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Emergency Department Management of Vaginal Bleeding in the Nonpregnant Patient

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Emergency Department Management of Vaginal Bleeding in the Nonpregnant Patient August 2013 Emergency Department Volume 15, Number 8 Management Of Vaginal Author Joelle Borhart, MD Assistant Professor of Emergency Medicine, Georgetown Bleeding In The Nonpregnant University School of Medicine, Department of Emergency Medicine, Washington Hospital and Georgetown University Hospital, Washington, DC Patient Peer Reviewers Lauren M. Post, MD, FACEP Abstract Attending Physician, Department of Emergency Medicine, St. Luke’s Cornwall Hospital, Newburgh, NY and Overlook Medical Center, Summit NJ Abnormal uterine bleeding is the most common reason women Leslie V. Simon, DO, FACEP, FAAEM seek gynecologic care, and many of these women present to an Assistant Residency Director, Associate Professor of Emergency Medicine, University of Florida College of Medicine-Jacksonville, emergency department for evaluation. It is essential that emer- Jacksonville, FL gency clinicians have a thorough understanding of the underly- CME Objectives ing physiology of the menstrual cycle to appropriately manage a nonpregnant woman with abnormal bleeding. Evidence to Upon completion of this article, you should be able to: 1. Discuss common and serious causes of vaginal bleeding guide the management of nonpregnant patients with abnormal in prepubertal children, nonpregnant adolescents, and bleeding is limited, and recommendations are based mostly on women. expert opinion. This issue reviews common causes of abnormal 2. Describe the ED approach to both the unstable and stable nonpregnant patient with vaginal bleeding. bleeding, including anovulatory, ovulatory, and structural causes 3. Select the common treatments of acute abnormal vaginal in both stable and unstable patients. The approach to abnormal bleeding in nonpregnant patients. bleeding in the prepubertal girl is also discussed. Emergency 4. Discuss the disposition and follow-up needs of the clinicians are encouraged to initiate treatment to temporize an nonpregnant patient with vaginal bleeding. acute bleeding episode until timely follow-up with a gynecolo- Prior to beginning this activity, see the back page for faculty gist can be obtained. disclosures and CME accreditation information. Editor-In-Chief Nicholas Genes, MD, PhD Keith A. Marill, MD Corey M. Slovis, MD, FACP, FACEP Research Editor Andy Jagoda, MD, FACEP Assistant Professor, Department of Assistant Professor, Harvard Medical Professor and Chair, Department Michael Guthrie, MD Professor and Chair, Department of Emergency Medicine, Icahn School School; Emergency Department of Emergency Medicine, Vanderbilt Emergency Medicine Residency, Emergency Medicine, Icahn School of Medicine at Mount Sinai, New Attending Physician, Massachusetts University Medical Center; Medical Icahn School of Medicine at Mount of Medicine at Mount Sinai, Medical York, NY General Hospital, Boston, MA Director, Nashville Fire Department and Sinai, New York, NY International Airport, Nashville, TN Director, Mount Sinai Hospital, New Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, York, NY Professor and Chair, Department FACEP Stephen H. Thomas, MD, MPH International Editors of Emergency Medicine, Carolinas Chairman, Department of Emergency George Kaiser Family Foundation Peter Cameron, MD Associate Editor-In-Chief Medical Center, University of North Medicine, Pennsylvania Hospital, Professor & Chair, Department of Academic Director, The Alfred Kaushal Shah, MD, FACEP Carolina School of Medicine, Chapel University of Pennsylvania Health Emergency Medicine, University of Emergency and Trauma Centre, Associate Professor, Department of Hill, NC System, Philadelphia, PA Oklahoma School of Community Monash University, Melbourne, Emergency Medicine, Icahn School Steven A. Godwin, MD, FACEP Michael S. Radeos, MD, MPH Medicine, Tulsa, OK Australia of Medicine at Mount Sinai, New Professor and Chair, Department Assistant Professor of Emergency York, NY Ron M. Walls, MD Giorgio Carbone, MD of Emergency Medicine, Assistant Medicine, Weill Medical College Professor and Chair, Department of Chief, Department of Emergency Editorial Board Dean, Simulation Education, of Cornell University, New York; Emergency Medicine, Brigham and Medicine Ospedale Gradenigo, University of Florida COM- Research Director, Department of Women’s Hospital, Harvard Medical Torino, Italy William J. Brady, MD Jacksonville, Jacksonville, FL Emergency Medicine, New York School, Boston, MA Professor of Emergency Medicine Hospital Queens, Flushing, New York Amin Antoine Kazzi, MD, FAAEM and Medicine, Chair, Medical Gregory L. Henry, MD, FACEP Scott D. Weingart, MD, FCCM Associate Professor and Vice Chair, Emergency Response Committee, Clinical Professor, Department of Robert L. Rogers, MD, FACEP, Associate Professor of Emergency Department of Emergency Medicine, Medical Director, Emergency Emergency Medicine, University FAAEM, FACP Medicine, Director, Division of University of California, Irvine; Management, University of Virginia of Michigan Medical School; CEO, Assistant Professor of Emergency ED Critical Care, Icahn School of American University, Beirut, Lebanon Medical Center, Charlottesville, VA Medical Practice Risk Assessment, Medicine, The University of Medicine at Mount Sinai, New Inc., Ann Arbor, MI Maryland School of Medicine, York, NY Hugo Peralta, MD Peter DeBlieux, MD Baltimore, MD Chair of Emergency Services, Professor of Clinical Medicine, John M. Howell, MD, FACEP Senior Research Editors Hospital Italiano, Buenos Aires, Interim Public Hospital Director Clinical Professor of Emergency Alfred Sacchetti, MD, FACEP Argentina of Emergency Medicine Services, Medicine, George Washington Assistant Clinical Professor, James Damilini, PharmD, BCPS Dhanadol Rojanasarntikul, MD Emergency Medicine Director of University, Washington, DC; Director Department of Emergency Medicine, Clinical Pharmacist, Emergency Attending Physician, Emergency Faculty and Resident Development, of Academic Affairs, Best Practices, Thomas Jefferson University, Room, St. Joseph’s Hospital and Medicine, King Chulalongkorn Louisiana State University Health Inc, Inova Fairfax Hospital, Falls Philadelphia, PA Medical Center, Phoenix, AZ Memorial Hospital, Thai Red Cross, Science Center, New Orleans, LA Church, VA Robert Schiller, MD Joseph D. Toscano, MD Thailand; Faculty of Medicine, Francis M. Fesmire, MD, FACEP Shkelzen Hoxhaj, MD, MPH, MBA Senior Faculty, Family Medicine and Chairman, Department of Emergency Chulalongkorn University, Thailand Professor and Director of Clinical Chief of Emergency Medicine, Baylor Community Health, Icahn School of Medicine, San Ramon Regional Suzanne Peeters, MD Research, Department of Emergency College of Medicine, Houston, TX Medicine at Mount Sinai, New Medical Center, San Ramon, CA Emergency Medicine Residency Medicine, UT College of Medicine, York, NY Eric Legome, MD Director, Haga Hospital, The Hague, Chattanooga; Director of Chest Pain Chief of Emergency Medicine, Scott Silvers, MD, FACEP The Netherlands Center, Erlanger Medical Center, King’s County Hospital; Professor of Chair, Department of Emergency Chattanooga, TN Clinical Emergency Medicine, SUNY Medicine, Mayo Clinic, Jacksonville, FL Downstate College of Medicine, Brooklyn, NY Case Presentations The resulting 6000 abstracts were reviewed for applicability, and results were limited to the Eng- It’s the middle of a busy night shift in the ED, and a lish language and to articles published in the last 23-year-old woman with vaginal bleeding has been wait- 20 years. Emphasis was placed on trials conducted ing several hours to be seen. Her vital signs are normal. in the ED or in the acute clinical setting. Additional She has no past medical history and takes no medica- references were identified by reviewing bibliogra- tions. She states that she has been bleeding continuously phies of relevant articles. The Cochrane Database for the past 2 weeks. Her menstrual periods have always of Systematic Reviews was searched using the term been irregular, but she has never bled for this long. She heavy menstrual bleeding, yielding 41 results, 14 of describes the bleeding as heavy, sometimes with clots, and which were applicable to this review. The National she is frequently changing her sanitary pad. A pregnancy Guideline Clearinghouse (www.guideline.gov) test was ordered from triage and is negative. The patient was queried using the search term heavy menstrual is desperate for you to stop the bleeding, and you wonder bleeding. A total of 24 guidelines were found, 2 of 2,3 if there is anything you can offer her besides a box of tam- which were applicable to this review. Both of the pons and a gynecology referral…. guidelines were produced by the American College As you walk out the room, the radio goes off and a of Obstetricians and Gynecologists (ACOG). ACOG panicked paramedic reports that they are en route with also recently released a Committee Opinion on the a 42-year-old woman who is having profuse vaginal bleed- management of abnormal uterine bleeding, which 4 ing and appears very ill. She is pale, tachycardic, and is included in this review. There are currently no hypotensive. She has a history of fibroids. She has been American College of Emergency Physicians (ACEP) bleeding heavily for 3 days, and the bleeding has acutely clinical policies that apply to vaginal bleeding in the increased in the past few hours. The on-call gynecologist nonpregnant patient. is delivering a baby at the hospital across town, and you It is inherently difficult to form an evidence- will have to stabilize this patient and manage
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