nancy (cervical, uterine or vaginal), infection (PID,

vaginal infections), trauma ( assault, sexual inter ­

course), foreign body (IUD, tampon, sexual devices),

and coagulopathies (genetic disorders, medical condi ­

tions, medications).

TREATMENT

When shock is present in a young woman with a positive

pregnancy test, ruptured ectopic pregnancy is presumed.

Initiate resuscitative measures immediately, including

oxygen administration, intravenous (IV) fluids, and/or

blood transfusion. Perform a bedside ultrasound and obtain

gynecology consultation for surgical intervention. A similar

work-up is pursued in women with a positive pregnancy

test and an acute abdomen (presumed ruptured ectopic

pregnancy), even when the initial vital signs are normal.

In pregnant patients with vaginal bleeding, always

obtain the Rh status. If the woman is Rh-negative (15% of

the white population), administer RhoGAM 50 meg intramuscularly (IM). Complete and threatened abortions

require no further treatment. In incomplete abortion,

bleeding will continue until all products of conception have

passed. Dilatation and curettage may be indicated if the

abortion does not complete on its own. Patients with a ruptured ectopic pregnancy require surgery. Some patients with

unruptured ectopic pregnancy are candidates for nonsurgical treatment by the gynecologist with use of methotrexate

and leucovorin (IV, orally [PO], or IM as a single dose).

In patients with vaginal bleeding unrelated to

pregnancy, consider blood transfusion in patients with

symptomatic anemia, especially when the hemoglobin is

<7 gm/dL. When bleeding is severe in patients with

chronic anovulatory bleeding, relief may be obtained with

hormonal therapy ( eg, medroxyprogesterone 10 mg PO for

10 days or Ortho-Novum 1/35 1 tablet QID for 5 days).

DISPOSITION

� Admission

Patients with hemodynamic instability, peritoneal findings, severe anemia (hemoglobin <7 grn!dL), or a con ­

firmed ectopic pregnancy on ultrasound should be

admitted. Pregnant patients with a closed cervical os, no

fetal tissue passed, no IUP visualized on ultrasound, and

�-hCG > 1,000 miU/mL are at high risk of ectopic preg ­

nancy; disposition should be made in consultation with a

gynecologist. Admission may be warranted.

� Discharge

Discharge patients with mild to moderate vaginal bleeding,

who are hemodynamically stable, and in whom ectopic

pregnancy has been excluded. Discharge with gynecology

follow-up, and a repeat �-hCG level in 48 hours is also

appropriate for reliable patients with no IUP seen on ultrasound when the �-hCG is < 1,000 miU/mL. This assumes

the patient is hemodynamically stable, has no significant

abdominal tenderness, and has no other ultrasound findings that suggest an ectopic pregnancy (moderate to large

amount of free fluid or a noncystic adnexal mass). In

patients with postmenopausal bleeding, refer to a gyne ­

cologist for endometrial biopsy.

CHAPTER 43

Complaint of vaginal bleeding

• Perform focused history and physical

• Assess risk factors for ectopic preg nancy

• Obta in urine pregna ncy test and hemoglobin

Os closed, no fetal tissue

rjo ectopic pregnancy, pelvic

us and serum �-hCG

Negative urine pregnancy test

Os open or feta l tissue present

Incomplete Abortion

Consider other etiologies

Figure 43-2. Vaginal bleeding diagnostic algorithm. ABCs, airway, breathing, and circu lation;

�-hCG, beta human chorionic gonadotropin; T&C, Type and Cross; US, ultrasound.

SUGGESTED READING

Clinical Policy: Critical Issues in the Initial Evaluation and

Management of Patients Presenting to the Emergency

Department in Early Pregnancy. Irving, TX: American

College of Emergency Physicians, April 1 0, 2012.

Krause RS, Janicke DM, Cydulka RK. Ectopic pregnancies and

emergencies in the first 20 weeks of pregnancy. In: Tintinalli

JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler

GD. Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York, NY: McGraw-Hill, 201 1, pp. 676-684.

Morrison LJ, Spence JM. Vaginal bleeding in the nonpregnant

patient. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 665-676.

Promes SB, Nobay F. Pitfalls in first-trimester bleeding. Emerg

Med Clin North Am. 2010;28:2 19-234.

Vaginal Discharge

joanna Wieczorek Davidson, MD

Key Points

• Vaginal discharge is a common presenting complaint in

reproductive-age women.

• Possible diagnoses include vaginitis, cervicitis, or pelvic

inflammatory disease (PI D).

INTRODUCTION

Many women come to the emergency department (ED)

with the chief complaint of vaginal discharge. It may be

accompanied by other symptoms such as fever, abdominal

or pelvic pain, malodor, itching, and dysuria. Vaginal discharge is usually due to vaginitis, cervicitis, or pelvic inflammatory disease (PID).

Vaginitis is a spectrum of diseases causing vulvovaginal

symptoms including burning, irritation, and itching, with

or without vaginal discharge. Normal vaginal flora maintains the vaginal pH at 3.8-4.5. Changes in the pH or disruption of the vaginal flora may result in the overgrowth of

pathogenic organisms, ultimately resulting in a change in

the appearance, consistency, or odor of vaginal secretions.

Noninfectious causes like atrophy and contact vaginitis are

fairly common-particularly in sexually inactive and postmenopausal women. The most common infectious causes

of vaginitis in descending order of frequency include hac ­

terial vaginosis (BV), vaginal candidiasis, and trichomonas

vaginitis. BV is caused by a pathologic overgrowth of nor ­

mal vaginal flora-Gardnerella vaginalis.

Infections of the upper reproductive tract (cervix, uterus,

fallopian tubes, adnexa) will also cause discharge. Cervicitis is

the term used when infection is present within the cervix

only. Pelvic inflammatory disease (PID) is a spectrum of

upper genital tract infections that includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually

transmitted organisms, especially Neisseria gonorrhoeae and

• Clinical eval uation for the diagnosis of PID is not

sensitive. Maintain a high suspicion and low threshold

to treat.

Chlamydia trachomatis, are implicated in the majority of

cases of both cervicitis and PID; however, other organisms

( Gardnerella vaginalis, Haemophilus influenza, anaerobic and

gram-negative bacteria, and Streptococcus agalactia) are also

causative. PID affects 1 1% of women of reproductive age and

requires hospital admission in 20%. Inflammation and infection can lead to scarring and adhesions within the fallopian

tubes, leading to major long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. The risk of

ectopic pregnancy is 12-15% higher in women who have had

PID.