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Management of Vaginal Bleeding Presenting to the Accident and Emergency Department

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Management of Vaginal Bleeding Presenting to the Accident and Emergency Department 130 3 Accid Emerg Med 1999;16:130-135 CLINICAL MANAGEMENT J Accid Emerg Med: first published as 10.1136/emj.16.2.130 on 1 March 1999. Downloaded from Management of vaginal bleeding presenting to the accident and emergency department Karen Buckingham, Alison Fawdry, Diana Fothergill Vaginal bleeding is a common presenting com- age group. The most important diagnosis to plaint in the accident and emergency (A&E) exclude is that of ectopic pregnancy; this department. It can occur in all age groups from currently occurs at a rate of 9.6/1000 the young girl to the elderly woman. Vaginal pregnancies.3 An average district general hospi- bleeding occurs in up to 25% of all pregnancies tal will expect to deal with one ectopic and many of these women present to A&E pregnancy a week, although not all present via rather than to their general practitioner (GP) A&E. This condition still kills women and or antenatal clinic because of 24 hour access.' caused nine maternal deaths in the UK in In one teaching hospital 0.7% of patients seen 1991-93.' Unfortunately clinical diagnosis has in one year presented with bleeding in early poor sensitivity, around 50%.4 There are a wide pregnancy.' The main aim of management in range of clinical presentations ranging from the the A&E department is to identify potentially classic collapsed patient with a haemoperito- life threatening conditions and to separate neum, to vaginal spotting. The safest approach those that require urgent gynaecological refer- is to have a high degree of suspicion in each ral from those that can be managed by the GP patient. or on an outpatient basis. The following sections will discuss some of This article will highlight important points the most important points in both history and to note when taking a history from a patient examination and relate these to possible with vaginal bleeding, critical aspects of the diagnoses/conditions. Department of examination, and the range of investigations Obstetrics and that may be useful. It will also deal with those KEY POINTS IN HISTORY (TABLE 1) Gynaecology, Northern aspects of management pertinent to the A&E The most important question to answer is General Hospital, department and appropriate arrangements for "Could the woman be pregnant"? Herries Road, the further care of these women. Sheffield S5 7AU http://emj.bmj.com/ K Buckingham It is helpful to subclassify the presenting * Volume and duration ofbleeding A Fawdry population as detailed in the algorithm shown The amount does not indicate the diagnosis, a D Fothergill (fig 1). pregnancy may still be viable despite quite a heavy loss. However an ectopic pregnancy is Correspondence to: Dr Fothergill, Consultant. Reproductive age group not usually associated with excessive vaginal The majority of women presenting to the A&E bleeding. Recognisable products of conception Accepted 5 September 1998 department with vaginal bleeding will be in this such as a jelly-like sac may have been lost which would suggest that a miscarriage has on October 1, 2021 by guest. Protected copyright. Abnormal vaginal bleeding occurred. Woman also occasionally describe the passage of vesicular "frog spawn"-like material which suggests a molar pregnancy. Menstrual blood does not normally clot so the passage ofclots indicates a heavier than normal Prepubertal Reproductive age group Postmenopausal loss. * Associated symptoms Non-pregnant Pregnant or Nausea, breast tenderness, urinary frequency, suspicious of pregnancy and fatigue may reinforce suspicions that the patient is pregnant. These symptoms may be exaggerated with a molar pregnancy, but may <20 weeks > 20 weeks not be present when a pregnancy has failed to develop (missed abortion or blighted ovum). Abdominal pain may be severe as a preg- Miscarriage Ectopic Abno irmal Abruption nancy is miscarrying, or in a ruptured ectopic concei eption placenta praevia pregnancy. Specific inquiry should be made about shoulder tip pain. A history of vaginal discharge, pelvic pain, dyspareunia, or fever Threatened Inevitable Complete may suggest pelvic inflammatory disease which Figure 1 Algorithm subclassifying presenting population. can also cause irregular vaginal bleeding. Management ofvaginal bleeding 131 Table 1 Points to cover in history taking * Past obstetric history Specific inquiry should be made about the out- Bleeding Amount, volume, duration come ofprevious pregnancies, and the stages at Associated symptoms Abdominal pain, syncope, and shoulder tip discomfort J Accid Emerg Med: first published as 10.1136/emj.16.2.130 on 1 March 1999. Downloaded from Common symptoms of pregnancy, for example nausea and breast which any miscarriages occurred. A secondary tenderness postpartum haemorrhage may present via A&E Menstrual history Date of last period Normal cycle length and regularity particularly if bleeding is very heavy. This Contraception Current and recent commonly occurs 7-10 days after delivery. Past gynaecological history Previous surgery, history of pelvic infections, or infertility Any recent treatment, for example cervical diathermy Past obstetric history Previous miscarriages, ectopic and viable pregnancies * Previous medical history Past medical history Bleeding disorders, for example von Willebrand's disease Menstrual disturbances can be due to other Drug history Warfarin, HRT medical disorders such as thyroid and renal disease. Heavy vaginal bleeding may also be * Menstrual history secondary to a coagulation disorder, or antico- Ask about the regularity of the cycle, the date agulant medication. In adolescents coagulation of the last menstrual period, and whether this disorders such as idiopathic thrombocytopenic was normal in time, duration, and loss. Last purpura and von Willebrand's disease are the menstrual periods are notoriously unreliable: second most common cause of menorrhagia.6 10% of patients in one study were found to be pregnant even when the patient stated that her * History of trauma last period was normal and that she could not If bleeding resulted from a sexual assault and be pregnant.5 Although ectopic pregnancy the patient's condition is stable it is advisable to classically presents after 6-10 weeks of amen- discuss with the patient if she wishes to involve orrhoea, many women have had some bleeding the police at an early stage so that a police sur- around the time of the expected period and do geon can attend to ensure that appropriate not suspect that they are pregnant. Not all forensic specimens are obtained. Even if the patients with prolonged amenorrhoea before police are not involved there should be very presentation are pregnant: anovulatory cycles careful documentation of the injuries. It is very occur with polycystic ovary syndrome, and rare for a woman to be seen after an illegal there may be heavy, persistent bleeding after abortion, but this possibility should be borne in several months of amenorrhoea. mind particularly ifthere is bleeding associated Bleeding between the periods or after with a watery loss in the second trimester. In intercourse suggests the possibility of a cervical this circumstance sepsis is a major concern, lesion causing the bleeding. and disseminated intravascular coagulation may be a consequence. * Contraception KEY POINTS IN EXAMINATION (TABLE 2) Always ask about the form of contraception It is recommended that a chaperone should be used. Conceptions that occur with an intrau- present during examination, regardless of the terine contraceptive device (IUCD) in situ, or sex of the examining doctor.7 when taking the progesterone only pill, are more liable to be ectopic gestations. These * Cardiovascular status-evidence ofshock http://emj.bmj.com/ methods are also prone to cause erratic bleed- The blood pressure may remain normal ing. No method of contraception is entirely despite a large blood loss, tachycardia is usually reliable, pregnancies can occur several years the first indicator of excessive loss. Occasion- after sterilisation due to recanalisation and fis- ally "cervical shock" due to intense vagal tula formation. The risk of an ectopic preg- stimulation by products sitting in the os will nancy is higher if conception occurs after steri- lead to profound bradycardia. This is best resolved by removing the products with a lisation. Most failures of oral contraception are on October 1, 2021 by guest. Protected copyright. due to forgetting to take the tablets, but drug sponge forceps. interactions or gastrointestinal upsets can affect absorption. Recent changes in contra- * Abdominal examination ception may also affect the menstrual cycle: The majority of miscarriages occur before 12 periods may become heavier or more painful weeks and the uterus will not normally be pal- after cessation of the oral contraceptive pill or pable abdominally. If the woman is known to after insertion of an IUCD. be pregnant assess if the size of the uterus is appropriate for her dates, and if more than 14 weeks it may be possible to hear the fetal heart * Past gynaecological history with a Doppler ultrasound. However not all Altogether 25-50% of ectopic pregnancies swellings arising from the pelvis are due to occur in women with risk factors such as previ- pregnancy: fibroids and ovarian cysts are other ous pelvic inflammatory disease, tubal surgery, possible causes. Look for tenderness: general- previous ectopic pregnancy, and after assisted conception.4 Cervical malignancy may also Table 2 Key points on examination present with vaginal bleeding so it is worth Cardiovascular status Tachycardia, bradycardia,
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