SIGNS AND SYMPTOMS 
History
- Light headedness
- Fatigue
- Weakness
- Thirst
- Duration of bleeding
- Quantity:
- Average tampon holds ~5 mL
- Average pad holds ~5–15 mL
- Last menstrual period
- Home pregnancy tests
- Prior ectopic pregnancy
- Passage of clots or tissue
- Menstrual history
- Family history
- Trauma
Physical Exam
- Vital signs
- Cardiopulmonary exam
- Abdominal exam (gravid uterus, masses)
- Pelvic exam:
- Source of bleeding
- Evidence of trauma
- Cervical os open or closed
- Change in mental status may occur with significant blood loss and/or hypotension
ESSENTIAL WORKUP
- Qualitative pregnancy test:
- Point-of-care urine-based pregnancy test preferred
- Pelvic exam:
- Essential for all women with vaginal bleeding
- Assess whether cervical os open or closed
- Delay pelvic exam pending US result in late pregnancy:
- Evaluate for placenta previa
- Defer exam if patient is near term with possible rupture of fetal membranes
- Pregnancy test mandatory for all patients with childbearing potential
- Early pregnancy:
- Blood type and Rh
- US to confirm intrauterine pregnancy (IUP)
- Quantitative β-human chorionic gonadotropin (HCG)
- Hematocrit
- Type and cross-match:
- Ectopic pregnancy
- Low hematocrit levels
- Hemodynamic instability
- UA
- Later pregnancy:
- Type and Rh
- Fetal heart tones
- US indications:
- No fetal heart tones
- No documented IUP
- Unknown placental lie
- Hematocrit if significant bleeding
- Type and cross-match if placenta previa/abruption or low hematocrit levels
- DIC panel if placental abruption:
- Platelets, PT, PTT, Fibrinogen, fibrin split products
- Early postpartum:
- US for retained products
- Hematocrit
- β-HCG if concern for retained tissue
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Qualitative and/or quantitative HCG
- Hematocrit for women with significant bleeding
- Type and Rh
- Platelet count for suspected thrombocytopenia
- PT/PTT for suspected coagulopathy
- Send any passed tissue or clot for pathology evaluation
Imaging
- Bedside US may be indicated based on presentation, pregnancy status, and other considerations:
- US and discriminatory zone:
- Transabdominal US:
- Should detect gestational sac if HCG > 6,500 mIU/mL
- Transvaginal US:
- Should detect gestational sac if HCG > 1,000–1,500 mIU/mL
DIFFERENTIAL DIAGNOSIS
- DUB
- Ectopic pregnancy
- Menorrhagia
- Menometrorrhagia
- Threatened miscarriage
- Placental abruption
- Placenta previa
- Postpartum hemorrhage
- Leiomyoma
- Pelvic masses and tumors
- Postcoital bleeding
- Traumatic injury
- Thyroid dysfunction
- Bleeding disorders
[Outline]
PRE-HOSPITAL
- Establish IV 0.9% NS with 1–2 L fluid bolus for significant bleeding or hypotension
- Administer high-flow oxygen in pregnant or unstable patients
- In later pregnancy:
- Place patient in left lateral recumbent position to prevent occlusion
INITIAL STABILIZATION/THERAPY
- Manage airway and resuscitate as indicated
- Place cardiac/pulse oximeter monitors
- Oxygen for significant bleeding or unstable patient
- Establish 2 large-bore IV lines and initiate fluid bolus (1–2 L) for hypotensive patients
- Type and cross-match:
- Transfuse blood if continued hypotension from blood loss despite IV fluid resuscitation
- Conjugated estrogens (Premarin) 25 mg IV slowly over 10–15 min q4–6h until bleeding stops for uncontrolled menorrhagia:
ED TREATMENT/PROCEDURES
- If unstable with surgical condition, arrange for transfer of the patient to the OR as soon as possible
- RhoGAM for vaginal bleeding, pregnancy, and Rh-negative mother
EARLY PREGNANCY
- If US reveals an ectopic pregnancy:
- Methotrexate according to standards at treating institution
- Definitive treatment is surgery
- If US reveals an IUP without concerns of heterotopic pregnancy (1/2,600–1/30,000):
- Discharge patient with arranged obstetric follow-up with precautions for a threatened miscarriage
- US indeterminate for IUP or ectopic with β-HCG greater than institutional discriminatory zone:
- Cannot exclude ectopic pregnancy
- If hemodynamically stable with little bleeding, repeat measurement of β-HCG and outpatient obstetric follow-up within 48 hr
- Strict return parameters
- US indeterminate for IUP or ectopic with β-HCG level less than institutional discriminatory zone:
- Patient stable with low risk for ectopic pregnancy may be discharged
- Repeat measurement of β-HCG level and obstetric follow-up within 48 hr
- Patient may still have an ectopic pregnancy
- Complete abortion:
- Discharge patient if stable without significant ongoing bleeding
- Incomplete abortion:
- Obstetric consultation is required
- Dilation and curettage vs. expectant management
- Missed abortion:
- Expectant management initially
- Septic abortion:
- IV antibiotics and admission
- Molar pregnancy:
- Chemotherapy
- Very responsive in early stages of disease
LATER PREGNANCY
- Placenta previa:
- Obstetric consultation for possible admission
- Placental abruption:
- Induction of labor if large
- Can lead to fetal/maternal death
- May require cesarean section
IMMEDIATE POSTPARTUM
- Uterine inversion:
- Prevent by avoiding strong traction on umbilical cord after delivery
- Replace uterus immediately
- Occasionally requires operative management
- Postpartum hemorrhage:
- Extraction of placenta if retained
- Hysterectomy if uncontrolled life-threatening bleeding
EARLY POSTPARTUM
- Retained tissue:
- Endometritis:
NONPREGNANT
- Menses:
- NSAIDs and supportive care
- DUB:
- < 35–40 yr of age:
- Patients > 35–40 yr of age:
- US for any masses palpated during physical exam
- Gynecologic referral
- Uterine sampling necessary before initiation of hormonal treatment
- Evaluate for endometrial cancer
STRUCTURAL ABNORMALITIES
- Pap smear/biopsy for cervical lesions
- US for workup of pelvic masses
- Fibroids or uterine tumors
- Conservative management or lumpectomy/hysterectomy
MEDICATION
- Conjugated estrogens 25 mg IV slowly over 10–15 min q6h until bleeding stops (not to exceed 4 doses)
- If no response after 1–2 doses re-evaluation needed
- Known anovulatory DUB:
- Medroxyprogesterone 10 mg PO per day for 1st 10 days of menstrual cycle (warn patient about withdrawal bleeding)
- Norethindrone and ethinyl estradiol (Ortho-Novum) 1/35 BID for 7 days
- MICRhoGAM 50 µg IM if < 12 wk pregnant
- RhoGAM 300 µg IM if > 12 wk pregnant
[Outline]
DISPOSITION
Admission Criteria
- Ectopic pregnancy not meeting methotrexate discharge criteria
- Uterine inversion
- Septic abortion
- Placental abruption
- Postpartum hemorrhage
- Endometritis
- Unstable DUB
- Newly diagnosed molar pregnancy
Discharge Criteria
- Stable vital signs
- Confirmed IUP
- Ectopic pregnancy meeting institutional methotrexate discharge criteria
- Pregnant patient with low risk for ectopic pregnancy:
- No findings of IUP on US
- Levels of β-HCG below discriminatory zone
- Nonpregnant patients with vaginal bleeding that are hemodynamically stable
Issues for Referral
Obstetric/gynecologic referral
FOLLOW-UP RECOMMENDATIONS
- Obstetric referral within 48 hr for 1st-trimester vaginal bleeding without identified IUP
- OB/GYN referral for patients with menorrhagia for continued evaluation, workup, and treatment
PATIENT EDUCATION
Ectopic precautions: Return immediately for increasing abdominal pain, vaginal bleeding more than 1 pad per hr for 3–4 hr, fever > 100.4°F, syncope, or dizziness. Patients should not be left alone until the diagnosis of ectopic pregnancy can be safely ruled out. Family and friends should also be instructed on the warning signs and symptoms of ruptured/bleeding ectopic pregnancies.
[Outline]
- Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008;35:219–234.
- McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin North Am. 2008;88:265–283.
- Oyelese Y, Scorza WE, Mastrolia R, et al. Postpartum hemorrhage. Obstet Gynecol Clin North Am. 2007;34:421–241.
- Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician. 2007;75:1119–1206.
- Tsai MC, Goldstein SR. Office diagnosis and management of abnormal uterine bleeding. Clin Obstet Gynecol. 2012;55:635–650.
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