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!