vaginal bleeding

CRACKCast E034 – Vaginal Bleeding

In CRACKCast, Podcast by Adam Thomas1 Comment

This episode of CRACKCast covers Rosen’s Chapter 34, Vaginal Bleeding. This chapter covers a complaint that ranges from mostly benign to life threatening, and covers causes and management.

Also check out EM Cases Rapid Reviews Videos on Vaginal Bleeding

Shownotes – PDF Here

1) List 12 causes of vaginal bleeding, indicating at what age groups each is more common

vaginal bleeding

  • Nonpregnant patients
    • Ovulatory
      • Single episode of spotting in between regular menses
    • Anovulatory
      • Causes 90% of DUB
        • Leads to an overgrowth of uterine tissue due to excessive estrogen – due to stress, weight loss, exercise.
          • The H-P-A axis is disrupted.
      • Consider:
        • Fibroids
        • Exogenous hormone use
        • Uterine AVM
    • Non-uterine
      • Need to consider vulva, vault, vagina, forchette, cervix, urethral, rectal, anal, foreign bodies, genital trauma, cervical polyps
  • Acute menorrhagia in ADOLESCENTS
    • 20% of cases due to
      • Von-wilibrand’s disease
      • Myeloproliferative disorders (polycythemia vera, CML, thrombocytosis)
      • ITP
  • Non uterine causes:
    • Cervix – cancer, polyps, condylomata, OCP use, PID
    • Vagina – lacerations, trauma, tumours,
    • Adnexa – hemorrhagic ovarian cyst, ovarian tumours, PCOS, endometriosis
    • Urinary tract – urethral diverticula, urethral furuncles
    • Anal or rectal causes

2) List 6 causes of bleeding in early pregnancy

  • Pregnant patients
    • Before 20 weeks
      • Ectopic
        • Serum BHCG levels
          • False negative rate for
            • Serum < 0.5% (when 10 mIU/mL used)
            • Urine < 1% (when 20 mIU/mL used)
              • Usually 95-100% sensitive and specific for pregnancy
          • The discriminatory level for ectopic pregnancy is 1500-2000 mIU/mL
      •  Miscarriage
        • Threatened
        • Inevitable
        • Spontaneous
        • Complete
        • Incomplete
        • Missed
        • Septic
      • Implantation bleeding
      • GI or GU bleeding
      •  Trauma
      • Cervical carcinoma
      • Gestational trophoblastic disease
        • Hydatidiform mole or molar pregnancy

3) Describe the management of severe third trimester bleeding and post-partum hemorrhage

Third trimester

  • After 20 weeks
    • Placental abruption
    • Placental previa / increta / percreta


  • Early
    • Uterine atony
      • Prolonged labour, infection, polyhydramnios, multiparity, induced labour, precipitous labour, magnesium therapy, intrauterine injection
    • Uterine trauma (instrumentation)
  • Late
    • Uterine atony
      • Prolonged labour, infection, polyhydramnios, multiparity, induced labour, precipitous labour, magnesium therapy, intrauterine injection
    • Retained foreign body
    • Infection


1) Outline options for managing vaginal bleeding in the non-pregnant patient?

  • Crystalloids and then RH Negative blood until Rh status known
  • IF blood in abdomen +/- shocky
    • Consult
      • Gen surg
      • Obs gyne
      • Radiology – IR techniques
    • May need hysterectomy, embolization, and determination of other bleeding sources (in trauma – liver, spleen, etc)
  • If < 20 weeks pregnant and not unstable:
    • Determine if os if open (use ring locking forceps to see if it is an inevitable miscarriage)
      • Give Rhogam if mother is Rh negative!

NON-pregnant patients

  • Treatment:
    • NSAIDS
    • Tranexamic acid 1 g TID x 7 days
    • Premarin (conjugated ESTROGEN) – IV or IM 25 mg and q 6 hrs prn
      • IF bleeding continues insert foley catheter into cervical os and inflate to tamponade the bleeding
      • Leave in place for 12-24 hrs
    • Birth control pill with at least 35 mcg of estradiol BID until bleeding stops or up to 7 days

2) When would you avoid estrogen products in non-pregnant women with vaginal bleeding?

  • Contraindications to estrogen use:
    • Thromboembolic events / strokes
    • Estrogen dependent tumour
    • Active liver disease
    • Pregnancy

3) 7 critical causes of vaginal bleeding NOT to miss!

Critical diagnoses NOT to miss!

  1. Ectopic
  2. Heterotopic (1:40000 – 1:100 (if on fertility treatment))
  3. Miscarriage
  4. Placenta previa / accreta
  5. Placental abruption
  6. Uterine perforation / rupture / trauma
  7. Arteriovenous malformation
  • ABCD’s and pregnancy test!
  • Bedside ultrasound for IUP and free fluid in abdomen
  • Then appropriate systemic analysis of possible bleeding causes
    • pregnancy vs. non-pregnancy
    • Anatomic approach

4) BONUS: What’s the incidence of ectopic AND the incidence with an IUD in place? 1

  • Ectopic pregnancy in general 2/100 – 2% in GENERAL population
    • But 6-16% among women who come to the ED with first trimester bleeding, and/or pain
  • Ectopic pregnancies as a proportion of all pregnancies based on contraceptive method:
    • Mirena IUD 1:2
      • !!(50% of all pregnancies, IF the woman with an IUD gets pregnant)
    • Copper IUD 1:16
    • Pills 0 – 1:20
    • Tubal sterilize opioid receptors in the gut

This post was copyedited and uploaded by Sean Nugent (@sfnugent)


Tulandi T. Ectopic pregnancy: Incidence, risk factors, and pathology. UpToDate. Accessed March 20, 2017.
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Adam Thomas

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Adam Thomas
- 1 day ago
Chris Lipp
Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine. His interests are in endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..