Vaginal Bleeding – SOGC 2013

Abnormal uterine bleeding: Change in frequency, duration or amount of menstrual flow Normal Menses: Last up to 7 d, ~35ml of blood loss, wide range of normal Menorrhagia – xs bleeding during menses Metrorrhagia – uterine bleeding at irregular times Oligomenorrhea – menses Q>35d Hx: 

  • Pregnancy status
  • Timing: cyclic, acute vs chronic
  • Systemic dz & medications (hormones)

Approach

1) Gynecological
  • Menorrhagia
    • Hormone imbalance
    • Fibroids / leiomyomata / uterine polyps / adenomyosis
    • Copper IUD
  • Metrorrhagia / menometrorrhagia
    • Trauma, sexual abuse, foreign body
    • Infection: endometritis, cervicitis, vaginitis, STI
    • Benign growth: uterine, cervical, vaginal
    • Pregnancy related
    • Wt loss, xs exercise, stress
    • PCOS
    • Dysfunctional uterine bleeding (DUB) – dx of exclusion
2) Non-gynecological
  • Endocrine
    • Hyper/hypothyroidism
    • Adrenal insufficiency
    • PCOS
    • Prolactinoma
  • Blood Dyscrasias
    • Coagulopathy (vWD)
    • Platelet abnormalities (ITP)
    • Leukemia / hematologic malignancy
  • Renal Failure
    • Impaired estrogen excretion
  • Drugs
    • Anticoagulants
    • Danazol / spironolactone
    • Steroids
    • Chemotherapy, neuroleptics
    • OCP, HRT (breakthrough bleed)
  • Hepatic Dz
    • decrease coagulation factors
    • Impaired estrogen Metabolism

1 In any woman with vaginal bleeding, rule out pregnancy.

  • b-HCG produced by placental trophoblastic cells – maintains the corpus luteum during pregnancy
    • Positive in serum 9 d post-conception
      • Plasma level double q1-2d, peak at 8-10 wk, then fall to a plateau until delivery
    • Positive in urine 28d after first day of LMP
  • If bleeding and + bHCG
    • r/o ectopic, placental abruption, trophoblastic dz
    • Tx hemodynamic instability

2 In pregnant patients with vaginal bleeding a) Consider worrisome causes (e.g., ectopic pregnancy, abruption, abortion), and confirm or exclude the diagnosis through appropriate interpretation of test results. b) Do not forget blood typing and screening, and offer rH immunoglobulin treatment, if appropriate. c) Diagnose (and treat) hemodynamic instability.

1st trimester bleeding (first 12 weeks) & 2nd trimester bleeding (<20wk)

  • Always r/o ectopic, check Rh & give Rhogam if negative, and ensure pt is hemodynamically stable
ddx:
  • Physiologic bleeding: spotting due to implantation of placenta – check serial b-HCG
  • Abortion: threatened, inevitable, incomplete, complete
  • Abnormal pregnancy: ectopic, molar
  • Trauma: post-coital, after pelvic exam
  • Genital lesion: cervical polyp, neoplasms
Hx:
  • Characteristics of the bleeding (any tissue passed)
  • characteristics of the pain (cramping suggests SA)
  • Dizziness (significant blood loss, ? ruptured ectopic)
  • Fever (? septic abortion)
  • Risk factors of ectopic:
    • Previous ectopic
    • hx of STI/PID, IUD use
    • previous pelvic Sx
    • smoking
  • Previous SA, Gyne / OB hx, Hx of coagulopathy
  • Recent trauma
PEx
  • VS (including orthostatic)
  • Abd: SFH, tenderness, ?CTX
  • Perineum: ?trauma, genital lesions
  • Speculum: cervical os open/closed?, presence of active bleeding / clots / tissue
  • Pelvic exam: uterine size, adnexal mass, uterine / adnexal tenderness
    • no exam in T2/3 without r/o placenta previa / vasa
Ix
  • B-HCG: lower than expected for GA in SA or ectopic
  • U/S: confirm intrauterine pregnancy & fetal viability
  • CBC, group & screen
Tx
  • IV resuscitation for hemorrhagic shock
  • Tx underlying cause
  • Rhogam if RH negative

Spontaneous Abortions

1) Threatened:
  • Vaginal bleeding ± cramping
  • Cervical closed & soft; u/s shows viable fetus
  • Watch & wait <5% go on to abort

2) Inevitable
  • Increasing bleeding & cramps ± ROM
  • Cervical closed until products start to expel, then external os opens
3) Incomplete
  • Extremely heavy bleeding & cramps ± passage of tissue noticed
  • Cervix open & u/s shows products of conception
4) Missed
  • No bleeding (fetal death in utero)
  • Cervix closed, us may show SGA, no fetal heart activity; nonviable fetus
  1. Watch and wait (up to 4 weeks – usually 1 week) if VS stable and no s/sx of infection
  2. Misoprostol 800 mcg po /pv (WHO)
  3. Misoprostol 400 mcg pv Q4h x 4 (UpToDate 2014) – 70-90% expulsion rate in 24hr
  4. D&C ± oxytocin ± broad spectrum abx if unstable VS, s/sx of infection

5) Complete
  • Bleeding & complete passage of sac & placenta
  • Cervix open & u/s shows no products of conception
  • Expectant management (no D&C)
6) Septic
  • Contents of uterus infected – infrequent
  • D&C + IV broad spectrum abx
7) Recurrent
  • 3+ SA
  • Evaluate mechanical, genetic, environmental & other risk factors

Ectopic pregnancy

  • Embryo implants outside of the endometrial cavity
  • 1/100 pregnancies, leading cause of death in T1
  • 3 commonest location: ampullary (70%) > isthmic (12%), fimbrial / infundibular(11%)m < ovarian (3%) / interstitial / abdominal
Etiology
  • 50% due to damage of fallopian tube cilia following PID
  • intrinsic abn of the fertilized ovum; conception late in cycle
  • Transmigration of fertilized ovum to contralateral tube
Clinical features – 4Ts + 1S
  • Temp >38oC
  • Tenderness: abdominal (90%) ± rebound (45%)
  • Tenderness on bimanual exam, CMT (cervical motion tenderness)
  • Tissue: palpable adnexal mass (50%)
  • Signs of pregnancy: Chadwick’s, Hegar’s
  • If ectopic ruptures:
    • acute abdomen with increasing pain / abdominal distention / shock
Risk Factors
  • Prev ectopic
  • smoking
  • Gyne:
    • IUD / Hx of PID or salpingitis
    • infertility
    • clomiphene citrate for induction of oluation
  • Previous procedure:
    • fallopian tube surgery (ectopic / tubal),
    • abd Sx for ruptured appendix etc,
    • IVF pregnancies following ovulation induction (7%)
  • Structural:
    • Uterine leiomyomas
    • adhesions / abn uterine anatomy (T shaped uterus)
Ix:
  • Serial B-HCG (2x Q1.6-2.4d) – <20% is 100% predictive of a nonviable pregnancy
    • Prolonged doubling time, plateau / decreasing level before GA8wk implies non-viable gestation
    • 85% ectopic has abn B-HCG doubling
  • U/S – only definitive if cardiac activity detected in the tube / uterus
    • Intrauterine sac visible when b-HCG is >1500 (TV) or >6000 / GA6wk if transabdominal
    • Specific finding: tubal ring
  • Laparoscopy: definitive dx
Tx
  • Conservative (preserve tube if possible), ABC, Rhogam prn
  • Sx: laparoscopy
    • Linear salpingostomy if salvageable tube
    • Salpingectomy if tube damaged / ectopic is ipsilateral recurrence
    • 15% risk of persistent trophoblast – must monitor b-HCG qwk till non-detectable
    • Laparotomy if unstable, extensive abdominal Sx etc
  • Medical: methotrexate only if – 
    • 1) < 3.5 cm unruptured ectopic + 2) no FHR, 3) bHCG <5000, 4) NO hepatic/renal/heme dz + 5) compliance / able to f/u
    • 50mg/m2 body surface area – single IM
    • 1/5 – 1/6 chemo dose – min s/e: reversible hepatic dysfunction, diarrhea, gastritis, dermatitis
    • follow bHCG qwk till non-detectable
    • plateau / rising suggest persisting trophoblastic tissue – Sx
    • 80% maintain tubal patency post Tx

3 In a non-pregnant patient with vaginal bleeding: a) Do an appropriate work-up and testing to diagnose worrisome causes (e.g., cancer), using an age-appropriate approach. b) Diagnose (and treat) hemodynamic instability. c) Manage hemodynamically stable but significant vaginal bleeding (e.g., with medical versus surgical treatment).

 1) Anovulatory (90%) – Tx with OCP

  • Unpredictable endometrial bleeding of variable flow & duration
  • Hormones produced, but no cyclically
Etiology
  • Hypothalamic: menorrhagia, oliomenorrhagia, amenorrhea spotting
    • PCOS
    • Thyroid dysfunction, Liver / Renal dz
    • Elevated prolactin or cortisol levels
    • Stress, wt loss, exeercise
  • Rare estrogen producing tumor
  • Perimenopause / puberty
  • OCP – inadequate estrogen / poor adherence – metrorrhagia
Pathophysiology
  • Unopposed estrogen – thickened endometrium – focal necrosis – irregular, prolonged, heavy pv bleed

2) Ovulatory (10%)

Cyclic, heavy / prolonged

Etiology
  • Anatomic / physicla lesions: polyp, fibroid, adenomyosis, neoplasm, FB (foul odor)
  • Hemostatic defect (menorrhagia ± metrorrhagia)
  • Infxn, trauma
  • Local disturbances in prostaglandins / medications (metrorrhagia)

3) Postmenopause (>40yo) – endometrial cancer until proven otherwise

Post-menopausal spotting or menorrhagia

Etiology:
  • Vaginal: atrophic
  • Cervix: polyps, erosion, cancer
  • Uterus: polyp, fibroid, endometrial cancer
Ix:
  • CBC, ferritin, bHCG, coagulation profile (r/o VWD)
  • TSH / free T4, prolactin, glucose, FSH, LH, serum androgens (free testosterone & DHEA)
  • D21 (luteal phase) progesterone to confirm ovulation
  • Pap test, swab – r/o infection / urine G+C
  • Pelvic u/s: polyps, fibroids, measure endometrial thickness (POSTmenopausal)
  • SHG – intrauterine pathology: polyps, submucous fibroids
  • HSG
  • Endometrial Assessment:
    • >35yo with changing menstrual pattern / postmenopausal bleed 
    • <35yo + 2-3yr of untreated anovulatory bleed, esp obses
    • Endometrial biopsy: if >40yo – must do endometrial bx in all women presenting w/ postmenopausal bleeding to exclude endometrial ca
    • D&C – not for Tx, dx only (usually with hysteroscopy)
 Tx Underlying disorders

DUB (Dysfunction uterine bleeding) – if no anatomic / systemic dz (dx of exclusion)

1) Medical:
Mild DUB
  • NSAIDs, combined OCP
  • Progestins (Provera) first 10-14 days each month if oligomenorrhea
  • Mirena IUD
  • Danazol / anti-fibrinolytic (cyklokapron) at time of menses
Acute severe DUB
  1. ABC
  2. Estrogen (premarin) 25mg IV q4h x 24 with Gravol 50mg q4h iv/po
  3. Ovral or any OCP with min 50mcg estradiol 1tab po q4h x 24h with gravol 50mg q4h
  4. Taper Ovral to 1 tab tid x 2day – bid x 2d – OD
  5. Then monophasic OCP for next several months 

Clomiphene citrate – anovulatory pt who wish to get pregnant


SOGC 2014 Guideline:
  1. Menstrual suppression and therapeutic amenorrhea should be considered safe and viable options for women who need or want to have few or no menses
  2. Combined hormones or progesterone only products can be used in an extended or continuous manner to obtain menstrual suppresion
Indications for menstrual suppression:
  1. social choice
  2. severe dysmenorrhea associated with endometriosis
  3. abnormal uterine bleeding, hemorrhagic diatheses
  4. hormone withdrawal symptoms, and premenstrual dysphoric disorders

2) Sx

  • endometrial ablation – consider pre-Tx with danazol / GnRH agonists
    • finished childbearing & may repeat procedure if reoccur
  • Hysterectomy: definitive Tx

4 In a post-menopausal woman with vaginal bleeding, investigate any new or changed vaginal bleeding in a timely manner (e.g., with endometrial biopsy testing, ultrasonography, computed tomography, a Pap test, and with a pelvic examination)


References:

Advertisements
Posted in 96 Vag Bleeding, 99 Priority Topics, FM 99 priority topics, Gyne

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s

Follow Preparing for the CCFP Exam 2015 on WordPress.com
CCFP ExamApril 30th, 2015
The big day is here.
January 2015
M T W T F S S
« Dec   Feb »
 1234
567891011
12131415161718
19202122232425
262728293031  
%d bloggers like this: