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Basics ⬇

[Section Outline]

Author:

Carla C.Valentine

Description!!navigator!!

Etiology!!navigator!!

PREGNANT PATIENTS

NONPREGNANT PATIENTS

Diagnosis ⬆ ⬇

[Section Outline]

Signs and Symptoms!!navigator!!

History

  • Lightheadedness
  • 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!!navigator!!

Diagnostic Tests & Interpretation!!navigator!!

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!!navigator!!

Treatment ⬆ ⬇

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Prehospital!!navigator!!

  • Establish IV
    • 1-2 L 0.9% normal saline 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 venous obstruction

Initial Stabilization/Therapy!!navigator!!

  • Manage airway and resuscitate as indicated
  • Place cardiac/pulse oximeter monitors
  • Oxygen for significant bleeding or unstable patient
  • Establish 2 large-bore IVs 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:
      • Not to exceed 4 doses

ED Treatment/Procedures!!navigator!!

  • If unstable with surgical condition, arrange for transfer 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 stand ards 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 -hCG greater than institutional discriminatory zone:
    • Cannot exclude ectopic pregnancy
    • If hemodynamically stable with little bleeding, repeat measurement of -hCG and outpatient obstetric follow-up within 48 hr
    • Strict return parameters
  • US indeterminate for IUP or ectopic with -hCG level less than institutional discriminatory zone:
    • Patient stable with low risk for ectopic pregnancy may be discharged
    • Repeat measurement of -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:
    • Dilation and curettage
  • Endometritis:
    • IV antibiotics

NONPREGNANT

  • Menses:
    • NSAIDs and supportive care
  • AUB:
    • <35-40 yr of age:
      • If known anovulatory AUB:
      • Medroxyprogesterone (Provera) - warn patient about withdrawal bleeding
      • Oral contraceptive pill daily for 7 d
    • 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!!navigator!!

  • Conjugated estrogens 25 mg IV slowly over 10-15 min q4-6h until bleeding stops (not to exceed 4 doses)
    • If no response after 1-2 doses re-evaluation needed
  • Known anovulatory AUB:
    • Medroxyprogesterone 10 mg PO per day for first 10 d of menstrual cycle (warn patient about withdrawal bleeding)
    • Norethindrone and ethinyl estradiol (Ortho-Novum 1/35) b.i.d for 7 d
  • MICRhoGAM 50 mcg IM if <12 wk pregnant
  • RhoGAM 300 mcg IM if >12 wk pregnant

Follow-Up ⬆ ⬇

[Section Outline]

Disposition!!navigator!!

Admission Criteria

  • Ectopic pregnancy not meeting methotrexate discharge criteria
  • Uterine inversion
  • Septic abortion
  • Placental abruption
  • Postpartum hemorrhage
  • Endometritis
  • Unstable AUB
  • 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 -hCG below discriminatory zone
  • Nonpregnant patients with vaginal bleeding that are hemodynamically stable

Issues for Referral

Obstetric/gynecologic referral

Follow-up Recommendations!!navigator!!

  • Obstetric referral within 48 hr for first-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

Pearls and Pitfalls ⬆ ⬇

  • Pregnancy test for all women of reproductive age
  • If there is first-trimester vaginal bleeding, evaluate for ectopic pregnancy

Additional Reading ⬆

  • GoldsteinSR, LumsdenMA. Abnormal uterine bleeding in perimenopause . Climacteric. 2017;20(5):414-420.
  • HaamidF, SassAE, DietrichJE. Heavy menstrual bleeding in adolescents . J Pediatr Adolesc Gynecol. 2017;30(3):335-340.
  • HaukL. ACOG releases guidelines on management of abnormal uterine bleeding associated with ovulatory dysfunction. American College of Obstetricians and Gynecologists . Am Fam Physician. 2014;89(12):987-988.
  • MatthewsML. Abnormal uterine bleeding in reproductive-aged women . Obstet Gynecol Clin North Am. 2015:42(1):103-115.

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