Per Vaginum (PV) Bleeding

PV bleeding (vaginal bleeding) is one of the most common gynecological and obstetric presentations. The approach depends critically on age and pregnancy status.

Classification by Clinical Context

1. Pregnancy Status First

Always exclude pregnancy before evaluating non-pregnant causes. Pregnancy-related complications are the most common cause of abnormal vaginal bleeding during the reproductive years.

A. First-Trimester Bleeding (< 20 weeks)

About 25% of all pregnancies experience bleeding in the first half. The two most important causes are:

Ectopic Pregnancy

Prevalence: 1 in 28 to 1 in 200 pregnancies; accounts for the majority of first-trimester maternal deaths
Over 40% are misdiagnosed on first presentation
Classic triad: pain (97-100%) + amenorrhea (74-84%) + bleeding
Risk factors (in descending significance):
- IUD in place or recently used
- Previous tubal/abdominal/pelvic surgery
- Prior ectopic pregnancy
- Prior STI / PID
- Infertility
- Recent therapeutic abortion
Diagnosis: serial quantitative beta-hCG + transvaginal ultrasound (TVS)
- An intrauterine gestational sac with fetal pole essentially excludes ectopic in most cases (heterotopic pregnancies are rare)

Threatened / Inevitable / Incomplete / Missed Abortion

If fetal heartbeat is confirmed by Doppler, miscarriage risk falls to < 10%
TVS is the first-line investigation from 5-7 weeks onward

B. Second Half of Pregnancy (> 20 weeks) - Antepartum Hemorrhage (APH)

APH complicates 3-5% of pregnancies and is a leading cause of maternal and perinatal mortality.

Critical rule: Do NOT perform digital or speculum examination until TVS confirms placental location - mechanical disruption of placenta previa can cause catastrophic hemorrhage.

Placenta Previa

Placenta extends near, partially over, or beyond the internal cervical os
Presentation: painless, bright red vaginal bleeding, usually after 28 weeks
Risk factors: previous cesarean scar, tobacco use, advanced maternal age, multiparity, multiple gestation
The risk increases in a dose-dependent manner with number of prior cesareans
Associated with uterine atony and placenta accreta
Accreta risk escalates from 3% (primary cesarean with previa) to 61% with three prior cesareans
Management:
- Expectant if fetus immature + bleeding not profuse
- Neuraxial anesthesia preferred if hemodynamically stable
- Vaginal delivery is contraindicated
- Cesarean if severe bleeding or fetal maturity

Placental Abruption (Abruptio Placentae)

Premature separation of a normally implanted placenta
Incidence: ~1% of deliveries, peak between 24-32 weeks
Presentation: painful vaginal bleeding + uterine tenderness/hypertonus (dark, clotted blood)
Bleeding may be concealed (revealed, concealed, or mixed)
Risk factors: abdominal trauma, cocaine use, hypertension/preeclampsia, smoking, multiple gestation, oligohydramnios, chorioamnionitis, advanced maternal age/parity
Severity spectrum:
- Mild: mild tenderness, normal vitals, no coagulopathy, fetal distress absent
- Severe: heavy or no visible bleeding, fetal distress, coagulopathy (DIC), maternal shock, continuous contractions
When placental separation > 50%: stillbirth is the most likely outcome
Investigations: CTG (100% negative predictive value when reassuring), TVS, CBC, coagulation panel (fibrinogen, FDPs), type & cross-match
Complications: DIC, hemorrhagic shock, uterine rupture, multi-organ failure
Management: maternal stabilization, obstetric consultation, large-bore IVs, RhoGAM if Rh-negative; emergency delivery for severe abruption

Vasa Previa

Fetal vessels traverse the internal cervical os unsupported by placenta or cord
Painless PV bleeding at time of membrane rupture = fetal blood loss (extremely high fetal mortality if unrecognized)

C. Postpartum Hemorrhage (PPH)

Definition (ACOG): Blood loss ≥ 1000 mL after any delivery, OR any blood loss with signs/symptoms of hypovolemia within 24 hours of birth. (Traditional: > 500 mL vaginal delivery, > 1000 mL cesarean)

Primary PPH (within 24 hours) - The "4 T's"

Cause	% of PPH	Notes
Tone (uterine atony)	~70-80%	Most common cause
Trauma (lacerations, rupture, inversion)	~20%	Cervical, vaginal, perineal
Tissue (retained placenta/products)	~10%	Including accreta
Thrombin (coagulopathy)	uncommon	Congenital or acquired

Important: Up to 30% of total blood volume can be lost before BP drops - the first sign may be only a mild tachycardia. Plasma volume increases 40% and RBC volume 25% at term, masking typical hemorrhage signs.

Uterine Atony Management (stepwise):

Bimanual uterine massage (fist in anterior fornix + suprapubic compression)
Oxytocin 20-30 units in 1000 mL, rate ≤ 100 mU/min - avoid bolus IV (causes hypotension)
Methylergonovine / Ergonovine 0.2 mg IM - do NOT give IV (risk of hypertension, CNS vasospasm); contraindicated in hypertension
Carboprost (15-methyl PGF2α) 250 µg IM, repeatable - use with caution in cardiovascular disease or asthma
Misoprostol 800-1000 µg rectal/intrauterine - useful when conventional therapy fails
Uterine balloon tamponade (Bakri balloon, Foley catheter)
Uterine packing with sterile gauze
Pelvic vessel embolization (if facilities available)
Laparotomy: B-Lynch sutures, iliac artery ligation, peripartum hysterectomy

Secondary PPH (24 hours to 6 weeks postpartum)

Causes: subinvolution of placental site, retained products, genital tract infection/wounds

D. Non-Pregnant PV Bleeding (Abnormal Uterine Bleeding - AUB)

PALM-COEIN Classification (FIGO)

Structural (PALM):

Polyp - intermenstrual bleeding; most common > 35 years
Adenomyosis - ectopic endometrial glands in myometrium; heavy + painful periods
Leiomyoma (fibroids) - submucosal fibroids most likely to bleed; common mid-30s onward
Malignancy / hyperplasia - endometrial cancer (postmenopausal >> reproductive)

Non-structural (COEIN):

Coagulopathy - von Willebrand disease is most common (accounts for up to 20% of AUB in adolescents); also myeloproliferative disorders, ITP, anticoagulants, liver disease
Ovulatory dysfunction - anovulation in perimenarchal, perimenopausal, PCOS, thyroid disease, eating disorders, excessive exercise; increases risk of endometrial hyperplasia
Endometrial causes - normal ovulation + normal cavity; bleeding from local endometrial disorder
Iatrogenic - hormonal medications, IUDs, anticoagulants
Not otherwise classified

Age-Based Differential

Age Group	Most Likely Causes
Adolescent (13-19)	Anovulation, coagulopathy (vWD), pregnancy
Reproductive (20s-30s)	Pregnancy complications, fibroids, polyps, anovulation
Perimenopausal (40s-50s)	Anovulatory bleeding, fibroids, malignancy
Postmenopausal	Atrophic vaginitis, exogenous hormones, malignancy

FIGO Bleeding Terminology (current)

Term	Definition
Heavy menstrual bleeding (replaces menorrhagia)	Excessive flow interfering with quality of life
Intermenstrual bleeding (replaces metrorrhagia)	Between normally timed periods
Irregular menstrual bleeding	Cycle variation > 20 days over 1 year
Postmenopausal bleeding	Any bleeding > 12 months after cessation of menses
Prolonged menstrual bleeding	Periods exceeding 8 days

Note: Terms "dysfunctional uterine bleeding," "menorrhagia," "metrorrhagia," "menometrorrhagia" are all discarded.

Emergency Management of Massive PV Bleeding

From Tintinalli's Emergency Medicine:

Treatment	Initial Dose	Schedule	Contraindications
Conjugated equine estrogen (Premarin)	25 mg IV	Every 4-6 h until bleeding stops	VTE, thrombophilia, vascular disease, malignancy
Tranexamic acid	1.0-1.3 g IV	Can continue PO TID; effective in ~3 h	VTE, thrombophilia
Fluid/blood resuscitation	-	Identify + treat coagulopathies	-

Key Investigations

Urine/serum beta-hCG - always first in reproductive-age women
TVS - first-line imaging; do BEFORE any pelvic examination if placenta previa possible
CBC - hemoglobin, hematocrit, platelets
Coagulation panel - PT, APTT, fibrinogen, FDPs (especially in abruption/PPH)
Type & cross-match - in significant bleeding
Thyroid-stimulating hormone - if anovulatory bleeding of undetermined cause
Hysteroscopy / saline infusion sonography - for structural causes (polyps, fibroids)
Endometrial biopsy - mandatory in postmenopausal bleeding and in women > 45 with AUB to exclude malignancy

Sources: Tintinalli's Emergency Medicine (9e), Barash Clinical Anesthesia (9e), Creasy & Resnik Maternal-Fetal Medicine, Pfenninger & Fowler's Procedures for Primary Care (3e)

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