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
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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
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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
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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
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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
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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.

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.
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 (Innovative Sport Medicine Calgary). His interests are in paediatrics, 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…..