Pocket ObGyn – Acute Uterine Bleeding 
See Abbreviations

Definition and Epidemiology (Fertil Steril 2011;95:2204; Obstet Gynecol 2002;99:1100)

• Heavy vaginal bleeding suff to require immediate May or may not occur in the setting of Chronic Abnormal Uterine Bleeding. See Chap. 5, Abnormal Uterine Bleeding.
• Affects 10–30% of 12% of gyn visits in ER. See SABs below, also.

Physical Exam

• Rapidly determine acuity: General appearance & Orthostatic VS.
• Speculum exam: Rule out nonuterine causes (eg, rectal bleeding, genitourinary, vaginal lacerations, cervical lesions), assess extent of bleeding (eg, active/ongoing hemorrhage)
• Bimanual exam: Evaluate for structural abnormalities, such as a prolapsing fibroid

Diagnostic Workup/Studies

• Always rule out Preg – qualitative Labs: CBC, coags including fibrinogen, type & screen. Imaging: Consider TVUS.

Treatment and Medications

• If unstable: 2 large bore IVs, crystalloid fluid resusc
• Consider xfusion of 2 U packed RBCs if Hgb <5
• If anemic, start PO ferrous sulfate at discharge from hospital
• Initiate goal-directed therapy

 

Medical management of acute uterine bleeding
Category	Agent	Dose	Comments
Estrogen	Premarin (Consider rx for antiemetic)	25 mg IV q4–6h up to 24 h	Avoid in smokers >35 yo, uncontrolled HTN, CAD, Hx VTE, stroke, liver dz
COCs	EE/norethindrone (Consider rx for antiemetic)	35 mg/1 mg TID ´ 1 w, then QD ´ 3 w	Avoid in smokers >35 yo, uncontrolled HTN, CAD, h/o VTE, stroke, liver dz
Progestin	Aygestin (norethindrone acetate)	5 mg TID ´ 1 w, then BID ´ 3 w	Use w/ caution in pts w/ Hx VTE, stroke or MI, liver dz
	Provera (Medroxyprogesterone)	20 mg TID ´ 1 w, then BID ´ 3 w
Nonhormonal	Tranexamic acid	1.6 g PO TID ´ 5 d OR 10 mg/kg IV q8h up to 5 d	Avoid in pts w/ active thromboembolic dz or intrinsic risk of thrombosis
From Obstet Gynecol 2006;108:924; J Obstet Gynecol 1997;37:228; Am J Obstet Gynecol 1982;59:285.

 

Surgical management of acute uterine bleeding
Intracavitary tamponade	Foley balloon (30–50 cc); Bakri balloon
D&C; hysteroscopy	Reserve for emergent cases; may help w/ acute episode, subseq menses unchanged
UAE	Reserve for emergent cases; particularly w/ leiomyoma or suspected AVM
Hysterectomy	Reserve for emergent cases; definitive
From Clinical Guideline for Heavy Menstrual Bleeding, National Institute for Health and Clinical Excellence, 2007.

See Abbreviations

Recurrent Abnormal Uterine Bleeding (AUB)

Definition and Etiology

AUB: Menstrual flow outside of nml vol, duration, regularity, or frequency. Excessive bld loss is based on pts’ perception.

 

PALM-COEIN classification
Structural causes of AUB
P	Polyp
A	Adenomyosis
L	Leiomyoma (submucosal, other)
M	Malig, hyperplasia
Nonstructural causes of AUB
C	Coagulopathy
O	Ovulatory dysfxn
E	Endometrial
I	Iatrogenic
N	Not yet classified
Pair AUB with terms to describe bleeding pattern &/or qualifying letter from above to indicate etiology (eg, AUB-P, AUB-A, AUB-L). From Int J Gynaecol Obstet 2011;113(1):3.

 

Pathophysiology

• See PALM-COEIN
• Anovulation ® no cyclic progesterone production ® ­ estrogen ® ­ endometrial proliferation ® amenorrhea ® eventually, endometrium overgrown & structurally fragile ® random & dyssynchronous endometrial sloughing ® irreg vaginal bleeding

® AUB/menorrhagia. An anovulatory pt is always in follicular phase of ovarian cycle & in proliferative phase of endometrial cycle. No luteal or secretory phase b/c no cycles. Unopposed estrogen ­ risk of endometrial hyperplasia.

Differential Diagnosis

• Always consider Preg or related complications (SAB, ectopic).
• Teens: MCC d/t persistent anovulation d/t immaturity or dysregulation of HPA (= nml physiology), coagulopathy, contraception, infxn,
• Reproductive age (19–39 y): Structural abnormalities (PALM), anovulatory cycles, contraception, endometrial Cancer less common but may occur.
• Perimenopause: Endometrial hyperplasia, cancer, anovulatory bleeding d/t declining ovarian fxn (= nml physiology).

Diagnostic Workup (BMJ 2007;334:1110; Obstet Gynecol Clin N Am 2008;35:219)

• Detailed history & physical exam, including bimanual exam to evaluate uterus & speculum exam to evaluate cervix & Complete menstrual Hx is essent & can provide dx w/ suff confidence that rx can begin empirically.
• Regular, heavy menses usually anatomical lesion or bleeding d/o.
• Lab tests: Preg test, CBC, Consider pap smear & chlamydia testing. R/o bleeding disorders, particularly in teens. Serum progesterone in luteal phase >3 ng/ mL sugg recent ovulation, but timing of test difficult w/ irreg menses.
• An EMB is not always req, except for >45 Consider before rx if long-term unopposed estrogen exposure present, regardless of age.
• Imaging reserved to evaluate finding on physical, when sx persist despite rx, or suspicious for intrauterine pathology (AUB-P or AUB-L).

Treatment & Medications (Obstet Gynecol Clin N Am 2008;35:219; Menopause 2011;18:453)

• Treat underlying If no ­ risk of endometrial hyperplasia, cancer, or underlying structural abnormalities, start empiric medical rx. Expect improv in 3 mo. Failure to improve ® need to r/o other etiologies before changing mgmt. See also Chap. 2 for acute bleeding.
• Rx goals: (1) reverse abnormalities of endometrium d/t chronic anovulation,

(2) induce or restore cyclic predictable menses of nml vol & duration.

• Surgical mgmt:

Acute surgical mgmt: Rare. If hemodynamic unstable, bleeding refrac to 2 doses of IV premarin, or bld loss that cannot be replaced w/ xfusion, OR mgmt (D&C) req. Should continue medical therapy after D&C. Informed consent should include hypogastric artery ligation & hysterectomy should D&C fail.

Uterine artery embolization may be considered as an alternative, if available.

Endometrial ablation: High success rate. 25–50% are amenorrheic, & 80–90% have

¯ bleeding. Effective alternative to hysterectomy. ­ success if pretreated w/ progest or GnRH. R/o cancer prior to Surg. Up to 1/3 will eventually elect for hysterectomy.

Hysterectomy: High satisfaction, but more morbidity & poor choice in pts w/ medical conditions w/ high risk for Surg.