Evaluation of vaginal bleeding

Abnormal vascularity, white change with acetic acid, and exophytic lesions are key diagnostic criteria.

Confirms the diagnosis and establishes invasive disease.

Serial serum hCG titers are helpful if there is diagnostic uncertainty. A drop of >50% in 48 hours is suggestive of a failing pregnancy.

A rise in serum hCG of more than 50% over a 48 hour period is suggestive of possible ongoing pregnancy.

Differentiates between different stages and types of miscarriage.

Indicates the need for Rho(D) immune globulin.

Smooth, lobular, friable mass[Figure caption and citation for the preceding image starts]: Cervical polypScience Photo Library; used with permission [Citation ends].

Also helpful to detect concurrent endometrial polyps (present in 26% of patients with a bleeding cervical polyp).[69]Coeman D, Van Belle Y, Vanderick G, et al. Hysteroscopic findings in patients with a cervical polyp. Am J Obstet Gynecol. 1993 Dec;169(6):1563-5. http://www.ncbi.nlm.nih.gov/pubmed/8267062?tool=bestpractice.com

Also helpful to detect concurrent endometrial polyps (present in 26% of patients with a bleeding cervical polyp).[69]Coeman D, Van Belle Y, Vanderick G, et al. Hysteroscopic findings in patients with a cervical polyp. Am J Obstet Gynecol. 1993 Dec;169(6):1563-5. http://www.ncbi.nlm.nih.gov/pubmed/8267062?tool=bestpractice.com

Helpful to exclude cervical intraepithelial neoplasia and cancer.

Should be offered to women who are eligible for cervical screening and due a smear test.

Endometrial thickening, particularly in older women in the postmenopausal period, is highly suggestive of endometrial cancer.

Histologic confirmation of the diagnosis. Can also identify subtype and grade, and allows biomarker analysis using immunohistochemistry.

CT can assess for advanced disease (e.g., in the upper abdominal area).

An elevated CA-125 level is more predictive of malignancy in postmenopausal women than in premenopausal women.[70]Einhorn N, Sjövall K, Knapp RC, et al. Prospective evaluation of serum CA 125 levels for early detection of ovarian cancer. Obstet Gynecol. 1992 Jul;80(1):14-8. http://www.ncbi.nlm.nih.gov/pubmed/1603484?tool=bestpractice.com [71]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: ovarian cancer/fallopian tube cancer/primary peritoneal cancer [internet publication]. https://www.nccn.org/guidelines/category_1 ​​

Confirms the diagnosis and establishes invasive disease.

In cases of suspected placental abruption, the fetal heart rate should be monitored continuously, at least initially. Depending on how stable the mother and fetus are, and gestational age at presentation, monitoring may later be done intermittently on a case-by-case basis.

May be normal if not much blood has been lost, or before volume replacement has occurred. In cases of severe blood loss or prolonged bleeding, anemia may be present.

Blood should be cross-matched in major hemorrhage.[72]O'Brien KL, Shainker SA, Lockhart EL. Transfusion management of obstetric hemorrhage. Transfus Med Rev. 2018 Oct;32(4):249-55. http://www.ncbi.nlm.nih.gov/pubmed/29934136?tool=bestpractice.com Rho(D) immune globulin required in Rh-negative women.​

Ultrasound is highly specific (96%) but not very sensitive (24%) for diagnosing placental abruption.[73]Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. J Ultrasound Med. 2002 Aug;21(8):837-40. http://www.ncbi.nlm.nih.gov/pubmed/12164566?tool=bestpractice.com ​​

Ultrasound is also crucial for excluding other causes for the bleeding or pain, such as placenta previa or fibroids.

Significant abruption may cause low platelet count and coagulopathy. Should be performed if a woman has major hemorrhage, if platelet count is abnormal in women with minor hemorrhage or if there is evidence of disseminated intravascular coagulation.[72]O'Brien KL, Shainker SA, Lockhart EL. Transfusion management of obstetric hemorrhage. Transfus Med Rev. 2018 Oct;32(4):249-55. http://www.ncbi.nlm.nih.gov/pubmed/29934136?tool=bestpractice.com

Preferred initial screening tool for placenta previa. Duplex Doppler color flow analysis is used as an adjunct to identify vessels overlying the internal cervical os and distinguish fetal from maternal vessels.[29]Expert Panel on GYN and OB Imaging; Shipp TD, Poder L, et al. ACR appropriateness criteria® second and third trimester vaginal bleeding. J Am Coll Radiol. 2020 Nov;17(11S):S497-504. https://www.jacr.org/article/S1546-1440(20)30942-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33153560?tool=bestpractice.com

Hemoglobin usually decreases in pregnancy, and normal values vary with gestational age (may be as low as 10 mg/dL in mid pregnancy).

Patients with significant hemorrhage may present with Hb <10 mg/dL.

Blood should be cross-matched in major hemorrhage.[72]O'Brien KL, Shainker SA, Lockhart EL. Transfusion management of obstetric hemorrhage. Transfus Med Rev. 2018 Oct;32(4):249-55. http://www.ncbi.nlm.nih.gov/pubmed/29934136?tool=bestpractice.com

Should be performed if a woman has major hemorrhage, if platelet count is abnormal in women with minor hemorrhage or if there is evidence of disseminated intravascular coagulation.[72]O'Brien KL, Shainker SA, Lockhart EL. Transfusion management of obstetric hemorrhage. Transfus Med Rev. 2018 Oct;32(4):249-55. http://www.ncbi.nlm.nih.gov/pubmed/29934136?tool=bestpractice.com

Assesses depth of invasion and lateral extension of myometrial invasion, especially with posterior placentation and/or in women with ultrasound signs of parametrial invasion.[29]Expert Panel on GYN and OB Imaging; Shipp TD, Poder L, et al. ACR appropriateness criteria® second and third trimester vaginal bleeding. J Am Coll Radiol. 2020 Nov;17(11S):S497-504. https://www.jacr.org/article/S1546-1440(20)30942-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33153560?tool=bestpractice.com

Urine, vaginal swab (self-obtained), cervical swab, or combined with cervical cytology screening. Cervical specimens have the greatest sensitivity, but urinary and some vaginal swabs also have comparable predictive power.

Sensitive indicator of cervical inflammation, in the absence of inflammatory vaginitis.[74]Marrazzo JM, Martin DH. Management of women with cervicitis. Clin Infect Dis. 2007 Apr 1;44 Suppl 3:S102-10. http://www.ncbi.nlm.nih.gov/pubmed/17342663?tool=bestpractice.com High negative predictive value in patients at high risk of infection (<26 years). Microscopy is only approximately 50% sensitive for detection of Trichomonas vaginalis; symptomatic women with cervicitis and negative wet-mount microscopy for trichomonads should receive further testing.[15]Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344968 http://www.ncbi.nlm.nih.gov/pubmed/34292926?tool=bestpractice.com ​​

Results for OSOM Trichomonas rapid test are available within 10 minutes, with sensitivity and specificity of 82% to 95% and 97% to 100%, respectively. Affirm VP III results are available within 45 minutes, with sensitivity and specificity of 97.0% and 81.0% , respectively.[15]Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344968 http://www.ncbi.nlm.nih.gov/pubmed/34292926?tool=bestpractice.com ​​

Scored according to Nugent classification (by counting bacterial morphotypes). Reduced or absent lactobacilli indicate bacterial vaginosis.[75]Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol. 1991 Feb;29(2):297-301. http://jcm.asm.org/content/29/2/297.full.pdf+html http://www.ncbi.nlm.nih.gov/pubmed/1706728?tool=bestpractice.com

For detection of N gonorrhoeae.

Should be offered to women who are eligible for screening

Not a cause for cervicitis, but testing should be offered if any other sexually transmitted infection is diagnosed.

Not a cause for cervicitis, but testing should be offered if any other sexually transmitted infection is diagnosed.

Syphilis is not a cause for cervicitis, but testing should be offered if any other sexually transmitted infection is diagnosed.

Vaginal pH is normally 4.5 in women of childbearing age, generally 6.0-7.0 in postmenopausal women, and elevated in bacterial infections, including trichomoniasis, and in atrophic vaginitis.

Generally, Candida infections present with a normal-range pH.

Volatile amines (fishy odor) are not present in normal vaginal fluids.

Presence of a fishy odor after addition of 10% potassium hydroxide (KOH) to vaginal sample is a positive result for bacterial vaginosis.

Vaginal samples added to 2 different slides, 1 with saline solution and 1 with KOH solution.

Bacterial vaginosis: clue cells present, seen as vaginal epithelial cells covered with many rods and cocci, with a granular appearance. Decreased number of lactobacilli and WBCs absent.

Candidiasis: hyphae and budding yeast are better seen with the KOH preparation microscopy.

Trichomoniasis: significant number of WBCs and epithelial cells. The parasite is a motile oval or fusiform-shaped protozoan, 15 mm long.

Scored according to Nugent classification (by counting bacterial morphotypes). Reduced or absent lactobacilli indicate bacterial vaginosis.[75]Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol. 1991 Feb;29(2):297-301. http://jcm.asm.org/content/29/2/297.full.pdf+html http://www.ncbi.nlm.nih.gov/pubmed/1706728?tool=bestpractice.com

Screening for sexually transmitted infections should be considered in all patients with infective vaginitis.

Screening for sexually transmitted infections should be considered in all patients with infective vaginitis.

Screening for sexually transmitted infections should be considered in all patients with infective vaginitis.

Screening for sexually transmitted infections should be considered in all patients with infective vaginitis.

If sexual abuse is suspected, follow local protocols for reporting suspected sexual abuse. In many countries specific sexual assault centers have been developed, with specially trained staff and facilities.

A left hand/wrist radiograph helps estimate skeletal age. The appearance of representative epiphyseal centers on the x-ray is compared with age- and sex-appropriate published standards.

Laboratory measurement of serum FSH and LH concentrations will help differentiate patients with gonadotropin-dependent precocious puberty (GDPP), with elevated levels, from those with gonadotropin-independent precocious puberty (GIPP), with low levels.

Measurement of serum FSH and LH should be done with early morning blood samples using an ultrasensitive pediatric assay.

Caution must be exercised in interpretation of the gonadotropin levels in patients with long-standing GIPP, as prolonged exposure to high levels of sex steroids leads to GDPP.

Examination under anesthesia should be considered if crucial to making a diagnosis or to providing definitive treatment or if there is clinical suspicion for urethral injury.[76]British Society for Paediatric and Adolescent Gynaecology. Genital trauma in girls. Jun 2017 [internet publication]. https://britspag.org/wp-content/uploads/2018/10/Genital-Trauma-in-Girls-BritSPAG-June-2017.pdf

Considered if the child cannot tolerate clinical examination.