What are the management options for heavy vaginal bleeding?

Management of Heavy Vaginal Bleeding

Heavy vaginal bleeding should be managed with immediate external pelvic compression if trauma is suspected, followed by rapid transfer to a trauma center for definitive treatment through either angiographic embolization or surgical pre-peritoneal packing, with bleeding control procedures performed within 60 minutes of hospital admission. 1

Initial Assessment and Stabilization

Hemodynamic Assessment

• Assess vital signs to determine hemodynamic stability
• Establish large-bore IV access (at least two lines)
• Begin crystalloid fluid resuscitation targeting systolic BP 80-100 mmHg until major bleeding is controlled 1
• Consider tranexamic acid administration (loading dose 10-15 mg/kg followed by infusion of 1-5 mg/kg/h) as early as possible 2, 3

Immediate Interventions for Suspected Pelvic Trauma

• Apply external pelvic compression immediately using a pelvic binder placed around the great trochanters 1
• Transport directly to a trauma center equipped to handle severe pelvic trauma 1
• Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) to identify free fluid and potential sources of bleeding 1

Diagnostic Approach

Imaging

• For hemodynamically unstable patients: immediate pelvic X-ray 1
• For hemodynamically stable patients: CT scan with IV contrast 1
• Look for radio-anatomical criteria of severe pelvic trauma:
  • Unstable pelvic fractures (Young-Burgess types APC2, APC3, LC2, LC3, VS)
  • Pelvic ring disruptions with posterior fractures
  • Active extravasation of contrast during arterial phase 1

Laboratory Assessment

• Complete blood count
• Coagulation profile (PT, PTT, fibrinogen)
• Type and cross-match for blood products
• Monitor fibrinogen levels (hypofibrinogenemia is most predictive of severe postpartum hemorrhage) 1

Definitive Management Options

Bleeding Control Procedures

• Time is critical - bleeding control procedures should be performed within 60 minutes of hospital admission 1
• Two primary options for active pelvic bleeding:
  1. Angiographic embolization
  2. Surgical pre-peritoneal packing

Angiographic Embolization

• Recommended for stable patients with multiple active bleeding sites on CT scan 1
• Non-selective embolization through common femoral artery is preferred for unstable patients 1
• Mortality increases by 1% for every additional 3 minutes required for embolization 1

Surgical Management

• Temporary extra-peritoneal packing when bleeding is ongoing and angioembolization cannot be achieved quickly 1
• Can be combined with open abdominal surgery when necessary 1
• Consider Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a bridge between hemodynamic collapse and definitive hemorrhage control 1

Pharmacological Management

• Tranexamic acid: 10 mg/kg loading dose followed by infusion 3
  • Contraindicated in patients with active intravascular clotting, subarachnoid hemorrhage, or hypersensitivity 3
  • Dose adjustment required for renal impairment 3
• For postpartum hemorrhage: consider carboprost tromethamine (prostaglandin) 4
  • Note: May cause significant gastrointestinal side effects (vomiting, diarrhea, nausea) 4

Special Considerations

Postpartum Hemorrhage

• Consider placenta accreta spectrum in postpartum patients 1
• Keep patients warm (temperature >36°C) to optimize clotting factor function 1
• Avoid acidosis 1
• Consider massive transfusion protocol with fixed ratio of packed red blood cells, fresh frozen plasma, and platelets 1

Other Causes of Heavy Vaginal Bleeding

• Uterine artery pseudoaneurysm rupture (rare but life-threatening) 5
• Medication-induced bleeding (e.g., anticoagulants like rivaroxaban) 6
• In prepubertal girls: trauma is the most common cause of local lesions 7

Post-Procedure Care

• Intensive hemodynamic monitoring in the early post-operative period 1
• Consider ICU admission for patients with significant blood loss 1
• Monitor for ongoing abdominopelvic bleeding, fluid overload from resuscitation, and other postoperative complications 1

Pitfalls to Avoid

• Delaying definitive treatment beyond 60 minutes significantly increases mortality 1
• Failing to re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1
• Overlooking hypofibrinogenemia, which is highly predictive of severe postpartum hemorrhage 1
• Waiting for laboratory results before initiating treatment in cases of active hemorrhage 1