Espresso: Acute Uterine Bleeding

What causes bleeding?

Remember - PALM-COEIN! We talked about this way back in episode 47. As a quick refresher:

PALM - the structural causes:

• P - polyp

• A - adenomyosis

• L - leiomyoma (fibroids)

• M - malignancy

COEIN - the non-structural causes

• C - coagulopathy

• O - ovulation (i.e., anovulatory)

• E - endometrial (local endometrial factors)

• I - iatrogenic 

• N - not otherwise specified

Your EM colleagues call you STAT! It’s really bad! What should you do?

• Start ABCs! 

  • Get your vital signs - assess for signs of hemorrhagic shock

  • IV access - 2 large-bore if possible

  • Resuscitate - balanced crystalloid is a good place to start if relatively stable; blood if appearing unstable 

• Laboratories:

  • Pregnancy test

    • Remember, pregnancy heavy bleeding opens up a whole new can of differential diagnosis and management -- from miscarriages to retained placental fragments.

      • We’ll set that aside for today.

  • CBC - know where you’re starting from. 

    • Note that with an acute bleeding episode, H/H may not accurately reflect actual RBC status as there hasn’t been time to equilibrate.

    • CBC may also clue you into rarer disorders -- i.e., thrombocytopenia due to TTP-HUS or leukemia -- that may result in vaginal bleeding.

  • Coag panel - do you suspect coagulopathy?

    • In the adolescent patient, this may be sign of underlying bleeding disorder like von Willebrand’s disease or hemophilia. 

    • In an older patient without history of bleeding, abnormal coags may point to evolving DIC from very significant bleeding, or acquired coagulopathy (i.e., overdose with warfarin).

  • Type and screen/crossmatch - get blood ready! 

    • A type and screen is always a good place to start, and will be the test that takes the longest.

      • Assuming no antibodies to screen against, a crossmatch can then be had relatively quickly in most large medical centers.

• History & Exam:

  • History should be directed towards understanding how much, how long, and how frequently.

    • How much - get a sense for the amount of acute blood loss, and whether this is life threatening.

    • How long - understand timing of the bleeding as another marker of amount of blood loss, and how long the episodes have lasted if they have happened in the past.

    • How frequently - understand if this is a one-off acute event versus a recurrent issue.

      • Frequent heavy bleeding events may be suggestive of underlying bleeding disorder in younger patients, versus structural causes of heavy bleeding (i.e., fibroids) in older patients. 

    • Examination may help point towards cause immediately - trauma, prolapsing fibroid/polyp. 

      • Also, exam should help increase or ease your suspicion for life-threatening hemorrhage based on what you find!

    • Imaging and other testing may be warranted:

      • Imaging if patient is stable, and suspect but need to diagnose underlying cause (i.e., pelvic ultrasound)

      • Consider endometrial biopsy in those under age 45 with risk factors (unopposed estrogen).

How do I stop the bleeding?!?!

Medical therapy is most ideal in the moment, though surgical therapy is occasionally required! 

Meds to remember:

• Conjugated equine estrogen (IV estrogen). 

  • Source: equine (horses)

  • Dose: 25mg IV, every 4-6 hours for 24 hours

  • Avoid in patients with breast cancers, history or risk of thromboembolic disease,

  • Efficacy: excellent

    • Small RCT demonstrated stoppage of bleeding in 72% of women with exposure to IV estrogen over 8 hours (vs 38% with placebo).

  • Requires observation/inpatient administration as IV only, and will ultimately need to transition to a PO medication (can’t use unopposed estrogen forever!)

• Combined oral contraceptives

  • Suggested dose: 35mcg monophasic combined pill, TID x 7 days.

    • Many alternative regimens that are discussed, likely one exists that is a favorite at your hospital.

  • Avoid in patients who are smokers age 35+, history of or current VTE, migraine with aura, or other major risk factors for VTE (diabetes with vascular complications, recent surgery with immobility, etc).

  • Easy to administer, and patients are generally familiar with OCPs.

  • Side effects generally include nausea from high amount of estrogen - consider coprescription with antiemetic.

  • High efficacy -- 88% stop bleeding within 3 days.

• Medroxyprogesterone acetate (Provera)

  • Suggested dose: 20mg PO, TID x 7 days

    • Like COCs, many alternative regimens exist, and likely one is a favorite at your hospital.

  • Similar contraindications: avoid in those with past/current history of DVT/PE, breast cancer, or liver disease.

  • High efficacy -- 76% stop bleeding within 3 days.

  • May have improved side effect profile over COCs (less nausea)

• Tranexemic acid

  • Dose: 1300mg PO TID x 5 days; alternatively, can use IV formulation at max 600mg q8h.

  • Uncertain thromboembolic risk, but follows again that may increase this risk so use with caution in those with significant risk factors.

  • Reduces bleeding in those with chronic AUB 30-55%.

Bleeding disorder suspected?

Get hematology involved! Resuscitation / treatment may be influenced by particular factor deficiencies.

Surgical management

• D&C, hysteroscopy, etc.

  • May be helpful for known causes (i.e., polyp, submucosal fibroid) but are often just temporizing measures otherwise.

  • Unless cause is truly identified, will not necessarily impact bleeding beyond the current cycle.

• Balloon tamponade

  • On the small, nonpregnant uterus, use a 26F Foley catheter with 30cc saline in the balloon.

• Interventional radiology for uterine artery embolization; hysterectomy

  • These can be considered as options, though ideally not in the mega-acute situation. More ideal to have some planning involved first!