Approach to Vaginal Bleeding

Lecture Notes

Pt’s presenting with vaginal bleeding can be some of the sickest patients in the emergency department. With that said they can also be some of the fastest dispos. Here is our approach to patients who present with a chief complaint of vaginal bleeding.

Critical Differential Diagnosis

  • Ectopic Pregnancy

  • Vaginal Laceration/Trauma

  • Dysfunctional Uterine Bleeding/Fibroids

  • Malignancy

  • Bleeding Disorder

Step 1: Is She Pregnant?

Find out if your patient is pregnant as fast as possible. If you work at a highly efficient place your triage nurse will know how valuable this is and will get the urine pregnancy test cooking as soon as the patient checks in. If the patient is pregnant then this will require a completely different evaluation. Stop here. If the patient is not pregnant please continue.

Step 2: Don’t Delay the Pelvic Exam

Go into the examination room with all the equipment you need to do the pelvic exam. Do not first perform a history, leave the room, document, and then plan to go back to the pelvic exam later. This will hang over you head while you are seeing other patients and add to your stress. Better yet a trauma will come in and destroy your flow. Go in, get your history, do the physical exam and pelvic exam and then you can leave the room. The 5 minutes it will take for you to do the exam will feel like forever, especially after you have gone through a full history and physical. But remember, it is only 5 minutes.

Specific Things To Ask On History

Make sure to get the patient’s Gs and Ps. Be sure to ask about how frequently patient is changing pads. Ask questions about anemia (light headedness, shortness of breath, chest pain). pelvic exam you will look to see if the

Specific Things to Look For On Pelvic

External lesions leading to bleeding. Vaginal Lacerations. Lesions on the cervix. Feel for a large boggy uterus that is full of fibroids. Be sure to put chucks and a bedpan on the floor. Be sure to bring a bunch of the long q-tips with you. You will try to assess if the patient is hemorrhaging. If you cannot clear the vault with the qtips then the patient is hemorrhaging and you will need to call gyn. If you can clear the vault and blood is not pouring out of the cervical os then the patient is not hemorrhaging.

Step 3: Order your labs

Some people will have this be step 2 but we encourage seeing the patient before ordering labs. Here are the labs that can be ordered on these patients.

  • CBC : Seeing if your patient is anemic or thrombocytopenic

  • PT/INR/PTT: Seeing if your patient is anticoagulated

  • Urine Pregnancy Test: This should have been performed as part of step 1

  • Type and Screen/Cross: If the patient is hemorrhaging or has h and p consistent with anemia

Step 4: Treat the Patient

  • If the bleeding is minor give iron supplements and ibuprofen

  • If the bleeding is moderate give medroxyprogesterone. Don’t give this if the patient needs endocervical curretage/endometrial biopsy as medroxyprogesteroone could alter the results.

  • If the bleeding is life threatening: Start 2 large bores, initiate massive transfusion protocol, temporize by packing, and consider txa.

Step 4: DC the patient

If the patient meets any of the following they should be considered for admission:

  • Active hemorrhage on exam

  • Thrombocytopenia

  • Anticoagulated

  • Hypotensive

  • Anemia (although most women with fibroids have become anemic after a long period of bleeding and do fine after a blood transfusion)

Presentation and Documenting

When presenting to your attending or an OB/Gyn be sure to start your presentation with

__YO F G__P__ with a GYN history significant for _____ who is +/- on anticoagulants presents with vaginal bleeding.

Also when documenting be sure to include in your mdm that you cannot rule out malignancy. This is especially important in post menopausal women who present with vaginal bleeding.

Approach to First Trimester Vaginal Bleeding