How do you stop acute vaginal bleeding?

Management of Acute Vaginal Bleeding

Tranexamic acid should be administered promptly as the first-line pharmacological treatment for acute vaginal bleeding, particularly in cases of postpartum hemorrhage, with a recommended dose of 1g IV given over 10 minutes, followed by a second dose of 1g if bleeding continues after 30 minutes. 1

Assessment and Initial Management

1. Rapidly assess severity and source:

   • Determine if bleeding is postpartum hemorrhage (>500 mL after vaginal delivery or >1000 mL after cesarean)
   • Evaluate hemodynamic stability (blood pressure, heart rate)
   • Assess blood loss using established grading systems 1
   • Monitor serum lactate and base deficit as markers of shock severity 1

2. Immediate stabilization measures:

   • Establish IV access
   • Begin fluid resuscitation with crystalloids 1
   • Target systolic blood pressure of 80-100 mmHg until bleeding is controlled 1
   • Avoid hyperventilation in hypovolemic patients 1

Pharmacological Management

For Postpartum Hemorrhage:

1. Tranexamic acid (TXA):

   • Administer within 3 hours of birth for maximum benefit 1
   • Dosage: 1g IV (100 mg/mL) given at 1 mL/min (over 10 minutes) 1
   • Second dose of 1g IV if bleeding continues after 30 minutes or restarts within 24 hours 1
   • Early administration is critical - efficacy decreases by 10% for every 15-minute delay 1
   • Do not administer beyond 3 hours after birth due to potential harm 1

2. Uterotonics:

   • Use in conjunction with TXA for postpartum hemorrhage 1
   • Options include oxytocin, misoprostol, and other uterotonics

For Non-Postpartum Vaginal Bleeding:

• Tranexamic acid:
  • For heavy menstrual bleeding: 10-15 mg/kg followed by infusion of 1-5 mg/kg/h 1
  • Alternative: ε-aminocaproic acid 100-150 mg/kg followed by 15 mg/kg/h 1

Procedural Interventions (if pharmacological management fails)

1. Non-surgical interventions:

   • Bimanual compression
   • Intrauterine balloon tamponade
   • Non-pneumatic antishock garment
   • External aortic compression 1

2. Surgical interventions (escalate as needed):

   • Direct surgical bleeding control and local hemostatic procedures 1
   • Packing for ongoing bleeding 1
   • For postpartum hemorrhage with pelvic trauma: angiographic embolization 1
   • For severe cases: brace sutures, arterial ligation, or hysterectomy 1
   • For exsanguinating patients: consider aortic cross-clamping 1

Special Considerations

• Timing is critical: The elapsed time between onset of bleeding and intervention should be minimized 1
• Contraindications to TXA: Known thromboembolic events during pregnancy 1
• Early pregnancy bleeding: Clinically unstable patients with bleeding before 20 weeks require urgent procedural management (uterine aspiration, D&E, or surgical removal of ectopic pregnancy) 2
• Septic abortion: Requires prompt procedural management, IV antibiotics, and IV fluids 2

Evidence Quality and Efficacy

• WHO strongly recommends TXA for postpartum hemorrhage based on the WOMAN trial and subsequent meta-analyses 1
• TXA reduces the risk of hysterectomy in women with established PPH after vaginal delivery (0.5% vs 0.8%; RR 0.63) 3
• TXA administration does not increase the risk of thrombotic events 3, 4
• For non-postpartum bleeding, TXA is effective for heavy menstrual bleeding and improves quality of life 5

The evidence strongly supports early intervention with tranexamic acid as a cornerstone of management for acute vaginal bleeding, particularly in postpartum hemorrhage, with a clear dose-dependent relationship between timing of administration and efficacy.