Vaginal Bleeding / AUB
In any woman with vaginal bleeding, rule out pregnancy.
In pregnant patients with vaginal bleeding
Consider worrisome causes (e.g., ectopic pregnancy, abruption, abortion), and confirm or exclude the diagnosis through appropriate interpretation of test results.
Do not forget blood typing and screening, and offer Rh immunoglobulin treatment, if appropriate.
Diagnose (and treat) hemodynamic instability.
In a non-pregnant patient with vaginal bleeding:
Do an appropriate work-up and testing to diagnose worrisome causes (e.g., cancer), using an age-appropriate approach.
Diagnose (and treat) hemodynamic instability.
Manage hemodynamically stable but significant vaginal bleeding (e.g., with medical versus surgical treatment).
In a post-menopausal woman with vaginal bleeding, investigate any new or changed vaginal bleeding in a timely manner (e.g., with endometrial biopsy testing, ultrasonography, computed tomography, a Pap test, and with a pelvic examination).
Abnormal Uterine Bleeding (AUB)
Definitions
Volume
Heavy (ovulatory, interferes with QOL)
Regularity (Normal variation is 2-20 days)
Irregular (>20 day bleed-free intervals within 90 days)
Absent/amenorrhea (No bleed in 90 days)
Frequency (Normal 24-38 days)
Infrequent (>38d)
Frequent (<24d)
Duration (Normal 3-8 days)
Prolonged (>8d)
Shortened (<3d)
Irregular, non-menstrual
Intermenstrual bleeding (light/short between normal menstrual periods)
Post-coital
Premenstrual/post-menstrual spotting
Outside reproductive age
Post-menopausal
Precocious (<9y)
Acute (not pregnant requires immediate intervention)
Chronic (>6 months)
DDx
Pregnancy (Ectopic)
Trauma
Infection
Systemic (Hypothyroid, Hyperprolactinemia, Cushing's, PCOS, Adrenal, Hypothalamic suppression - stress)
Iatrogenic / Medication (anticoagulants, hyperprolactinemia - antipsychotics, antidepressants)
AUB
PALM (structural)
Polyp
Adenomyosis
Leiomyoma (Submucosal, Other)
Malignancy/hyperplasia
COEIN (nonstructural)
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
History
Anemia (presyncope, SOBOE)
Sexual and reproductive history (pregnancy, STI, vaginal discharge, cervical screening)
Systemic (hypothyroidism, hyperprolactinemia, coagulation disorder, PCOS, adrenal/hypothalamic)
Pelvic pain/pressure
Impact on QOL
Fam Hx (coagulation, PCOS, endometrial/colon CA)
Comorbid (hormone tumours, thromboembolic disease, CVD) could impact treatment options
Physical Exam
Potential sites of bleeding
Vulva, vagina, cervix, urethra, anus, perineum
Pelvic examination, speculum
Mass, laceration, friable area
Cervical polyp
Uterine enlargement (pregnancy, leiomyoma, adenomyosis, uterine malignancy)
General exam for systemic illness, thyroid, hyperandrogenism, acanthosis nigricans, galactorrhea
Investigations
Labs:
CBC (Hb)
B-hCG
Serum positive 9d post-conception
Urine positive 28d after LMP
TSH, Prolactin
Blood type and screen
Coags, vWF, Fibrinogen (history of menorrhagia)
Iron studies
Gono/Chlam (cervicitis)
Cervical cancer screening (as per guidelines)
Endometrial sampling if
>40yo
Note: If postmenopausal on HRT <12mo can observe for one year before diagnosing AUB
Risk factor
Obesity, PCOS, nulliparity, diabetes
HNPCC (Lynch Syndrome 40-60% endometrial CA)
Failed management / persistent AUB
Consider if Infrequent AUB >3y (suggests anovulatory)
Imaging if exam findings of structural lesion, symptoms persist
Pelvic ultrasound (eg. ovulatory heavy bleeding)
Saline sonography for submucosal fibroids
Management of Non-Pregnant
Hypovolemia/Hemodynamic instability
Acute
Conjugated equine estrogen 25mg IV q4-6h x24h
Consider antiemetic due to side effects of nausea/vomiting
Combined OCP TID x7d
Medroxyprogesterone acetate 20mg TID x7d
Tranexamic acid 1g PO/IV TID x5d
Procedure (D&C, endometrial ablation, uterine artery embolization, hysterectomy)
Treat underlying primary pathology
Correct anemia (iron replacement)
Rule out malignancy (if high risk)
AUB-HMB (most leiomyomas or adenomyosis)
Mirena IUD (LNg20)
Combined OCP
Progestin
Tranexamic, NSAIDs
Expectant if not anemic or does not desire treatment
AUB-O (Ovulatory dysfunction)
Mirena IUD (LNg20)
Combined OCP
Progestin
Dysmenorrhea/pelvic pain
Gonadotropin-releasing hormone agonists
Surgery (uterine fibroid embolization, myomectomy, and hysterectomy)
Pregnancy
Remember to give anti-D Ig (Rhogam 300mcg IM) for Rh (D)-neg patient to protect against isoimmunization
First Trimester
DDx
Implantation bleed
Abnormal pregnant (Ectopic/molar)
Abortion (threatened, inevitable, incomplete, complete, missed, septic)
Non-Obstetrical (Uterine, Cervical Vaginal Pathology)
On exam
Vitals (r/o hemodynamic instability, fever)
Abdominal exam (r/o surgical abdomen)
Speculum
Source of bleeding (Vagina/Cervical/Uterine)
Cervical os (r/o cervical dilation)
Bedside ultrasound (r/o free fluid, confirm IUP)
Investigations
CBC
Blood type
Serial b-hCG
Rising b-hCG >35% over 48h consistent with viable IUP (but ectopic may also display rising hCG)
hCG <35% over 48h suggest ectopic or abnormal IUP
Abdominal Ultrasound
IUP if b-hCG >6000 IU/L
Transvaginal Ultrasound
Gestational sac and yolk sac at 5w gestation
Cardiac activity at 6w gestation
IUP if b-hCG >2000 IU/L
Absence of IUP does not always ectopic (eg. early multiple gestation)
Treatment
If excessive bleeding
Tranexamic acid 1g IV over 10-20 mins
Misoprostol 800mcg SL/PO/PR/(avoid PV if excessive bleeding), then 400mcg q3h PRN
Vasopressin injected on anterior lip of cervix (see paracervical block)
If incomplete abortion, consider dilation & aspiration
Prophylactic antibiotics (eg. Azithromycin 500mg PO x1 or Doxycycline 200mg PO x1)
If cervix is not open, dilate PRN
Clean cervix with proviodine or diluted chlorhexidine (10mL in 1L sterile NS)
Paracervical block
Inject 2mL Lidocaine orXylocaine 1% where tenaculum is placed
Inject in two or more injection points with total 10-20mL (eg. 2 and 10 o'clock at the cervico-vaginal junction)
Avoid 3 and 9 o'clock due to vessels
Can add vasopressin (3-5 units) in syringe to reduce bleeding
If bleeding from puncture site, can use silver nitrate PRN
Consider procedural sedation (eg. Fentanyl 100mcg IV and Midazolam 2mg IV, and increase PRN)
Monitoring PRN
Ideally place in knee stirrups
Place tenaculum
Insert cannula on MVA (manual vaccuum aspirator)
Cannula must be large enough to aspirate the products (usually corresponds to the number of weeks rounded up - eg. 9 weeks = 9mm cannula)
Click/Push on both sides of the aspirator to engage the vaccuum system
Pull on plunger to create vaccuum
Once inside the uterus, unclick aspirator
Ideally two aspirations
Ensure to rotate and to avoid going past fundus
Stop when uterus feels empty (less bleeding, 'orange peel feeling')
For Rh negative, consider Rh Ig PRN
Second and Third Trimester
DDx
Bloody show (onset 72h prior to labor, PPROM)
Placenta previa (20%)
Touching/covering internal os (low-lying is within 2cm)
Risk: Previous placenta previa, previous C/S, uterine surgery, advanced age, multiparity, smoking/cocaine, multiple gestation, in vitro
Placental abruption (30%)
Painful contractions, hypertonus tender uterus, vaginal bleeding may be concealed
Risk: Prior abruption, thrombophilia, iron deficiency, PROM, Hypertension, Overdistended uterus, maternal age/parity, smoking/cocaine, abdominal trauma, c/s
Clinical diagnosis, not well diagnosed on ultrasound
Kleihauer-Betke test (fetal cells in maternal blood)
Uterine rupture (rare)
Suspect in shock, acute abdominal pain, change in station, abnormal FHR, vaginal bleeding
Risk: Uterine scar, hyperstimulation (IOL), multiparity
Vasa previa (rare)
Suspect in painless bleeding with change in FHR
Risk: Twins, placenta previa (consider TVUS screen at 32w), IVF
Apt test (positive = fetal blood, negative = maternal blood)
Wright stain (nucleated RBC on smear)
Non-Obstetrical (Uterine, Cervical, Vaginal Pathology)
On exam
Vitals (r/o hemodynamic instability)
Abdominal exam (including uterine tone/activity)
Bedside ultrasound (r/o placenta previa)
Sterile speculum
Avoid digital cervical exam until placenta previa ruled out by ultrasound (also if possible prior to speculum)
Labs:
Type (Rh) and Crossmatch
CBC
Kleihauer-Betke if abruption
Bedside clot test
INR
Manage
Get help, oxygen, IVF (LOTS!), foley
Massive transfusion protocol
Follow Hb and Coag
References:
ACOG 2013. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. http://www.acog.org/-/media/Committee-Opinions/Committee-on-Gynecologic-Practice/co557.pdf
SOGC 2013. Abnormal Uterine Bleeding in Pre-Menopausal Women. https://sogc.org/wp-content/uploads/2013/05/giu292CPG1305E1.pdf
SOGC 2001. https://sogc.org/wp-content/uploads/2013/01/106E-CPG-August2001.pdf
AAFP 2004. http://www.aafp.org/afp/2004/0415/p1915.html