30. Vaginal bleed Flashcards
Normal menstrual period parameters
28d +/- 7d
35ml per menses
>80 abnormal
ddx vaginal bleed
PALM - polyps, adeno, leiomyomas, malignancy
COEIN - coagulopathy, ovulatory dysfunc, endometrial, iatrogenic, not yet classified
Which fibroids cause worst bleed?
submucosal
Placenta previa after which week of pregnancy?
20th
List 10 non structural causes of nonpregnant vaginal bleed
Coagulopathies
von Willebrand disease
Factor XI deficiency Thrombocytopenia
Idiopathic thrombocytopenic purpura Endocrine
Polycystic ovarian syndrome Hypothyroidism
Hyperprolactinemia
Adrenal hyperplasia
Cushing disease
Weight loss, extreme exercise Stress
Obesity
Trauma
Sexual abuse
Infections
Sexually transmitted infection Tubo-ovarian abscess
Vaginitis
Systemic disease
Liver disease
Kidney disease
Foreign bodies
Medications
Antiepileptics
Antipsychotics
Anticoagulants
Hormonal medications
Steroids
Intrauterine device
RF postpartum hemorrhage
postpartum hemorrhage prior
prolonged labor
induced labor
augmentation of labor with oxytocin and instrumented delivery
<24h after delivery bleed mc
uterine atony (tend to occur if LGA fetus, polyhydram, multiparity)
MC bleed >24h after delivery
RPOC
Prepubescent girls ddx vaginal bleed
vaginal bleeding include vaginitis, foreign bodies, sexual abuse, tumors, and trauma
Adolescent girls ddx vaginal bleed
abnormal vaginal bleeding is persistent anovulation due to immaturity of the hypothalamic-pituitary-ovarian axis.
Early pregnancy bleed prior to 20th week ddx
miscarriage, ectopic pregnancy, implantation bleeding, molar pregnancy, and ruptured corpus luteum cyst
RF ectopic pregnancy
pelvic inflamma- tory disease, previous ectopic pregnancy, prior tubal surgery, use of an intrauterine device, and endometriosis
Vaginal bleed third trimester - ddx
placenta previa, placental abruption, and uterine rupture.
What is considered heavy bleeding tampon/pad wise
soaking more than one pad or tampon every 1 to 2 hours is suggestive of heavy bleeding
Ongoing bleeding - how to manage
IVF
blood if needed - if pregn Rh status req or neg blood
TXA 1g
foley cath
Stable nonpregn management of vaginal bleed
-Assess for anemia
- Transfuse as indicated - Management depends
on age and underlying
cause
- Ensure timely GYN f/u
CI to E2 OCP
History of a thromboembolic event or stroke, pregnancy, active liver disease, severe uncontrolled hypertension, and women older than 35 years who smoke
AUB hormonal tx with conjugated equine e2 dose
25 mg IV every 4–6 h until bleeding stops, up to 24 h
AUB combined OCP dosing
Monophasic oral contraceptive pills containing <35 μg ethinyl estradiol recommended: One pill tid PO for 7 days
or
One pill bid PO for 5 days, then one pill qd until pack is finished
AUB Progestin-only oral contraceptive pills (medroxypro- gesterone acetate) dose
20 mg tid PO for 7 days
Pain management in AUB
nsaids - ibuprofen
mefenamic acid
naproxen
To avoid the potential for misdiagnosis and possible disruption of a desired intrauterine pregnancy, American College of Obstetricians and Gynecologists (ACOG) recommends using which value of β- human chorionic gonadotropin (β-hCG) for the discriminatory zone?
a. 1500 IU/mL b. 2000 IU/mL c. 3500 IU/mL d. 4500 IU/mL
c
What is the most common cause of uterine bleeding in the immedi- ate postpartum period?
a. Uterinerupture
b. Vaginal lacerations
c. Retained products of conception
d. Uterine atony
d
A 30-year-old woman with a history of polycystic ovarian syndrome (PCOS) and prior deep vein thrombosis (DVT) presents to the ED with 10 days of irregular, heavy uterine bleeding. Her vital signs are normal. What is the first step in her ED management?
a. Check complete blood count (CBC).
b. Order urine pregnancy test.
c. Administer 25 mg intravenous conjugated estrogen. d. Prescribe a taper of oral contraceptive pills.
b
A 30-year-old woman with a history of polycystic ovarian syn-
drome (PCOS) and prior deep vein thrombosis (DVT) presents to the emergency department (ED) with 10 days of irregular, heavy uterine bleeding. Her vital signs are normal, and a urine pregnancy test is negative. She currently takes no medication. Which of the following is the most appropriate treatment?
a. Oral contraceptive taper
b. Medroxyprogesterone acetate c. Oral tranexamic acid
d. Ibuprofen
d
A 32-year-old woman who is 26 weeks pregnant describes a 1-hour history of painless vaginal bleeding after tripping and falling from a standing height. Her vital signs are normal, and physical examination of the abdomen reveals a nontender uterus with a fundal height 1 cm above the umbilicus. Of the following, which would be the most appropriate next step in evaluating this patient?
a. Abdominal magnetic resonance imaging (MRI) b. Bimanual examination
c. Sterile speculum examination
d. Ultrasound
d
