CASE: VAGINAL BLEEDING CASE 1

Tonya is a 49yo African-American female being wheeled into the ED by her daughter. She presents to triage saying she’s been having vaginal bleeding for 1 week with some cramping and feels weak. It is a weekday evening, and you are at a small ED facility where there are 24-hr onsite laboratory, limited after-hours radiology andGYN on-call consultation services available.

ABCs are intact. Tonya reports vaginal bleeding consistently for the past week, going through 2-3 pads/hour for the past 2 days. She feels lightheaded and dizzy, has a “pounding heart”, SOB, nausea, lower abdominal cramping and weakness. Her LMP was 2 weeks ago and was heavy. She is sexually active, and when asked if she could be pregnant, she says “Oh no, I’m too old for that.” Tonya screens negative for violence or trauma.

VS: T 97.8, HR 110, BP 105/50, RR 28, 96% on room air

Pain:2/10, crampy ache, non-radiating, started with bleeding and constant since

Tonya was placed in monitored treatment room and changed into a gown. On your initial nurse assessment, you note a middle-aged woman, laying on a gurney in mild-to-moderate distress. She appears fatigued and pale. She says she felt really dizzy when she was getting into the gown and feels like she has to stay lying down. Her daughter is present.

On additional questioning, she is G2P2 (both vaginal deliveries), no history of ectopic pregnancy or STIs. She is sexually active with 1 male partner and they do not use contraception.

VS reassessment reveals

HR 135, BP 86/42, RR 26, 95% on RA

The provider orders IVFs and after 500cc NS on a pressure bag and with Tonya lying flat and feeling slightly better

VS reassessment reveals

HR 105, BP 98/52, RR 20, 99% on 2L NC

The provider is now in to assess Tonya.

Appropriate questions to ask for vaginal bleeding history:

1. LMP? Was it normal? Are periods regular?

2. Onset of bleeding?

3. Duration of bleeding?

4. # soaked pads or tampons/hour?

5. Any tissue or clots passed?

6. Vaginal discharge or fluid other than blood?

7. Pain? cramping? back pain?

8. OB history: G___ (# of pregnancies, vaginal or C/S) P___ (#live births) AB____(# abortions – spontaneous/elected)

9. History of previous ectopic pregnancy?

10. Are you sexually active? With men, women or both? When were you last sexually active?

11. History of sexually transmitted infections?

12. Method of contraception: oral contraceptives, implant, *tubal ligation, *IUD, barrier. Used consistently?

13. Attempting to get pregnant/fertility treatment?

14. Any recent GYN procedures?

15. Last meal?

16. Allergies?

17. Medications? (specificallyASA, warfarin, etc.)

*confers increased risk for ectopic pregnancy

While the provider is assessing Tonya, the female nurse is gathering supplies for the pelvic exam (detailed above).

Tonya tells the provider she’s been passing clots for 2 days, but no tissue. No vaginal discharge. ROS is confirmed from nurse assessment, but Tonya and says that her SOB seems to be getting better since she’s been here. She has no past medical nor surgical histories, no recent GYN procedures. She’s allergic to penicillin. She takes only vitamin D. She last ate 6 hours before coming. Her family history is non-contributory, and she denies tobacco, alcohol or drug use.

The nurse relays negative pregnancy test results.

The female nurse serves as the chaperone, supplies are ready, exam steps have been described, and Tonya has given verbal consent for pelvic exam. Her privacy has been attended to.

Physical exam

GEN: fatigued and pale, mild distress, but A&O

HEENT: OP clear, conjunctival pallor, dry mucous membranes

CV: tachycardic, regular rhythm, 3/6 systolic murmur heard throughout precordium

PULM: CTAB

ABD: soft, non-distended, diffuse lower abdominal tenderness, no rebound or guarding, no CVAT, no HSM

PELVIC:

External inspection: normal external genitalia, no lesions, no signs of trauma

Speculum:moderate bleeding visible at introitus, swabs/gauze to clear blood and clots shows moderate bleeding from a closed cervical os,

Bimanual:no CMT, bulky enlarged mildly tender uterus to ~12 week pregnancy, no adnexal tenderness, no masses

RECTAL: no bleeding

SKIN: pallor

NEURO: non-focal, GCS-15

Vaginal packing is placed

Results are as follows:

WBC 10,000INR: 1K 4.2LFTs normal

Hgb 7.4Na 136BUN/Cr13/0.9UA: 3+ blood o/w negative

Hct 21.2Cl 97Glucose 101T&C 2 units PRBC

Platelets 350,000HCO3 23Cardiac enzymes: negativeCXR: negative

After 1L NS and the first of 2 units PRBCs, Tonya continues to report feeling better. Her vaginal packing was changed once by the provider.

VS Reassessment reveals

HR 100, BP 102/60, RR 18, 99% on 2L NC

GYN consult – agree with resuscitation, transfusion, and vaginal packing. Recommend IV estrogen, keep NPO, GYN will be in to evaluate and repeat pelvic exam. Plan for admission.

*Treatment considerations:

-ifthere was an embolic history, would avoid IV estrogen and favor provera

-ifsignificant N/V, may avoid high-dose OCPs or may need antiemetic prior

-amount of bleeding may influence IV vs PO treatment; also anticipation of procedure would influence avoiding PO

IV estrogen is started in the ED based on dosing recommendations from GYN. GYN is expected within the hour.

Tonya was admitted to the General Medicine unit with GYN consultation and had an uncomplicated 3-day inpatient admission. Her bleeding stopped with IV estrogen. She did not require additional blood products. She had a TVUS which demonstrated multiple submucosal and subserosaluterine fibroids. Tonya underwent an endometrial biopsy which was negative. Uterine fibroids were the suspected cause of her menorrhagia and resultant symptomatic anemia. She was placed on combined oral contraceptive therapy and will follow-up with GYN as an outpatient for discussion of further treatment options.

KEY LEARNING POINTS – VAGINAL BLEEDING CASE 1

  • Unstable patients should be identified immediately, triaged appropriately and placed in a resuscitative bed
  • All female patients with abdominal pain, pelvic pain, and/or vaginal bleeding who are <52 years of age should have pregnancy assessed at triage
  • Life and fertility threatening conditions must be recognized
  • Emergency providers should perform a pelvic exam prior to specialty consultation when a patient complains of vaginal bleeding
  • When performing a pelvic exam, adhering to patient dignity, privacy and appropriate female chaperone requirements are crucial
  • It is important to ensure adequate pelvic exam set-up and anticipate the need for additional supplies (i.e. vaginal packing) in the setting of heavy vaginal bleeding
  • Not all acute vaginal bleeding warrants an emergent TVUS; indications include evaluation for ectopic pregnancy, tubo-ovarian abscess, ovarian torsion, significant pain, etc.
  • The plan of care should be effectively communicated to patientand family as well as among ED staff throughout the encounter