vitro

  • Placental abruption (30%)

    • Painful contractions, hypertonus tender uterus, vaginal bleeding may be concealed

    • Risk: Prior abruption, thrombophilia, iron deficiency, PROM, Hypertension, Overdistended uterus, maternal age/parity, smoking/cocaine, abdominal trauma, c/s

    • Clinical diagnosis, not well diagnosed on ultrasound

    • Kleihauer-Betke test (fetal cells in maternal blood)

  • Uterine rupture (rare)

    • Suspect in shock, acute abdominal pain, change in station, abnormal FHR, vaginal bleeding

    • Risk: Uterine scar, hyperstimulation (IOL), multiparity

  • Vasa previa (rare)

    • Suspect in painless bleeding with change in FHR

    • Risk: Twins, placenta previa (consider TVUS screen at 32w), IVF

    • Apt test (positive = fetal blood, negative = maternal blood)

    • Wright stain (nucleated RBC on smear)

  • Non-Obstetrical (Uterine, Cervical, Vaginal Pathology)

• On exam

  • Vitals (r/o hemodynamic instability)

  • Abdominal exam (including uterine tone/activity)

  • Bedside ultrasound (r/o placenta previa)

  • Sterile speculum

    • Avoid digital cervical exam until placenta previa ruled out by ultrasound (also if possible prior to speculum)

• Labs:

  • Type (Rh) and Crossmatch

  • CBC

  • Kleihauer-Betke if abruption

  • Bedside clot test

  • INR

• Manage

  • Get help, oxygen, IVF (LOTS!), foley

  • Massive transfusion protocol

  • Follow Hb and Coag