PV Bleeding

PV Bleeding

1. ED Management of PV bleeding CME JUNE 2017

2. Common ED presentation 20-40% of pregnancies have 1st trimester bleeding Wide range of differential diagnoses Can be life-threatening Distressing Introduction

3. Assessment of patient Important causes Management/Disposition

4. Assessment

5. two important questions Stable or unstable ? Pregnant or not ?

6. History Amount or volume of bleeding and duration Relation to menstrual cycle Normal cycle Other symptoms Gynae/Obstetric history including IVF PMH/FH Drugs

7. Examination Observations General appearance Abdominal examination Pelvic examination

8. Investigations Urine bHCG Serum/Quantitative bHCG Bloods/Group&Hold Check rhesus status USS

9. Causes of PV bleeding

10. Abnormal PV bleeding Reproductive age Pregnant <20 weeks Ectopic Miscarriage Pre-menarchal Vulvovaginitis Trauma Sexual abuse Non-pregnant Abnormal uterine bleeding Structural causes Non-structural PID Ovarian cyst rupture Post-menopausal Malignancy >20 weeks Placenta previa Placental abruption

11. Abnormal PV bleeding Reproductive age Pregnant <20 weeks Ectopic Miscarriage Pre-menarchal Vulvovaginitis Trauma Sexual abuse Non-pregnant Abnormal uterine bleeding Structural causes Non-structural PID Ovarian cyst rupture Post-menopausal Malignancy >20 weeks Placenta previa Placental abruption

12. Abnormal PV bleeding Reproductive age Pregnant <20 weeks Ectopic Miscarriage Pre-menarchal Vulvovaginitis Trauma Sexual abuse Non-pregnant Abnormal uterine bleeding Structural causes Non-structural PID Ovarian cyst rupture Post-menopausal Malignancy >20 weeks Placenta previa Placental abruption

13. Structural causes Polyps Adenomyosis Fibroids Malignancy

14. Non-structural causes Coagulopathy Ovulatory dysfunction Endometrial dysfunction Iatrogenic

15. Management and disposition Pharmacological options

16. Management and disposition Pharmacological options Caution with VTE risk Outpatient follow up with USS to identify structural causes +/- gynaecology follow up

17. Abnormal PV bleeding Reproductive age Pregnant <20 weeks Ectopic Miscarriage Pre-menarchal Vulvovaginitis Trauma Sexual abuse Non-pregnant Abnormal uterine bleeding Structural causes Non-structural PID Ovarian cyst rupture Post-menopausal Malignancy >20 weeks Placenta previa Placental abruption

18. unstable PV bleeding Move to resus Good IV access x2 FBC, UEC, Crossmatch Urgent bedside USS Resuscitate with fluid+/- blood products Consider cervical shock Urgent obs & gynae input

19. Rhesus status Check rhesus status for all pregnant patients Rhesus negative RhD immunoglobulin 250 units IM <20 weeks RhD immunoglobulin 625 units IM >20 weeks Unclear role if <12 weeks Prevents maternal formation of antibodies from isoimmunisation

20. Quantitative bhcg Levels increase at least 66% every 48hrs in the first 10 weeks Serial measurements are more useful Falling bHCG consistent with non-viable pregnancy No discrimination between miscarriage/ectopic Discriminatory zone is usually >1500 - BHCG level at which gestational sac visible on TV USS

21. Trans vaginal USS Most useful tool for determining pregnancy location Sensitivity ~98% and specificity 100% for IUP Sensitivity ~85% and specificity ~99% for ectopic

22. Viable intrauterine pregnancy or threatened miscarriage Miscarriage Ectopic Pregnancy of unknown location

23. Threatened miscarriage PV bleeding +/- abdominal cramping with a viable foetus inside the uterine cavity with a closed cervix Can affect up to 20% of pregnancies <20 weeks 17% go on to have further complications Management RhD immunoglobulin if rhesus -ve Discharge with advice Follow up in EPAS clinic

24. Miscarriage Pregnancy loss before the 20th week of gestation 8-20% of pregnancies Most common in 1st trimester Risk factors include - advancing maternal age, previous miscarriage and smoking

25. Inevitable

26. Inevitable miscarriage Spontaneous miscarriage than can’t be stopped Persistant lower abdominal cramps and heavy PV bleeding Cervical os open Products of conception often visible

27. Inevitable Incomplete

28. incomplete miscarriage Part of the products of conception is retained in the uterus Persistant cramps and heavy PV bleeding

29. Inevitable Incomplete Complete

30. Complete miscarriage All products of conception expelled Cramps and PV bleeding stop Cervical os closed

31. Inevitable Incomplete Complete Missed

32. Missed miscarriage Foetal demise picked up on USS Products of conception retained Sometimes get an asymptomatic brownish discharge

33. Ectopic Ectopic pregnancy occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity 1-2% of pregnancies but 6-16% of pregnancies that present to ED with symptoms High morbidity and mortality - 10-15% of all pregnancy deaths Risk factors include previous ectopics, previous tubal surgery, previous PID & smoking

34. Clinical picture History Bleeding Abdominal pain Amenorrhoea Examination Lower abdominal tenderness/mass Shock

35. Diagnosis TV USS TV USS + Discriminatory bHCG

36. Abnormal PV bleeding Reproductive age Pre-menarchal Post-menopausal Pregnant Non-pregnant >20 weeks <20 weeks Ectopic Miscarriage Vulvovaginitis Trauma Sexual abuse Abnormal uterine bleeding Structural causes Non-structural PID Ovarian cyst rupture Malignancy Placenta previa Placental abruption

37. DO NOT PERFORM A PELVIC EXAMINATION ON ANY PATIENT WITH PV BLEEDING WHO IS IN THE THIRD TRIMESTER OF THEIR PREGNANCY

38. Placenta previa Placental tissue extending over the cervical os History Painless PV bleeding Examination Soft uterus

39. Placental Abruption Bleeding between the placenta and the uterus lining that causes partial or complete detachment of the placenta Risk factors include previous abruption, abdominal trauma, cocaine, pre-eclampsia and hypertension History PV bleeding with abdominal pain Uterine contractions Examination Firm, tender uterus

40. Management OBSTETRIC EMERGENCY Resuscitation Consider USS if position of placenta unknown Often needs urgent caesarian

41. Learning points

42. A patient with PV bleeding is pregnant until proven otherwise Don’t do a PV examination on a patient with PV bleeding who is in the third trimester of pregnancy Don’t forget Rhesus status All the information you could ever possibly need is online

43. References KEMH clinical guidelines - http://www.kemh.health.wa.gov.au/development/manuals/ SCGH clinical guidelines - management of 1st trimester pain and bleeding - http://scghed.com/2015/11/scgh-early-pregnancy-guideline-102015/ eTG Complete - Menstrual disorders - https://tgldcdp-tg-org-au.smhslibresources.health.wa.gov.au/viewTopic?topicfile=menstrual-disorders&guidelineName=Endocrinology#toc_d1e84 Approach to vaginal bleeding in the emergency department - https://www-uptodate-com.smhslibresources.health.wa.gov.au/contents/approach-to-vaginal-bleeding-in-the-emergency-department?source=search_result&search=vaginal%20bleeding&selectedTitle=1~150 Diagnosis and management - Emergency Medicine - Seventh Edition. Anthony FT Brown and Michael D Cadogan. CRC Press.

44. Thank-you