VAGINAL BLEED NON-PREGNANT Flashcards
KEY CONCEPTS
KEY ED MANAGEMENT
Assess hemodynamic stability
Rule out pregnancy
Temporize bleeding
Ensure timely gynecology follow-up
DDX
Age and structural vs. non-structural
Structural: fibroids, adenomyosis, polyps
Non-structural: ovulatory dysfunction, coagulopathy, malignancy
PELVIC EXAM: A pelvic exam is necessary to rule out structural or traumatic causes
NSAIDs 1st line treatment
DISPOSITION
Timely f/u w/ Gyne, especially for > 45 yo
DDX
STRUCTURAL
MCC age 19-39
Polyps
Adenomyosis
Leiomyoma (fibroids)
Malignancy (critical DDx in advanced age)
NON-STRUCTURAL
Coagulopathy (MCC vWB)
(An)Ovulatory dysfunction (MCC age 13-18) / PCOS (common 19-39)
Endometrial
Iatrogenic (i.e. drugs, surgery)
Not classified
MANAGEMENT
MANAGEMENT: UNSTABLE
CIRCULATION
Isotonic Crystalloid IV Bolus 30 cc / kg
O-Negative pRBC and FFP 2:1
Consider Massive Transfusion Protocol
ANTICOAGULATION REVERSAL
Warfarin: Octaplex (PCC) 80 mL IV
Vit K 10 mg IV
4-6 U FFP if PCC not available
Heparin: 1 mg Protamine per 100 units of unfractionated Heparin
NOAC: Octaplex (PCC) 80 mL IV
4-6 U FFP if PCC not available
Dabigatran: Idarucizumab 5 g IV
conjugated estrogen 25 mg q4h until bleeding stops (up to 24h)
CONJUGATED ESTROGEN
(Premarin) 25 mg IV q4h-6hr until bleeding stops (up to 24h)
May increase risk of VTE
Caution:
CV disease, VTE risk factors
C/i:
active or past VTE, breast CA, Liver Disease
TXA
10 mg / kg IV over 10 min q 8 hrs up to 5 days (max dose 600 mg)
C/i: active intravascular clotting, subarachnoid hemorrhage
TAMPONADE
Uterine tamponade device (eg, Bakri balloon)
IMMEDIATE GYNE CONSULT
IMMEDIATE IR CONSULT
INVESTIGATIONS
Minimum Tests:
1) Qualitative B-HcG
IF POSITIVE, THEN
Quantitative b-hCG
2) CBC + ferritin
3) Imaging:
Transabdominal Ultrasound (TAUS) (always first step)
Transvaginal Ultrasound (TVUS): if NDIUP on TAUS, used to confirm IUP
Unstable:
type & screen
INR
PTT
Rh status
TSH
Additional:
Prolactin
+/- Androgen
+/- FSH / LH / Estradiol
+/- VWB
GC / CT
U/A
MANAGEMENT: STABLE
NAPROXEN
500 mg PO at the first sign of menses; followed by 250 q 6 - 8 hrs for up to 5 days
c/i renal disease, caution with h/o GI bleed
IBUPROFEN
400 mg PO q 4 hrs PRN (max 3200 mg / day)
c/i renal disease, caution with h/o GI bleed
TXA
1000 mg PO tid for up to 5 days
C/i: active intravascular clotting, subarachnoid hemorrhage; caution in CVD and VTE risk factors
OCPs
(monophasic OCP <35 ug ethinyl estradiol)
1 tablet PO every 12 hours for 5 days, then 1 tablet every 24 hours until pack is finished
c/i: Patients >35 years who smoke, patients who have a history of deep vein thrombosis or pulmonary embolism, breast cancer, liver disease, known thromboembolic disorders, pregnancy, ischemic heart disease, cerebrovascular disease, or uncontrolled hypertension
for unpredictable bleeding
IRON
Ferrous sulfate 300-325 mg by mouth every 8 hours for anemia.
Note: Vitamin C (ascorbic acid) 250-500 mg by mouth every 8 hours can increase iron absorption.
DISPOSITION
Most can be discharged home with close Gyne follow-up once pregnancy and anemia have been ruled out
DOCUMENTATION
HISTORY
Mentrual History
Pregnancy History
History of STI
Past Sx History
Current Sexual History
Sexual Abuse
PHYSICAL
Vitals
Signs of Anemia (pallor)
Signs of Bleeding Disorder (bruises, petechiae, signs of liver disease)
Bimanual Exam (confirm source of bleed, palpate uterus)
Speculum Exam (signs of trauma, cervix for friability, infection, polyps, lesions)
Thyroid Exam
