Vaginal Bleeding
INTRODUCTION
In the United States, menstruation usually begins between the ages of 10 and 15 and may be irregular for several years. For most women, cycles become regular in the late teens, and as menopause approaches, cycles once again become irregular. This natural history of menstrual cycle fluctuation must be kept in mind when evaluating patients with vaginal bleeding. For the emergency physician, vaginal bleeding that produces hemodynamic compromise or is associated with pregnancy is of the greatest concern. In these cases, a urinary HCG should be obtained if the patient is of reproductive age. Pregnancy must not be ruled out solely on the basis of the patient’s sexual or menstrual history; this is particularly true in the adolescent and in the perimenopausal woman.
In children younger than 10 years of age presenting with vaginal bleeding, a number of age-specific diagnoses must be considered:
Precocious sexual development
Genital malignancy
Vaginal candidiasis
Occult “straddle-type” injuries
Sexual assault
Vaginal foreign body
Occult birth control pill ingestion
Pregnancy
In patients older than 35 years of age, anatomic causes of vaginal bleeding are common and include endometrial and cervical polyps and a variety of gynecologic malignancies.
Because structural abnormalities are common in this age group, it is important that bleeding should not be designated simply as “perimenopausal” without a thorough pelvic examination as well as other appropriate studies.
Pregnancy must always be excluded.
In patients of reproductive age, vaginal bleeding is most often related to normal menses or to an anovulatory cycle; the latter is common near the menarche or menopause or can be related to a number of other phenomena, such as stress or rapid change in weight.
The emergency practitioner should remember the importance of Rh sensitization in Rh-negative women delivering Rh-positive infants; this is preventable by administering Rh0(D) immune globulin (300 μg) after delivery.
Rh0(D) immune globulin should also be administered to Rh-negative women after abortion, miscarriage, amniocentesis, and severe antepartum hemorrhage.
COMMON CAUSES OF VAGINAL BLEEDING
LESS COMMON CAUSES OF VAGINAL BLEEDING NOT TO BE MISSED
Gynecologic malignancy
Vaginal or cervical injury
Vaginal foreign body
Gestational trophoblastic disease
Abruptio placenta
Placenta previa
Vasa praevia
Uterine rupture
HISTORY
The age of the patient is very helpful in suggesting a number of possible causes of vaginal bleeding.
Precocious sexual development, pregnancy, malignancy, candidal vaginitis, occult “straddle-type” injuries or sexual assault, occult birth control pill ingestion, and vaginal foreign body should be considered in children younger than 10 years of age.
In patients older than 35 years of age, endometrial and cervical carcinoma and polyps, pregnancy, vaginal or cervical trauma related to coitus, perimenopausal bleeding, and pelvic inflammatory disease must be considered.
In all patients of child-bearing age, pregnancy (intrauterine and ectopic), infection, spontaneous abortion, and coital trauma are common causes of bleeding.
In patients with an intrauterine contraceptive device, menorrhagia with midline, crampy abdominal pain is often reported.
A history of recent sexual exposure, fever, vaginal discharge, and pain with intercourse all suggest pelvic inflammatory disease.
A history of vaginal spotting, often after a normal, missed, or slightly abnormal menstrual period, when associated with lower quadrant pain should suggest ectopic pregnancy; rapidly evolving evidence of circulatory compromise completes the clinical picture.
PHYSICAL EXAMINATION
Vaginal or cervical laceration or injury will be apparent on pelvic examination, as will the presence of a foreign body; a foul-smelling vaginal odor may be noted in patients with a long-standing foreign body.
A blue vaginal or cervical discoloration, softening of the cervicouterine junction, breast enlargement, and nipple tenderness suggest pregnancy, either intrauterine or ectopic.
Fetal tissue in the vagina or cervical os is sometimes noted in patients with incomplete abortion, whereas vaginal bleeding or ruptured membranes in a patient in the first or second trimester associated with a dilated cervix without extruding tissue suggests that abortion is imminent.
Third-trimester, bright red painless bleeding suggests placenta previa, whereas painful bleeding with uterine tenderness or tetany suggests abruption.
Patients who present with painless third-trimester bleeding should not have a pelvic examination until ultrasound has excluded or documented the position of placenta previa.
Patients with ectopic pregnancy may also present with abdominal pain and a palpable adnexal mass or fullness, although subtle presentations with relatively painless vaginal spotting are common.
In patients with pelvic inflammatory disease, fever, lower pelvic pain with abdominal palpation, mild to moderate rebound tenderness, a purulent discharge from the cervix, and profound discomfort when the cervix is laterally displaced are often noted.
