Vaginal Bleeding

last authored: Sept 2009, David LaPierre

Introduction

PV bleeding is the most common gynecologic complaint. It occurs in 20-30% of pregnancies, with about half of these ending in miscarriage.

The Case of...

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Differential Diagnosis

Vaginal bleeding is, of course, most often physiologic. Changes in period frequency or severity can be alarming to patients but not signify anyhting worrying.

Vaginal bleeding during early pregnancy

ectopic pregnancy
implantation bleed
miscarriage
gestational trophoblastic disease

Bleeding in late pregnancy

placenta previa
abruptio placentae
labour
marginal placental separation

Nonobstetric bleeding

dysfunctional uterine bleeding
brain tumour
tubular-ovarian abscess
pelvic inflammatory disease
cervical cancer
endometrial cancer
vaginal trauma

Postmenopausal women

atrophic vaginitis
cervical cancer
cervical polyps
endometrial cancer, hyperplasia
ovarian tumours

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History and Physical Exam

history
physical exam

History

History is influenced b

HPI

colour, amount, clots
onset
previous bleeding

associated symptoms

abdominal pain
discharge?
dyspareunia
light-headedness, syncope

last menstrual period

reproductive history

period frequency, regularity, duration, severity (bleeding, cramps)
menarche
birth control
obstetric history
sexually transmitted infections
Pap history

medical history

trauma
bleeding disorders (nose, bruising, gums)
systemic causes of bleeding

family history

miscarriages/stillbirths
congenital anomalies

review of systems

Physical Exam

vitals (stable or unstable)?
abdominal exam:
- uterine,tenderness
- peritoneal signs
- uterus
pelvic exam (CONTRAINDICATED in late pregnancy until placenta previa is ruled out)
- cervical os - open or closed?
- adenexal tenderness/masses
- uterine size
- cervical motion tenderness
- trauma
- vaginitis
- cervicitis
- cervical polyps