Think A-B-C-P (Airway, Breathing, Circulation, Pregnancy Test) in ALL Women of Child-Bearing Age!

* It changes the differential diagnosis* It changes the medications you can give* It changes the tests you can order

Vaginal Bleeding Pearls

* Non-pregnant vaginal bleeding* Order a pelvic ultrasound (for structural causes)* Order a CBC and coagulation panel (for anemia and coagulopathy)* Pregnant vaginal bleeding* If sick…* Think ectopic pregnancy (early pregnancy)* Think uterine rupture (late established pregnancy)* Think placental abruption (recent trauma or cocaine)* Don’t forget to order a type and screen* Rh- mothers will need RhoGam* If patient is unstable and you can’t wait for blood type…* Transfuse type O negative blood* Postpartum vaginal bleeding* Most common cause is retained products of conception* Order an ultrasound* Consider endometritis if patient also has fever* Treat with clindamycin and gentamycin

Vaginal Discharge Pearls

* Cervical motion tenderness?* Pelvic Inflammatory Disease (PID)* Thin, grey, and smells like fish?* Bacterial vaginosis (BV)* Treat with metronidazole* Warn patient not to mix metronidazole with alcohol* Thick like cottage cheese?* Vulvovaginal candidiasis* Diagnosis with KOH prep* Look for yeast and pseudohyphae* Treat with fluconazole* Thin Yellow/Green and “frothy”?* Trichomoniasis* Diagnose with wet prep* Look for mobile organisms* Treat with metronidazole* Partners should be checked and treated too

Ovarian Torsion

Severe and sudden pain

* Can be intermittent* Diagnose with Pelvic ultrasound with Doppler* PITFALL: Frequently has normal arterial flow (dual blood supply to ovary)

Additional Reading

* Approach to Non-Pregnant Vaginal Bleeding (EM Clerkship)* Approach to 1st Trimester Vaginal Bleeding (EM Clerkship)