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Per Vaginal (PV) Bleeding

Assessment and management is based on pregnancy being diagnosed with bHCG.

Non pregnant PV bleeding may represent a spectrum from benign to significant pathology and other than clear and obvious simple explanations will require seeking advice and referral to gynaecological services:

  • Abnormal or normal menstrual period, first menstrual period

  • Trauma, FB, sexual assault

  • Hormonal contraception related

  • Infection UTI, PID, retained tampon

  • Cancer – cervical or uterine

  • Bleeding from another source (rectal, anal)

A clear history is essential

  • Bleeding history

  • Duration

  • Volume by pads and clots

  • Increasing / decreasing?

  • Associated with pain (ectopic)?

  • Products of conception or tissues seen

  • Other symptoms, such as urinary, general (anorexia/infection) or syncope (blood loss)

Examination may alert you to significant pathology

General examination:

Primary survey, ABCDE approach as in any patient particularly if unstable. (In unstable patients this will involve IV access and fluid)

Specific examination

Abdominal- tenderness and peritonism may indicate ruptured ectopic and potential for life threatening bleeding

PV examination- indicated if there is concern about a local non uterine cause of bleeding or about clots in the os leading to pain or vaginal symptoms. We suggest PV examination in cases of trauma, peritonism, large volume bleeding and shock.

Where there is no significant pain, vaginal vault or cervical pathology is not a concern and there are no other specific indications then it is not necessary.

Laboratory

FBC - WCC for infection, WCC often raised in pregnancy - so not specific if raised.

BHCg - quantitative - confirm pregnancy.

Blood Group and hold - If patient is unstable consider O-ve blood. May need anti-D if Rhesus negative.

NSW Health Guidelines - Maternity - Rh (D) Immunoglobulin (Anti D) - GL2015_011

Imaging

  • Pelvic ultrasound scan, to determine:

    • Intrauterine pregnancy

    • Tubal pregnancy

  • Evidence of bleeding such as pelvic / abdominal free fluid

  • Other pathology

Ectopic Pregnancy

1-2% pregnancies are ectopic.

Whenever there is bleeding in early pregnancy then we need to consider any red flags for ectopic pregnancy:

  • Past history of ectopic pregnancy

  • Previous PID

  • Intrauterine contraceptive device in situ

  • Previous tubal surgery

  • Smoker

  • Abdominal tenderness or peritonism

  • Associated pain

  • Absence of identified intrauterine pregnancy at appropriate bHCG levels (risk of intra and extra uterine pregnancy in IVF patients)

  • Lower than expected bHCG levels for dates

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