8.02 Vaginal Bleeding
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agk's Library of Common Simple Emergencies

Presentation
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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:
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- 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, demonstrat- 
    ed by tachycardia, lightheadedness, ortho- 
    static pressure changes, a pulse increase 
    of more than 20 per minute on standing, or 
    a hematocrit below 30%, start an intra- 
    venous 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 contribu- 
    ting 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 exam- 
    ination, 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 incom- 
    plete abortion) or closed (threatened 
    abortion, with roughly even odds of 
    survival, and generally treated by bed- 
    rest).
- Confirm suspicion of ectopic pregnancy either 
    with a sonogram showing the ectopic gestat- 
    ional 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 contra- 
    ceptives 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:
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- Do not leap to a diagnosis of dysfunctional 
    uterine bleeding without ruling out 
    pregnancy.
- Do not rule out pregnancy or venereal infect- 
    ion on the basis of a negative sexual 
    history--confirm with physical examination 
    and laboratory tests.

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

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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