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Rosens Chapters > Ch. 31 Vaginal Bleeding > Flashcards

Ch. 31 Vaginal Bleeding Flashcards

1
Q

30 y female presents with vaginal bleeding. What is the single most important thing to determine after hemodynamic stability?

A

Pregnancy status

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2
Q

Any age female presents with vaginal bleeding. What is the most important thing to determine?

A

ABC’s

Hemodynamic stability

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3
Q

How serious is vaginal bleeding, in general, in non-pregnant patients?

A

Abnormal vaginal bleeding in non-pregnant patients is rarely life-threatening, but may herald serious pathology including cancer

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4
Q

What are the two general categories for vaginal bleeding in non-pregnant patients?

A

Structural: polyps, adenomyosis, leiomyomas, malignancy
Non-structural: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified
(PALM-COEIN)

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5
Q

Describe anovulatory bleeding

A

No ovulation means there is no corpus luteum to produce progesterone meaning estrogen is unopposed.
Estrogen causes overgrowth of the endometrium to the point where it breaks down causing irregular and unpredictable bleeding

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6
Q

What is the most important diagnosis to rule out in early pregnancy with vaginal bleeding?

A

Ectopic and heterotopic pregnancy

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7
Q

What conditions are most important to consider with vaginal bleeding after 20 weeks?

A

Placenta previa
Placental abruption
Uterine rupture
AV malformation

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8
Q

You are concerned about possible placental abruption in a patient. What factors place the patient at higher risk?

A

1 is previous abruption

Hypertensive disorders in pregnancy: eclampsia, preeclampsia, HELLP, abnormal placental implantation
Smoking and cocaine use

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9
Q

Patient is 18 hours postpartum with severe vaginal bleeding, what is the most likely cause and the best initial intervention?

A

Uterine atony is the likely cause in first 24 hours

Fundal massage is the most important initial intervention in conjunction with pitocin

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10
Q

When is uterine atony more likely to occur?

A

Any time the uterus is distended: large for gestational age, polyhydramnios, multiparity

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11
Q

What factors increase the risk of postpartum bleeding?

A 
Hx of postpartum bleeding
Prolonged labor
Induced labor
Augmentation of labor
Instrument delivery
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12
Q

Pt is 48 hours postpartum with significant vaginal bleeding, what is the likely cause?

A

Retained products of conception are the most common cause after 24 hours

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13
Q

Differential diagnosis for prepubescent girl, nonpregnant with vaginal bleeding?

A 
Vaginitis
Foreign body
Sex abuse
Tumors
Trauma
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14
Q

Differential diagnosis for adolescent girl, nonpregnant with vaginal bleeding?

A

Anovulation due to immaturity of the hypothalamic-pituitary-ovarian axis
Coagulopathy
STI’s

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15
Q

Differential diagnosis for reproductive age woman, nonpregnant with vaginal bleeding?

A

Structural lesions: polyps, fibroids

Endocrine: PCOS

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16
Q

Differential diagnosis for perimenopausal woman with vaginal bleeding?

A

Endometrial atrophy is the most common cause

Cancer must be considered until proven otherwise

17
Q

What medications can lead to abnormal bleeding?

A

Antiplatelet and anticoagulant
Antiepileptic (valproic acid)
Antipsychotics
Steroids

18
Q

What is the differential diagnosis for early pregnancy bleeding?

A 
Ectopic (most important)
Miscarriage (very common)
Implantation bleeding
Molar pregnancy
Ruptured corpus luteum cyst
19
Q

What is the leading cause of first trimester maternal death?

A

Ectopic pregnancy

20
Q

What are risk factors for ectopic pregnancy?

A 
PID
Previous
Tubal surgery
IUD
Endometriosis
IVF
21
Q

What is the significance of clotting and vaginal bleeding?

A

Normal menstrual blood does not clot

Clotting indicates a more significant amount of bleeding

22
Q

Why is post-coital bleeding more common during pregnancy?

A

Cervical lesions are more common due to increased cervical blood flow

23
Q

How should the pelvic exam be approached in vaginal bleeding after 20 weeks gestation?

A

Do an ultrasound first to exclude placenta previa

24
Q

How early can a fetal heart rate be detected?

A

As early as 6 weeks

25
Q

What labs are helpful in a hemodynamically unstable patient with vaginal bleeding?

A

CBC
Type and Cross
Coagulation studies
Beta-hCG quant

26
Q

Describe the process or approach of ruling out an ectopic pregnancy

A

Ultrasound is done to determine the location of the pregnancy. If IUP is present and no IVF, then you are done.
If no IUP, then quant beta-hCG is needed to determine if IUP would be expected.
If bhCG is high and no IUP, then presume ectopic
If bhCG is low and no IUP, then everything is indeterminate and followup US and bhCG are needed unless hemodynamically unstable
Followup levels until either they decline, or an IUP is found

27
Q

At what level beta-hCG can an ectopic pregnancy be ruled out?

A

Only if completely negative. Otherwise, there is no level where ectopic can be ruled out.

28
Q

What is first line therapy for vaginal bleeding in non-pregnant women?

A

High dose IV conjugated estrogen (premarin) given every 4-6 hours until bleeding stops (max 24 hours)

29
Q

If bleeding non-pregnant pt doesn’t respond to medication, what else can be done to stop bleeding?

A

Vagina can be packed with gauze
Foley catheter can be inserted into uterus
Either of above can be left up to 24 hours

30
Q

What non-hormonal medications can be helpful to slow or stop bleeding in nonpregnant patients with vaginal bleeding?

A

NSAID’s decrease blood loss by reducing endometrial prostaglandin levels and promoting vasoconstriction in the uterus

31
Q

What medications can be prescribed to nonpregnant patients to help slow vaginal bleeding until they can be seen by their OB?

A

Monophasic oral contraceptive pills

Most likely to be helpful in anovulatory bleeding

32
Q

What are the contraindications to prescribing estrogen contraceptive pills to patients with vaginal bleeding?

A 
Hx of DVT/PE or stroke
Pregnancy
Liver disease
HTN
Older than 35 and smoker
33
Q

Who gets RhoGAM?

A

Rh negative patients with vaginal bleeding get RhoGAM

34
Q

What is the first step in management of a pt with vaginal bleeding?

A

Assess hemodynamic stability and initiate resuscitation

35
Q

What is the next step in management of a pregnant patient with vaginal bleeding that is unstable after resuscitation has been started and is not successful?

A

Determine the viability of the fetus to determine what’s next
Ectopic: OR with OB
Nonviable: IR for AVM or D&C for miscarriage
Viable: OR for c-section
Postpartum: Pitocin

36
Q

What is the next step in diagnosis in a stable pregnant patient with vaginal bleeding <20 weeks?

A

Ultrasound to differentiate between ectopic and abortion types

37
Q

What is the next step in diagnosis in a stable pregnant patient with vaginal bleeding >20 weeks?

A

Ultrasound to differentiate between miscarriage, abruption, placenta previa, uterine rupture, and labor

38
Q

What is next step in diagnosis for a stable patient, not pregnant, with vaginal bleeding who has no findings on exam except for bleeding?

A

Rule out coagulopathy

39
Q

What pregnant patients with vaginal bleeding can be discharged vs admitted?

A

Admit: ectopic, heterotopic, placenta previa, abruption, uterine rupture
DC: stable pt’s with threatened, inevitable, incomplete, or missed miscarriage and give close OB followup

Rosens Chapters (13 decks)

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