Vaginal bleeding

Question 1

DDX for vaginal bleeding in 1st TM pregnancy

Answer 1

Missed abortion 
Complete
Abortion 
Threatened abortion 
Ectopic 
Implantation bleed 
Trauma

Question 2

Difference between missed abortion, complete abortion and threatened abortion

Answer 2

Missed=Bleed with no fetal heart beat or growth failure
Complete=Bleeding and cramping have stopped after passing tissue
Threatened=Viable intrauterine pregnancy with bleeding

Question 3

How to manage missed abortion

Answer 3

Expectant management
Medical management (misoprostol or mifepristone with Misoprostol)
Surgical management D&C

Consider WinRHo

Always consider Tranexamic acid if excessive bleeding

Question 4

When do you give win rho

Answer 4

Technically not necassary <12 weeks but usually we do give 1/2 dose

Generally not needed unless major bleed
Also give after delivery if baby is positive

Question 5

How to manage threatened Abortion

Answer 5

1. Serial HCG (should double every 48 hrs, discriminatory zone for visualize on US 1500-2000)
2. Serial ultrasound
3. Safety netting

Bhcg corresponds to size of products, higher=bigger. No longer reliable after about 10 week. Also- should be able to see on US

Question 6

DDX for vaginal bleedin gin second and third trimester

Answer 6

Bloody show 
Placenta previa 
Placental abruption 
Uterine rupture 
Vasa previa

Question 7

Causes of Abnormal Uterine Bleeding

Answer 7

Polyp 
Adenomyosis
Leiomyoma 
Malignancy 
Coagulopathy
Ovarian dysfunction 
Endometriosis
Iatrogenic 
Not yet classified 

Pregnancy 
Hypothyroid, PCOS
Hyperprolactinemia 
Trauma 
Infection

Question 8

AUB management

Answer 8

IUS
OCP
Progestin
NSAIDS
TXA
Ablation 
Hysterectomy 
Polypectomy

Question 9

Investigations to do

Answer 9

Hemoglobin 
HCG
TSH
Prolactin 
Type and screen 
Coags
VWBF 
Fibrinogen 
Iron studies
STI testing 

Pap

Consider endometrial sampling and US

Question 10

When do to endometrial sampling

Answer 10

AUB >40
PCOS and changes to heavy bleeding
Lynch syndrome
AUB >3 years

Question 11

Post menopausal bleeding work up

Answer 11

Lab work

Pelvic exam
Pap
Endometrial biopsy
+/- ultrasound

Question 12

Risk factors for Endometrial cancer

Answer 12

Estrogen exposure

• Early menarche
• Late menopause
• Nulliparity

PCOS
Obesity
Previous breast cancer treatments (Tamoxifen)
Family history

OCP and IUD is protective

Question 13

Pt in 2/3rd trimester and has painless bleeding. What is the most likely dx and what exam should you NOT do? What are the risk factors? What are your treatments?

Answer 13

Placenta previa- no PELVIC!
RF: cs, smoker, multipreg

Treat: pelvic rest, and/or cs, give rhogam!

Question 14

Late in pregnancy bleeding differential

Answer 14

Placental aburption- pain, tense, tx with cs
Uterine rupture
Placenta previa - painless bleed, no pelvic exam, cs likely, pelvic rest
Vasa previa
Labour/bloody show
Cervical ectopy

Question 15

Options for managing ectopic?

Answer 15

Expectant- risk of tube failure/rupture and hemorrhage
Medical management - methotrexate
Sgx - laparoscopic with salpingectomy

Question 16

Contraindications to methotrexate for ectopic management?

Answer 16

Intrauterine pregnancy.
Evidence of immunodeficiency.
Moderate to severe anemia, leukopenia, or thrombocytopenia.
Sensitivity to methotrexate.
Active pulmonary disease.
Active peptic ulcer disease.
Clinically important hepatic dysfunction.
Clinically important renal dysfunction.

Question 17

What are relative contraindications to methotrexate for ectopic? When is follow up?

Answer 17

Bhcg >5000, cardiac activity on US, ectopic >4cm- these are signs medical management may not work

unreliable for follow up or remote, must have follow up Bhcg etc on day 4 and 7

Question 18

What are the signs of instability for an ectopic?

What is the management for an unstable ectopic?

Answer 18

Ssx: bleeding 1 pad every 1-2 hrs severe, postural/ vitals sign changes, low hgb

Treat: rhogam, fluids
Emergent suction dilatation and curettage
Rhogam

Question 19

What are US findings in keeping with early pregnancy loss?

Answer 19

CRL<7mm, no heartbeat, gestational sac with no yolk