Per vaginal bleeding at antepartum, postpartum and non pregnancy with differential diagnosis

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Per Vaginal Bleeding — Antepartum, Postpartum & Non-Pregnancy

I. ANTEPARTUM HEMORRHAGE (APH)

Definition: Vaginal bleeding occurring from 20 weeks of gestation to delivery. Complicates 3–5% of pregnancies and is a leading contributor to maternal and perinatal mortality worldwide. — Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e

Major Causes & Differential Diagnosis

Cause	Key Features	Bleeding Character
Placenta Previa	Painless bright-red bleeding	Fresh, profuse, recurrent
Placental Abruption	Painful bleeding + uterine tenderness	Dark, clotted; may be concealed
Vasa Previa	Rare; vessel rupture at ROM	Fetal blood; rapid fetal distress
Uterine Rupture	Prior scar; abdominal pain, loss of fetal station	Severe + hemodynamic instability
Bloody Show	Normal onset of labor	Blood-stained mucus; not profuse
Cervical Lesions	Polyps, ectropion, carcinoma	Spotting, post-coital
Vaginal Trauma/Laceration	History of trauma	Variable
Low-lying placenta	Incidental USS finding	Mild spotting

1. Placenta Previa

Implantation of the placenta over or near the internal cervical os.

Subtypes:

Marginal: Reaches the internal os but does not cover it
Partial: Partially covers the internal os
Complete: Completely covers the internal os

Risk Factors: Prior cesarean section, multiple uterine surgeries, advanced maternal age, multiparity, tobacco/cocaine use, assisted reproductive technology, minority group status

Clinical Features: Painless, fresh bright-red vaginal bleeding — typically after 28 weeks; may be recurrent. No uterine tenderness or hypertonus. Uterine irritability in ~20% of cases.

Diagnosis: Transabdominal or transvaginal USS (preferred and safe). Do NOT perform digital vaginal examination until placenta previa is excluded — can precipitate catastrophic hemorrhage.

Management:

Two large-bore IVs, CBC, coagulation studies, type and crossmatch
Rh immune globulin (300 µg) if Rh-negative and not yet given
Expectant management if immature fetus and bleeding not profuse
Cesarean delivery is indicated (vaginal birth is contraindicated in placenta previa)
Neuraxial anesthesia preferred if haemodynamically stable — Rosen's Emergency Medicine; Tintinalli's Emergency Medicine; Barash Clinical Anesthesia 9e

2. Placental Abruption (Abruptio Placentae)

Premature separation of a normally implanted placenta. Complicates ~1% of deliveries, usually in the final 10 weeks of gestation.

Risk Factors: Tobacco use, trauma, cocaine use, hypertension, preeclampsia, advanced maternal age, multiple gestation, preterm PPROM

Clinical Features:

Uterine tenderness and hypertonus (board-like rigidity)
Dark, clotted vaginal bleeding
Bleeding may be concealed if placental margins remain attached to uterine wall
Hypovolemia signs (tachycardia → hypotension) in severe cases
When placental separation >50% → stillbirth is the likely outcome

Complications: Disseminated intravascular coagulation (DIC) — coagulation studies must be followed closely

Management:

Mild: artificial rupture of membranes + oxytocin augmentation
Severe/nonreassuring fetal status: emergency cesarean delivery
Prepare for massive blood loss and resuscitation
Normal fibrinogen in pregnancy is 400–450 mg/dL; values <300 mg/dL indicate significant coagulation factor consumption — Barash Clinical Anesthesia 9e; Rosen's Emergency Medicine

3. Vasa Previa

Umbilical vessels course through the amniotic membrane at the level of the cervical os. When membranes rupture, fetal vessels tear → fetal exsanguination.

Risk Factors: Placenta previa, velamentous cord insertion, bilobed placenta, IVF conception

Diagnosis: Doppler colour USS early in pregnancy (often not recognized until catastrophic rupture)

Treatment: Rapid operative (cesarean) delivery — Tintinalli's Emergency Medicine

II. POSTPARTUM HEMORRHAGE (PPH)

Definition (ACOG): Blood loss ≥1,000 mL after any mode of delivery, OR any volume of blood loss accompanied by signs/symptoms of hypovolemia within 24 hours of birth.

Primary (early) PPH: Within 24 hours of delivery
Secondary (late) PPH: 24 hours to 6 weeks postpartum

Note: Plasma volume increases 40% and RBC volume 25% by end of third trimester — these hematologic changes of pregnancy can mask haemorrhage; up to 30% of total blood volume can be lost before BP drops. — Tintinalli's Emergency Medicine; Textbook of Family Medicine 9e

Differential Diagnosis — "4 T's" Mnemonic

T	Cause	Frequency
Tone	Uterine atony	~70% of PPH
Tissue	Retained placenta/fragments	~10%
Trauma	Cervical, vaginal, perineal lacerations; uterine rupture; uterine inversion	~20%
Thrombin	Coagulopathy (hereditary or acquired DIC)	Uncommon

1. Uterine Atony (Most Common — ~70%)

Failure of the uterus to contract after placental delivery.

Risk Factors: Preeclampsia, uterine overdistension (macrosomia, polyhydramnios, multiple gestation), prolonged/rapid labour, multiparity, intraamniotic infection, oxytocin/tocolytic use, retained placenta

Management:

Bimanual uterine massage and compression (fist in anterior fornix, compress fundus from suprapubic)
Oxytocin 20–30 units in 1 L IV fluid (avoid bolus — causes hypotension)
Methylergonovine / Ergonovine 0.2 mg IM (contraindicated in hypertension — causes vasoconstriction)
Carboprost (15-methyl PGF₂α) 250 µg IM q15–90 min (max 8 doses); use with caution in asthma/cardiovascular disease
Misoprostol 800–1000 µg rectally/transvaginally if first-line fails — Creasy & Resnik's Maternal-Fetal Medicine; Textbook of Family Medicine 9e

2. Retained Placenta / Placenta Accreta

Retained placental fragments may cause immediate or secondary PPH. Placenta accreta (abnormal placental implantation) may require:

Uterine balloon tamponade (Bakri balloon, Foley catheter)
Uterine cavity packing
Selective pelvic vessel embolisation
B-Lynch brace sutures
Peripartum hysterectomy (last resort)

Risk of placenta accreta in previa increases from 3% (1st cesarean) to 61% (3+ prior cesareans) — Barash Clinical Anesthesia 9e; Creasy & Resnik's Maternal-Fetal Medicine

3. Genital Tract Lacerations (~20%)

Cervical, vaginal, and perineal lacerations. Account for ~20% of PPH. Require surgical repair.

4. Uterine Rupture

Risk factors: Prior cesarean section (especially single-layer closure), grand multiparity, uterine structural anomalies, labour augmentation, fetal size >3500 g.

Signs: Persistent abdominal pain, severe vaginal bleeding, loss of fetal station, palpable fetal parts outside uterus.

5. Uterine Inversion

Excessive fundal traction during third stage. Requires immediate manual uterine replacement (Rüsch balloon can assist). May require general anaesthesia and tocolytic agents.

Secondary PPH (24 hours – 6 weeks)

Causes:

Sub-involution of the uterus at the placental site
Retained placental fragments
Genital tract wound infection
Uterogenital infection (endometritis)
Hereditary coagulopathy

III. ABNORMAL UTERINE BLEEDING — NON-PREGNANT

Definition: Uterine bleeding that is irregular in volume, frequency, or duration in the absence of pregnancy. Affects 10–30% of women of reproductive age.

Classification by Age Group

(From Robbins & Kumar Basic Pathology; Goldman-Cecil Medicine)

Age Group	Common Causes
Prepuberty	Precocious puberty (hypothalamic/pituitary/ovarian origin)
Adolescence	Anovulatory cycles (immature HPO axis), coagulation disorders
Reproductive Age	Anovulation, leiomyoma, adenomyosis, polyps, endometrial hyperplasia/carcinoma, pregnancy complications, coagulopathy, OCP/medications
Perimenopause	Anovulatory cycles, organic lesions
Postmenopause	Endometrial carcinoma (always rule out), endometrial atrophy, polyps

PALM-COEIN Classification (FIGO)

PALM — Structural causes:

Polyp (endometrial/cervical)
Adenomyosis
Leiomyoma (submucosal fibroids are most symptomatic)
Malignancy and hyperplasia

COEIN — Non-structural causes:

Coagulopathy (von Willebrand disease — most common; ITP)
Ovulatory dysfunction (anovulation, PCOS, thyroid disease)
Endometrial (primary endometrial disorders)
Iatrogenic (OCPs, anticoagulants, antipsychotics, SSRIs, tamoxifen)
Not yet classified

Key Differential Diagnoses in Non-Pregnant Women

Hormonal/Anovulatory (most common — ~75% of cases)

Dysfunctional uterine bleeding: anovulation → unopposed estrogen → irregular endometrial shedding
PCOS, hyperprolactinaemia, thyroid dysfunction, Cushing syndrome, Addison disease, diabetes mellitus, obesity, malnutrition

Structural Lesions

Endometrial polyps
Uterine fibroids (leiomyomas) — submucosal type causes heaviest bleeding
Adenomyosis — menorrhagia + dysmenorrhea + bulky uterus
Endometrial hyperplasia (pre-malignant; unopposed estrogen)
Endometrial carcinoma (especially in postmenopause)
Cervical carcinoma / cervical polyps / ectropion
Vaginal/cervical trauma, foreign bodies
Clear cell adenocarcinoma of vagina/cervix (DES-exposed women)

Coagulopathies

Von Willebrand disease (most common hereditary coagulopathy causing AUB — up to 20% of women with heavy bleeding)
Idiopathic thrombocytopenic purpura (ITP)
Leukaemia, renal disease

Iatrogenic

Oral contraceptives (breakthrough bleeding), anticoagulants, SSRIs, ginseng, tamoxifen

Diagnosis Approach

History: Bleeding pattern (cycle days, amount, clots), medications, family history of bleeding disorders, symptoms of systemic disease
Examination: Pelvic exam, speculum and bimanual (assess uterine size, adnexa, cervix)
Labs: CBC + platelets, coagulation screen (PT/aPTT, fibrinogen; screen for vWD), thyroid function, fasting glucose, hCG (always exclude pregnancy)
Imaging: Pelvic USS (first-line for structural causes)
Endometrial biopsy / D&C: Mandatory in all women >35 years and in any woman with prolonged anovulatory bleeding (risk of endometrial carcinoma)

Treatment of Non-Pregnant AUB (Anovulatory/Dysfunctional)

Acute haemostasis: Combined OCP q6h × 5–7 days (off-label but effective); bleeding should stop within 24 hours
Expect heavy withdrawal bleed 2–4 days after stopping
Blood transfusion if profound anaemia
If hormonal therapy fails → D&C, hysteroscopy, or endometrial ablation depending on aetiology

Quick Summary Table

Context	Top 3 Differentials	Key Distinguishing Feature
Antepartum	Placenta previa, Placental abruption, Vasa previa	Painless (previa) vs Painful (abruption)
Postpartum	Uterine atony, Lacerations, Retained placenta	"4 T's": Tone, Tissue, Trauma, Thrombin
Non-pregnant	Anovulation/DUB, Fibroids/polyps, Carcinoma	Age group + PALM-COEIN classification

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