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Chapter 38. Obstetric and Gynecological Emergencies and Rape

Ryan Tucker, MD; Melissa Platt, MD

Abnormal Vaginal Bleeding

See Table 38–1. Patients with active vaginal bleeding are at risk of exsanguination and require immediate evaluation and treatment.

Table 38–1. Causes of Abnormal Vaginal Bleeding.
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Table 38–1. Causes of Abnormal Vaginal Bleeding.
  • Premenarcheal vaginal bleeding
    • Menarche
    • Tumor (vaginal, uterine)
    • Genital trauma
    • Foreign body
    • Precocious puberty
    • Hematuria
    • Miscellaneous
  • Reproductive age bleeding
    • Variations in normal cycle
      • Hypermenorrhea (excessive bleeding at time of period)
      • Polymenorrhea (menstrual periods < 21 days apart)
    • Metrorrhagia (including ectopic)
      • Abortion
      • Pregnancy (including ectopic)
      • Endocrine abnormality (idiopathic, estrogens, thyroid)
      • Salpingitis
      • Cervictis
      • Coagulopathy (factor VIII deficiency)
      • Malignant neoplasm or polyps (cervical, vaginal, uterine)
      • Ovarian cyst
      • Myoma of uterus
      • Trophoblastic tumor
    • Miscellaneous (mittelschmerz)
  • Postmenopausal bleeding
    • Carcinoma (cervical, uterine)
    • Estrogen excess
    • Atrophic vaginitis
    • Cervical polyps
    • Trauma
    • Miscellaneous

Emergency Evaluation and Treatment

Assess for Hemodynamic Instability

Examine the patient for hypotension or tachycardia due to depletion of intravascular volume.

Hypotension

If blood pressure and pulse are normal in the supine position, measure them in the sitting position. If they are still normal, measure them in the standing position to detect more subtle volume depletion. Supine or postural hypotension can indicate life-threatening hemorrhage.

Tachycardia

Tachycardia while the patient is resting or when she assumes the upright posture also may indicate vascular depletion.

Poor Peripheral Perfusion

Cool, mottled skin and delayed capillary refill may indicate significant volume loss.

Treat Shock, If Present

(See Chapter 11) Briefly, the procedure is as follows:

  1. Insert at least 2 large-bore (≥16-gauge) intravenous catheters. A central venous catheter may be preferable if peripheral venous access is not readily obtainable. Intraosseus access is an acceptable alternative (Chapter 8).

  2. Determine the amount of blood loss and draw blood for (a) typing and crossmatching (reserve four units of fresh-frozen plasma and two to four units of packed red cells), (b) platelet count, prothrombin time, and partial thromboplastin time to uncover any bleeding abnormality, (c) complete blood count (CBC), (d) renal function tests and measurement of serum electrolytes, and (e) blood gas measurements and pH (useful in assessing adequacy of ventilation and perfusion).

  3. Insert a Foley catheter.

  4. If the patient is of child-bearing age, obtain a serum or urinary pregnancy test.

  5. Begin rapid infusion of crystalloid solution (Ringer's solution or normal saline), the rate depending on vital signs (eg, 200–1000 mL/h), to restore intravascular volume and maintain blood pressure until compatible blood becomes available for transfusion.

  6. Infuse crossmatched blood as soon as possible. If the patient is unstable and crossmatched blood is unavailable, transfuse O-negative blood. Give two or more units depending on vital signs.

Determine the Cause of Bleeding

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