(+)CharlottePageWills,MD
MDDepartmentofEmergencyMedicine,Alameda
HealthSystem–HighlandHospital,Oakland,CA;
AssociateClinicalProfessorofEmergency
Medicine,UniversityofCalifornia,SanFrancisco
SchoolofMedicine,SanFrancisco,CA
AdvancedPracticeProvider
Academy
April14‐18
SanDiego,CA
VaginalBleeding:NotJustMenstruation
WomenpresentingtotheEDwitheithernon‐pregnantor
pregnantvaginalbleedingisseenfrequently.Whenisthe
vaginalbleedinganemergencyandwhenisitsomething
thatcanbeseenandsenthomerightaway?Howcanthe
APPavoidmissingaseriouscauseofvaginalbleeding?
Objectives:
 Listthemostcommoncausesofnon‐pregnantvaginal
bleedinganddescribethemanagementforeach.
 Listthemostcommoncausesofpregnantvaginal
bleedinganddescribethemanagementforeach.
 Discussthe“redflag”findingsinthepatientwith
vaginalbleeding.
 Discusstheindicationsfor,andpitfallsof,physical
restraints.
 Discussthekeyhigh‐riskpresentationsand
documentationthatisessentialwhencaringforthese
patients.
Date:4/18/2014
Time:12:45PM‐1:15PM
CourseNumber:TH‐71
(+)Nosignificantfinancialrelationshipstodisclose
Vaginal Bleeding Charlo/e Page Wills, MD Associate Program Director Alameda Health System-­‐Highland Hospital EM Residency, Oakland CA Associate Clinical Professor of Emergency Medicine University of California, San Francisco School of Medicine Abdominal Pain Pregnancy Common Disease GYN Disorders Bleeding Can’t Miss Causes Bleeding “all females are pregnancy unNl proven otherwise” Abdominal Pain Pregnancy Bleeding Ectopic Pregnancy Bleeding in Early Pregnancy •  Ectopic pregnancy •  Heterotopic pregnancy •  1 in 100 to 1 in 500 with assisted reproducitve technologies •  Spontaneous or threatened miscarriage •  ImplantaNon bleed •  Subchorionic hemorrhage •  Anembryonic pregnancy 1. Pain, pregnant, and bleeding. •  33 yo G4P1 woman with LMP “last month” presents with a day of lower abdominal pain and spo/y vaginal bleeding. She denies any urinary symptoms, fever, nausea, vomiNng, ir diarrhea and has otherwise been well. She is sexually acNve and uses condoms. She has not to her knowledge had an STI previously. The bleeding is bright red, and has been “on and off” with clots but not Nssue seen. BP:90/60 HR:106 RR:14 T:98.0 O2: 100% Gen: well-­‐appearing, comfortable, obese HEENT: EOMI, PERRLA, OP clear CV and LUNGS: unremarkable ABD: diffuse lower abd tenderness, no reboud, no CVAT bilaterally •  GU: scant blood in the vault, os closed, nontender uterus, some adnexal tenderness more on the right, but no masses palpated •  Skin: warm and dry •  Neuro: nonfocal •
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WBC 10.5 Hgb 11.0 Plts 325K HIV screening – GC/Chlamydia pending RPR pending 0-­‐5 WBC’s and 5-­‐10 RBC’s LE negaNve Nitrite negaNve ABO: O+ hCG 4,358 mIU Ectopic Pregnancy QuanNtaNve beta hCG •  Primarily used to trend an early pregnancy. •  Indicates when we should see an IUP. •  Ectopic pregnancies have been reported from 5-­‐200,000 mIU. Cornual Ectopic Pregnancy •
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Larger size at Nme of rupture. Rupture occurs later (10-­‐12 weeks). Close to the inserNon of the uterine artery. Can appear intrauterine on ultrasound. Cornual Ectopic Summary: Ectopic Pregnancy Pijalls •  Failure to see unstable vital signs in the sekng of ectopic pregnancy. •  MisinterpretaNon of the bedside ultrasound. –  Early pregnancy –  Empty sac mistaken for gestaNonal sac –  Cornual ectopic •  Failure to perform Rh screening. •  Poor discharge instrucNons. 2. Vaginal Bleeding and Pregnant •  37 yo woman G4P4 LMP 4 weeks ago reports blood on the Nssue when she wiped this am. She otherwise denies any abdominal pain or cramping. She has not had intercourse in three days. She also denies any vaginal discharge or urinary symptoms. She is very concerned as this is a desired pregnancy. BP:100/ 76 HR:70 RR:14 T:98.0 O2: 100% Gen: well-­‐appearing, comfortable, obese HEENT: EOMI, PERRLA, OP clear CV and LUNGS: unremarkable ABD: nontender, no rebound, no CVAT bilaterally GU: no blood in the vault, os closed, nontender uterus, no adnexal tenderness or masses appreciated •  Skin: warm and dry •  Neuro: nonfocal •
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WBC 10.5 Hgb 11.0 Plts 325K HIV screening – GC/Chlamydia pending RPR pending 0-­‐5 WBC’s and 5-­‐10 RBC’s LE negaNve Nitrite negaNve ABO: O+ hCG 972 mIU Summary: Threatened Miscarriage •  Address the possibility of ectopic pregnancy, and include the paNent in this discussion. •  Standard labs include CBC, CMP, UA, STI tesNng, Rh status, and quanNtaNve hCG for trending purposes. •  Ultrasound. •  48 hour follow-­‐up either in the ED or with an OB provider. •  Strict return precauNons. 3. Vaginal Bleeding and Nausea •  35yo woman G4P4 LMP 7 weeks ago complains of persistent vaginal bleeding and nausea “much worse than my other pregnancies”. She has had spokng in previous pregnancies, but this seems different. She states although light, the bleeding has been happening for five days. She denies any abdominal pain, diarrhea, or other illness. BP:100/76 HR:90 RR:14 T:98.0 O2: 100% Gen: well-­‐appearing, comfortable, obese HEENT: EOMI, PERRLA, OP clear CV and LUNGS: unremarkable ABD: nontender, no reboud, no CVAT bilaterally GU: scant blood in the vault, os closed, nontender uterus, no adnexal tenderness or masses appreciated •  Skin: warm and dry •  Neuro: nonfocal •
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WBC 10.5 Hgb 11.0 Plts 325K HIV screening – GC/Chlamydia pending RPR pending 0-­‐5 WBC’s and 5-­‐10 RBC’s LE negaNve Nitrite negaNve ABO: O+ hCG 662, 987mIU BP:100/76 HR:90 RR:14 T:98.0 O2: 100% Gen: well-­‐appearing, comfortable, obese HEENT: EOMI, PERRLA, OP clear CV and LUNGS: unremarkable ABD: nontender, no reboud, no CVAT bilaterally GU: scant blood in the vault, os closed, nontender uterus, no adnexal tenderness or masses appreciated •  Skin: warm and dry •  Neuro: nonfocal •
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Transvaginal Ultrasound GestaNonal TrophoblasNc Disease •
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HydaNform mole Invasive mole Choriocarcinoma TrophoblasNc tumor Summary: TrophoblasNc Disease •  Clinical suspicion: hyperemesis, high hCG levels, and bleeding. •  Diagnosis: ultrasound •  ConfirmaNon: pathology specimen •  Treatment: surgical evacuaNon, staging, serial hCG levels, possible chemotherapy. Placental Catastrophes: Previa Placental Catastrophes: AbrupNon Placental Catastrophes •  Previa –  Painless bleeding –  Ultrasound is sensiNve and specific –  Avoid speculum and bimanual examinaNons –  Requires c-­‐secNon •  AbrupNon –  May be painful –  Ultrasound is not sensiNve –  May be in the sekng of trauma but not always –  Avoid speculum and bimanual examinaNons –  Obstetric emergency “and when they’re not pregnant, you’re not done” 4. Vaginal Bleeding •  18 yo G0P0 LMP 14 days prior presents onset of brisk vaginal bleeding aoer intercourse. She is accompanied by her partner, and both deny any foreign bodies or trauma. PaNent does state she has some discomfort “deep inside my vagina”, but otherwise has no abdominal pain or cramping. She is otherwise healthy. BP 110/70 HR 98 RR 12 T 98.0 O2 100% Gen: anxious appearing HEENT, CV, LUNGS: unremarkable ABD: soo and nontender GU: copious bright red blood that wells up in the speculum. A 2cm laceraNon is seen inferior to the cervix with acNve bleeding. •  SKIN: warm and dry. •
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Coital Trauma •
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IniNal intercourse, hurried intercourse Retroverted uterus, hyperflexed thigh posiNoning Foreign bodies IntoxicaNon •  SEXUAL ASSAULT: criNcal to screen all paNents for domesNc violence and inNmate partner violence. In Pregnancy •  Os becomes hyperemic. •  May be friable and more prone to bleeding during intercourse. •  Management is the same as a threatened miscarriage with pelvic rest. •  Screen for STI’s. Summary: Vaginal Trauma •  Inspect meNculously in a bloodless field. •  Document injuries. •  Involve a GYN consultant for acNvely bleeding laceraNons. •  SCREEN FOR INTIMATE PARTNER VIOLENCE. 5. Vaginal Bleeding •  45 yo G3P3 woman LMP “last month” presents with two weeks of constant vaginal bleeding. She came to the ED today because she is “Nred of bleeding so much”. She has made an appointment to be seen by her OB, but it’s not for several more weeks. She has had long and irregular periods in the past, but nothing like this. She reports 1-­‐2 pads per hour. “Please help me!”, she says to you in frustraNon. Triage RN note reports a negaNve hCG. BP: 115/76 HR: 70 RR: 12 T: 98.0 O2: 100% •  Gen: anxious appearing •  HEENT: pink conjuncNva, OP clear, neck supple •  CV, LUNGS: no murmur and no rales. •  ABD: soo and nontender •  GU: moderate blood that wells up in the speculum with some clots. Os is closed, unremarkable bimanual-­‐small mobile uterus. •  SKIN: pink, warm, and dry, good cap refill Non-­‐pregnant Vaginal Bleeding •  Fibroids •  InfecNon •  Systemic disease: hypothyroidism, clokng disorders, renal disease •  Cancer: endometrial and cervical •  DysfuncNonal uterine bleeding •  Perimenopause Fibroids •  Common – up to 20% of the populaNon. •  Easy to detect on ULS. •  Can become a source of significant pelvic pain with necrosis. ContracepNon •  Intrauterine device –  Spokng and bleeding a known complicaNon. –  SNll check for pregnancy! •  Hormonal therapies –  Medroxyprogesterone –  Oral contracepNves –  SNll check for pregnancy! Summary: Non-­‐pregnant Bleeding •  Look for anemia. •  Look for symptomaNc anemia. •  Headache, faNgue, dyspnea, chest pain •  Consider evaluaNon for systemic illness. •  GYN referral for hormonal therapy – these paNent require full evaluaNon and endometrial biopsy. •  Good return precauNons are essenNal. Discharge DocumentaNon •  Pregnancy status: negaNve •  Hemoglobin level: not anemic •  Status of the os: closed and no lesions •  Size of the uterus: no fibroids •  Skin: warm, dry, without bruising •  Mucosa: no petechiae or bleeding •  Discharge instrucNons: follow-­‐up and return precauNons. 6. Vaginal Bleeding •  26 yo G0P0 woman presents with one week of heavy vaginal bleeding. She has taken a pregnancy test at home that was negaNve, but is concerned as this bleeding is not her normal menses. She reports some vague headache and faNgue in addiNon to the bleeding, and has noNced some bruising on her legs. She has been healthy up unNl recently. BP: 115/76 HR: 70 RR: 12 T: 98.0 O2: 100% •  Gen: anxious appearing •  HEENT: pink conjuncNva, OP clear, neck supple •  CV, LUNGS: no murmur and no rales. •  ABD: soo and nontender •  GU: scant blood in the vault. Os is closed, unremarkable bimanual-­‐small mobile uterus. •  SKIN: sca/ered small bruises across the anterior Nbial surfaces. Screening for Systemic Illness •  CBC with smear, PT and PTT •  Adolescents with menorrhagia: von Willebrand’s Disease •  Secondary immune thrombocytopenias –  SLE, anNphospholipid syndrome, thyroid disease •  Viral associated thrombocytopenias: –  HIV, Hep C, CMV •  ITP: diagnosis of exclusion WBC 10.5 Hgb 11.0 Plts 90 K HIV screening + GC/Chlamydia pending RPR pending 0-­‐5 WBC’s and 5-­‐10 RBC’s LE negaNve Nitrite negaNve ABO: O+ hCG negaNve PT/PTT with normal range Summary •  Vaginal bleeding in pregnancy is an ectopic pregnancy unNl proven otherwise. •  Screen for vaginal trauma and inNmate partner violence. •  Look for symptomaNc anemia in the non-­‐
pregnant paNent. •  Think about systemic disease. •  Educate your paNent to ensure safe follow-­‐up. References •
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Sohoni A, Bosley J, Miss J. Bedside Ultrasound for Obstetric and Gynecologic Emergencies. Crit Care Clin 30 (2014) Shah S, Teismann N, Zaia B, et al. Accuracy of emergency physicians using ultrasound to determine gestaNonal age in pregnant women. Am J Emerg Med 2010;28(7):834–8. Barnhart KT. Clinical pracNce. Ectopic pregnancy. N Engl J Med 2009;361(4):379–87. Berkowitz RS, Tuncer ZS, Bernstein MR, et al. Management of gestaNonal trophoblasNc diseases: subsequent pregnancy experience. Semin Oncol 2000;27(6): 678–85. Cirilli A, Cipot SJ Emergency EvaluaNon and Management of Vaginal Bleeding in the Nonpregnant PaNent. Ererg Med Clin N Am 30 (2012) Evans P, Brunsell S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician 2007;75(10):1503–8. Bukulmez O, Doody KJ. Clinical features of myomas. Obstet Gynecol Clin North Am 2006;33(1):69–84. Livingstone M, Fraser IS. Mechanism of abnormal uterine bleeding. Hum Reprod Update 2002;8(1):60–7. Lethaby A, Cooke I, Rees MC. Progesterone or progesNn-­‐releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005;(4). CD002126. Promes SB, Nobay F. Pijalls in First Trimester Bleeding. Emerg Med Clin N Am Sloin MM, Karimian M, Ilbeigi P. Nonobstetric laceraNons of the vagina. J Am Osteopath Assoc 2006;106(5):271–3.