A 27 year old woman G3P2 presents with active vaginal bleeding. She has saturated multiple pads and is bleeding through her pants in triage.
Triage vital signs are HR:115, BP: 100/64, RR: 20, Temp: 37 C.
She is swiftly placed on the monitor, IV access is obtained, and labs are drawn. A pelvic exam reveals blood and clots, which are removed from the vault. Products of conception are noted in the cervix and removed which stopped the bleeding.
Take Away #1
In active heavy vaginal bleeding the most likely diagnosis is ectopic or miscarriage.
Do a pelvic and evacuate the vaginal vault of blood and POC, visualize the cervix and remove any products of conception with ring forceps
Use suction to help clear the vault
Send the products of conception for pathology! You must identify if there is gestational trophoblastic disease.
Take Away #2
Perform a bedside ultrasound to rule out any free fluid and identify a possible intrauterine pregnancy.
Take Away #3
“Cervical Shock” is a real thing. It can cause a vasovagal reaction and make the patient feel very uncomfortable. Removing the products of conception from the cervix fixes this problem!
Matthew McClure is a current third year resident at Stony Brook Emergency Medicine.