Rosen & Barkin's 5-Minute Emergency Medicine Consult (751 page)

FOLLOW-UP

• Ectopic pregnancy not meeting methotrexate discharge criteria
  
• Uterine inversion
  
• Septic abortion
  
• Placental abruption
  
• Postpartum hemorrhage
  
• Endometritis
  
• Unstable DUB
  
• Newly diagnosed molar pregnancy
  

• Stable vital signs
  
• Confirmed IUP
  
• Ectopic pregnancy meeting institutional methotrexate discharge criteria
  
• Pregnant patient with low risk for ectopic pregnancy:
  
  • No findings of IUP on US
    
  • Levels of β-HCG below discriminatory zone
    
• Nonpregnant patients with vaginal bleeding that are hemodynamically stable
  

Obstetric/gynecologic referral

• Obstetric referral within 48 hr for 1st-trimester vaginal bleeding without identified IUP
  
• OB/GYN referral for patients with menorrhagia for continued evaluation, workup, and treatment
  

Ectopic
precautions:
Return immediately for increasing abdominal pain, vaginal bleeding more than 1 pad per hr for 3–4 hr, fever >100.4°F, syncope, or dizziness. Patients should not be left alone until the diagnosis of ectopic pregnancy can be safely ruled out. Family and friends should also be instructed on the warning signs and symptoms of ruptured/bleeding ectopic pregnancies.

• Pregnancy test for all women of reproductive age
  
• If there is 1st-trimester vaginal bleeding, evaluate for ectopic pregnancy
  

• Casablanca Y. Management of dysfunctional uterine bleeding.
  Obstet Gynecol Clin North Am
  . 2008;35:219–234.
  
• McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies.
  Surg Clin North Am
  . 2008;88:265–283.
  
• Oyelese Y, Scorza WE, Mastrolia R, et al. Postpartum hemorrhage.
  Obstet Gynecol Clin North Am
  . 2007;34:421–241.
  
• Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding.
  Am Fam Physician
  . 2007;75:1119–1206.
  
• Tsai MC, Goldstein SR. Office diagnosis and management of abnormal uterine bleeding.
  Clin Obstet Gynecol.
  2012;55:635–650.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Vaginal Bleeding in Pregnancy
  
• Threatened Abortion
  
• Placental Abruption
  
• Placenta Previa
  
• Ectopic Pregnancy
  

CODES

• 623.8 Other specified noninflammatory disorders of vagina
  
• 640.90 Unspecified hemorrhage in early pregnancy, unspecified as to episode of care or not applicable
  
• 641.80 Other antepartum hemorrhage, unspecified as to episode of care or not applicable
  

BASICS

• Major cause of maternal/fetal morbidity and mortality
  
• Early pregnancy hemorrhage (≤20 wk):
  
  • Occurs in 30% of all pregnancies
    
  • 50% lead to spontaneous abortion
    
• Late pregnancy hemorrhage (>20 wk):
  
  • Occurs in 3–5% of all pregnancies
    
• Risk factors:
  
  • Advanced maternal age
    
  • Substance abuse
    
  • Pelvic inflammatory disease (PID)
    
  • Previous cesarean section
    
  • Previous termination of pregnancy
    
  • Previous dilation and curettage (D&C)
    
  • Previous ectopic pregnancy
    
  • Increased parity
    
  • Multiple gestation
    
  • Preeclampsia
    
  • Hypertension
    
  • Trauma
    
  • Use of assisted reproductive technology
    
• Genetics:
  
  • 50–60% of miscarriages due to chromosomal abnormalities
    

• Vaginal
  
• Cervical
  
• Uterine
  
• Uterine–placental interface
  
• Hematologic dysfunction
  

DIAGNOSIS

• Intensity and duration of bleeding:
  
  • Amount (clots, number of pads)
    
  • Color (dark or bright red)
    
  • Painful or painless
    
  • Watery, blood-tinged mucus
    
  • Life-threatening conditions may present with only minimal bleeding
    
• Last normal menstrual period
  
• Passage of tissue
  
• Estimated duration of gestation
  
• Gravidity/parity
  
• Fever
  
• Last intercourse
  
• Intrauterine device use
  
• Previous obstetric–gynecologic complications
  
• Syncope or near-syncope
  
• Previous obstetric–gynecologic complications
  
• Spontaneous abortion: Classically crampy, diffuse pelvic pain
  
• Ectopic pregnancy: Classically sharp pelvic pain with lateralization
  
• Placenta previa: Classically painless bright red hemorrhage
  
• Placental abruption: Classically painful dark red hemorrhage
  

• Vital signs:
  
  • Tachycardia
    
  • Hypotension
    
  • Orthostatic changes
    
  • Signs of hemodynamic instability may be absent due to pregnancy-related physiologic increase in blood volume
    
• Fetal heart tones:
  
  • Fetal cardiac activity seen on transvaginal US at 6.5 wk
    
  • Auscultated with hand-held Doppler past 10 wk gestation
    
  • Normal fetal heart rate: 120–160 beats/min
    
• Abdominal exam:
  
  • Uterine size:
    
    • 12 wk: Palpable in abdomen
      
    • 20 wk: Palpable at umbilicus
      
  • Peritoneal signs
    
  • Firm or tender uterus in late pregnancy suggests abruption
    
• Pelvic exam—only in early pregnancy:
  
  • Evaluate source and intensity of bleeding
    
  • Determine patency of cervical os (use finger and only in first trimester):
    
    • Threatened abortion: os closed
      
    • Inevitable abortion: os open
      
    • Incomplete abortion: os open or closed
      
    • Complete abortion: os closed
      
    • Embryonic demise (missed abortion): os closed
      
  • Products of conception (POC) may be noted in incomplete or completed abortion:
    
    • POC in the cervical os can result in profuse bleeding
      
  • Evaluate uterine size, tenderness
    
  • Evaluate for uterine fibroids or adnexal masses
    
  • Late pregnancy: Do not perform pelvic exam unless in controlled OR setting:
    
    • Severe hemorrhage may ensue
      
    • Placenta previa or vasa previa must be ruled out by US prior to pelvic exam
      

• CBC
  
• Type and screen
  
• Quantitative HCG in early pregnancy
  
• Urinalysis
  
• US:
  
  • Transvaginal US provides more information than transabdominal US in early pregnancy
    

• CBC:
  
  • Dilutional “anemia” is a normal physiologic change in pregnancy:
    
    • Blood volume expands by 45%
      
• Qualitative beta-human chorionic gonadotropin (β-hCG)
  
• Quantitative β-hCG:
  
  • Imperfect correlation with US findings
    
  • Detectable 9–11 days following ovulation
    
• Blood typing and Rh typing:
  
  • Cross-match if significant bleeding
    
• Disseminated intravascular coagulation (DIC) panel in embryonic demise, placental abruption
  
• Blood cultures with septic abortion
  
• Suspected POC to lab for identification of chorionic villi