PV Bleeding in the ED: Dr Beth Newstead

​I was recently supposed to have been facilitating a session on vaginal bleeding as part of ACCS teaching so here is my attempt at a little bit of online education. Not my favourite subject on either a personal or professional level and don’t expect me to start speaking like a gynaecologist.  
A little Covid humour to start:

​Here goes. Everything an EM doctor needs to know on the glamorous topic of PV bleeding.
Keep it simple, stupid:
Question 1:Is the woman bleeding so heavily that they are showing signs of haemodynamic compromise? (Are they pale, ashen, sweaty? Peripherally shut down with a tachycardia? Hypotensive?). This is generally not a good sign and might make you feel a bit sweaty too. Take a deep breath, ask for some help and get the patient moved into resus.

​Take another deep breath and start reciting the alphabet: A and B – pop some oxygen on, C – if you have always wanted to insert a MASSIVE cannula then now is your chance. Two would be even better. Be kind if time allows and use a little local anaesthetic. Take some bloods and send some for an urgent cross-match. If the patient is really unwell then consider activating the massive transfusion protocol and starting a balanced transfusion (PRBC, FFP, platelets).
Tranexamic acid is rarely a bad thing when people are bleeding a lot from any cause so think about it early.
If you are a bit handy with the ultrasound or can find someone who is then it is worth scanning the abdomen for free fluid (has the patient ruptured an ectopic?).

​A gynaecologist is going to want to know about this patient sooner rather than later so get on the phone early.
The most likely cause of shock due to vaginal bleeding is a ruptured ectopic pregnancy in a pre-menopausal woman and fibroids in a post-menopausal woman.
 
Learning Bite: If the woman presents with signs of shock but with a BRADYCARDIA then you need to think about CERVICAL SHOCK. The patient will feel faint, sick and generally awful with hypotension and bradycardia. In the ED this is usually due to a miscarriage. It occurs when the products of conception pass through the cervix and cause a profound vagal response.
The only treatment is to remove the products. This is a relatively simple procedure. The cervix is visualised with a speculum and the products are gently removed with sponge forceps (see below). It is very gratifying thing to do as the woman will literally improve before your eyes. One of our own registrars did this recently with good effect. It is important to think about it as a possibility and as always ask for help.

​Question 2: Is the woman pregnant? 
In Emergency medicine the dogma is that we should suspect pregnancy in any woman between the ages of 10 and 50. In reality most women know or recognise the possibility that they might be pregnant so do ask the question first. Establish when their last period was. Ask about symptoms of early pregnancy (e.g. breast tenderness, tiredness, urinary frequency). Try and get a urine sample as quickly as possible.
If the pregnancy test is positive then the woman has a RUPTURED ECTOPIC until proven otherwise. Classically a ruptured pregnancy will present 6-8/52 after the woman’s last period. Pain is often more of a feature than bleeding.

​If the patient is unstable then they will be managed as described above. If the patient is stable then the bottom line is that they need a trans-vaginal ultrasound as soon as possible. This can happen as an in-patient or an outpatient depending on degree of suspicion, extent of symptoms and confidence that the patient will adhere to safety netting precautions if they are allowed home. Please discuss this with a senior and then refer to the gynae team. Make sure they have had the relevant bloods sent first – don’t forget a group and save in case they deteriorate and a serum beta-HCG is helpful as a baseline for the gynae team (they may monitor this serially).
Clearly miscarriage is more common than an ectopic but is initially managed in the same way by us in the ED. 
PV bleeding in late pregnancy obviously has an entirely different differential including placental abruption, placenta previa, uterine rupture and labour. It is very rare to see such patients in our ED as they usually present to labour ward. If they do appear unexpectedly resuscitate as above and seek specialist help EARLY.

​Question 3: Is the woman pre or post-menopausal?
Any woman with post-menopausal bleeding has cancer until proven otherwise. At the time of writing we don’t have access to the 2WW pathways so the patient will need a letter or phone call to their GP to get this sorted.
We are now left with a pre-menopausal patient who isn’t haemodynamically compromised and isn’t pregnant. Breath. You now have time to take a bit more of a history!
Questions that will help you elucidate what is going on:

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1. You need a description of the bleeding. Heavy bleeding means different things to different people so worth trying to ask some objective questions – how often do they need to change their pads/ tampons (2-3 hours is considered heavy)? Any clots? Any flooding? Double protection required? (pads and tampons)
2. Is the bleeding menstrual, inter-menstrual or post-coital? - this obviously helps to focus your diagnosis
3. Is there associated pain? (more likely with ovarian cyst pathology, fibroids, PID, endometriosis)
4. Are there any infective symptoms? Fever, systemic upset, vaginal discharge? Think about sexually transmitted infections and PID.
5. Has there been any genital trauma or sexual assault? (not always disclosed easily)
6. Any foreign body? (retained tampon?)
7. Is there any bleeding tendency? (anti-coagulants, hereditary bleeding disorder)
8. Could this be due to a more systemic problem? – any symptoms suggestive of hypothyroidism, liver disease etc

For this last group of patients (stable, non-pregnant, pre-menopausal) it probably doesn’t matter whether or not you make a definite diagnosis in the ED. Let’s be honest ED docs are not going to be the best at managing these conditions. We need to try and help the patient feel symptomatically better and decide if they need admission or referral back to the GP.
So, what can we do in ED? (assuming as always that the patient is not in need of resuscitation)

• Prescribe pain killers if needed
• Remove a retained tampon
• Check for trauma if indicated by the history
• Palpate the abdomen for any large masses
• Consider a PV and speculum exam (but this may very often not be appropriate in the ED).
• Get some swabs done and prescribe antibiotics if you suspect PID (this may very reasonably require referral to the gynae team if this isn’t in your skillset)
• A VBG will show if they are anaemic. This may be all you need. Routine clotting and TFTs are NOT indicated unless clinical suspicion is high
• Consider oral tranexamic acid as an option to reduce bleeding

What we shouldn’t do in the ED:

• I don’t think it is suitable for ED to prescribe hormones to try and reduce bleeding. These should be started in primary care with appropriate risk assessment and follow up. 

The flow chart here is a really good summary of everything discussed above:

References and Further Learning
1. NICE guidance on ectopic pregnancy and miscarriage:
https://www.nice.org.uk/guidance/ng126
 
2. RCOG guidance on diagnosis and management of ectopic pregnancy:
https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14189
 
3. NICE guidance on heavy PV bleeding:
https://www.nice.org.uk/guidance/ng88/resources/heavy-menstrual-bleeding-assessment-and-management-pdf-1837701412549
 
4. RCEM learning module on bleeding in pregnancy:
https://www.rcemlearning.co.uk/modules/bleeding-in-pregnancy/
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