Vaginal Bleeding

8.02 Vaginal Bleeding

Presentation
A menstruating woman complains of greater than usual bleeding, which is either off her usual schedule (metrorrhagia), lasts longer than a typical period, or is heavier than usual (menorrhagia) perhaps with crampy pains and passage of clots.
What to do:



Obtain orthostatic pulse and blood pressure measurements, a hematocrit, and pregnancy test (urine or serum beta hCG). Try to quantify the amount of bleeding by number of saturated pads used.



If there is significant bleeding, demonstrated by tachycardia, lightheadedness, orthostatic pressure changes, a pulse increase of more than 20 per minute on standing, or a hematocrit below 30%, start an intravenous line of lactated Ringer's solution, and have blood ready to transfuse on short notice.



Obtain a menstrual, sexual, and reproductive history. Are her periods usually irregular, occasionally this heavy? Does she take oral contraceptive pills, and has she missed enough to produce estrogen withdrawal bleeding? Is an IUD in place and contributing to cramps, bleeding, and infection? Was her last period missed or light, or this period late, suggesting an anovulatory cycle or an ectopic? Might she be pregnant?



Perform a speculum and manual vaginal examination, looking particularly for signs of pregnancy, such as a soft, blue cervix, enlarged uterus, or passage of fetal parts with the blood. Ascertain that the blood is coming from the cervical os, and not frorn a laceration, polyp, or other vaginal or uterine pathology or infection. Feel for adnexal masses, as well as pelvic fluid or tenderness.



If there is an intrauterine pregnancy, determine whether this bleeding represents an incomplete, inevitable, or threatened abortion. Spread any questionable products of conception on gauze or suspend in saline to differentiate from organized clot. Press an 8mm curette or dilator against the cervix to see whether the internal os is open (indicating an inevitable or incomplete abortion) or closed (threatened abortion, with roughly even odds of survival, and generally treated by bedrest).



Confirm suspicion of ectopic pregnancy either with a sonogram showing the ectopic gestational sac, a sonogram showing an empty uterus despite a positive pregnancy test, or a culdocentesis, which cannot rule out an ectopic pregnancy, but which can quickly demonstrate blood in the cul-de-sac after an ectopic sac ruptures.



Discharge the stable patient home on oral contraceptive pills (Ortho-Novum 1/50 or Norinyl 1+50) one qid until the bleeding stops, then finishing the 28-day package one qid, followed by low-dose oral contraceptives for the next two to three months.



If the cause of the uterine bleeding was missed oral contraceptive pills, the patient may resume the pills, but should use additional contraception for the first cycle. (If the cause is a new IUD, the patient may elect to have it removed and use another contraceptive.)



The patient should be referred for followup to a gynecologist, and may be evaluated via endometrial biopsy.
What not to do:



Do not leap to a diagnosis of dysfunctional uterine bleeding without ruling out pregnancy.



Do not rule out pregnancy or venereal infection on the basis of a negative sexual history--confirm with physical examination and laboratory tests.
Discussion
The essential steps in the emergency evaluation of vaginal bleeding are fluid resuscitation of shock, if present, and recognition of pregnancy and its complications of spontaneous abortion or ectopic pregnancy. Treatment of more chronic and less severe dysfunctional uterine bleeding usually consists of iron replacement and optional use of oral contraceptives to decrease menstrual irregularity (metrorrhagia) and volume (menorrhagia). Bed rest has not been shown to improve the outcome for a threatened abortion, but is still usually part of the regimen. Medroxyprogesterone (Provera) 10mg po x10d can also be given to stop dysfunctional uterine bleeding, but warn the patient to expect a heavy bleed when it is stopped.
References



Falcone T, Desjardins C, Bourque J, et al: Dysfunctional uterine bleeding in adolescents. J Reprod Med 1994;39:761-764.