Vaginal Bleeding & OBGYN emergencies Flashcards
Abnormal Uterine Bleeding
- Uterine bleeding that is irregular in volume, frequency, or duration in nonpregnant women
Tintinalli’s Emergency Medicine, 9th edition - Normal menstrual blood loss <30 mL.
Blood loss >80 mL is considered abnormal
PALM-COEIN acronym for AUB
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not otherwise classified
Abnormal Uterine Bleeding workup
- Pregnancy test
- CBC
- Thyroid studies
- Coagulation studies
- Ultrasound
- CT
Treatment - UNSTABLE AUB
- Immediate resuscitation
- Gynecologic consult - ASAP
Tintinalli’s Emergency Medicine, 9th edition - IV Fluid
- Blood transfusion
- Identify and correct underlying coagulopathies
- Assess for other causes of bleeding (trauma,
infection, foreign bodies, etc.)
Options for Management of Acute Hemorrhage: hormonal vs. hemostatic vs. surgical
- Hormonal
– Give conjugated estrogen IV until bleeding stops - Hemostatic
– Tranexamic acid (prevents fibrin degradation) - Obtain gyn consult before giving IV
- Surgical
– If medical management fails or contraindication
– Options: D&C, hysteroscopy, tamponade, hysterectom
Options for Management of Heavy Menstrual Bleeding: hormonal vs. non-hormonal
- Hormonal
– Oral contraceptive pills, progestin-only regimens - Nonhormonal therapies
– NSAIDs
Ectopic Pregnancy workup
- Most common symptom: abdominal pain or
discomfort (90%) - Rupture pain is lateralized, sharp, severe, sudden
- Definitive diagnosis: US or direct visualization by
laparoscopy or surgery - Treatment: Surgical (laparoscopic salpingostomy) or
Medical (methotrexate)
Spontaneous Abortion
- WHO defines as loss of pregnancy before 20 weeks or
loss of fetus weighing <500 grams - Most common cause of fetal loss: chromosomal abnormalities
- Most common presenting complaint: bleeding with or without abdominal pain
Spontaneous Abortion management
Threatened abortion - discharge and monitor
Incomplete abortion - have uterus evacuated
(misoprostol or D&C)
Complete abortion - discharge and should f/u
Induced Abortion: three major methods
- Instrumental evacuation by vaginal route
- Stimulation of uterine contraction
- Major surgical procedures
Induced Abortion workup
Presentation of complications:
* Abd pain, bleeding, possibly fever
Physical Exam:
* Cervical os is usually open; uterus is boggy, enlarged
Treatment:
* D&C or misoprostol
Septic Abortion
- A spontaneous or other abortion complicated by a
pelvic infection - S/sxs: fever, abd pain, vaginal discharge, vaginal
bleeding, hx of recent pregnancy
MCC of septic abortion
- Most common causes: retained products of conception
due to incomplete abortion, and introduction of vaginal
bacteria by instrumentation
Septic abortion treatment
- Treatment: fluid resuscitation, IV abxs, OB consult for evacuation of the uterus
Preeclampsia
- The presence of HTN after 20 weeks gestation and proteinuria or other maternal organ dysfunction
- Risk factors: prior pregnancy with preeclampsia,
maternal age >40yo, HTN, DM, renal disease, multiple gestation
HELLP syndrome
An important variant of preeclampsia
Epigastric or RUQ pain is present; HTN may not be
Preeclampsia treatment
- Antihypertensive agents
- IV magnesium sulfate
Tintinalli’s Emergency Medicine, 9th edition - Consult with OB regarding admission or transfer
Eclampsia
The development of new-onset seizures with
preeclampsia, in women between 20 weeks gestation
and 4 weeks postpartum
Eclampsia treatment
● Treat seizures with IV magnesium sulfate
● Treat HTN
● OB consult ASAP
● Urgent delivery of fetus
Abruptio Placentae
- The premature
separation of a normally
implanted placenta from
the uterine lining
Tintinalli’s Emergency Medicine, 9th edition - Most often occurs
between 24-32 weeks - Can be spontaneous or
associated with trauma
Abruptio Placentae treatment
- Maternal stabilization
- Monitor fetal distress
- Emergent OB consult
Management: - Place two IVs
- Obtain a CBC, CMP, coag panel, fibrin degradation
product, and fibrinogen levels - Type and cross-match maternal blood
- Administer RhoGam if mother is Rh negative
Placenta Previa
- A placenta that extends
near, partially over, or
beyond the internal
cervical os
Placenta Previa presentation
painless bright-red vaginal bleeding
Placenta Previa workup
- Do not perform a digital or speculum vaginal exam
until placenta position is confirmed via US
– Disruption could cause hemorrhage
Hospital admission and observation may be
warranted, or delivery
Premature Rupture of Membranes workup
- The rupture of membranes prior to onset of contractions
Avoid digital cervical examination since it may
decrease the latent period and increase
infection
OB consult required. Treatment includes
corticosteroids and abx to treat group B Strep
Premature Rupture of Membranes Management
- Tocolytic therapy is controversial
and relatively contraindicated
– But may allow time for corticosteroid
administration and pt transfer
– Consult OB - Guidelines vary
– Historically expedited delivery was recommended after 34 wks - Cervical cerclage - a retention suture to support the
internal cervical os
Emergency Delivery: workup upon presentation
- Obtain maternal VS and fetal HR
– A persistently slow fetal heart rate indicates fetal distress - Obtain IV access
- Lab studies - blood type
- Obtain UA
Emergency Delivery management
- Measure VS and initiate supportive therapy
- Provide IV hydration
- Maternal and fetal monitoring
Before transferring, consider stage of labor and parity of pt. - Deliver the infant
