How is intrauterine bleeding managed?

Management of Intrauterine Bleeding

The management of intrauterine bleeding should follow a stepwise approach, with first-line treatment being intravenous tranexamic acid 1 g administered over 10 minutes, with a second dose if bleeding continues after 30 minutes or restarts within 24 hours. 1

First-Line Management

Pharmacological Management

• Tranexamic acid (TXA):

  • Administer 1 g IV over 10 minutes as soon as bleeding is identified 1, 2
  • Give second dose if bleeding continues after 30 minutes or restarts within 24 hours
  • Must be administered within 3 hours of onset for maximum effectiveness (69% reduction in mortality) 2
  • Cost-effective, heat-stable with long shelf life 2
  • No increased risk of thromboembolic events 2

• Uterotonics:

  • Oxytocin: Initial IV infusion of 10-40 units in 1000 mL of non-hydrating solution 3

    • Start at 1-2 mU/min and increase gradually as needed
    • Monitor uterine tone, contraction frequency, and fetal heart rate
    • Discontinue immediately if uterine hyperactivity or fetal distress occurs

  • Methylergonovine: For postpartum atony and hemorrhage 4

    • Use with caution in patients with sepsis, vascular disease, or hepatic/renal involvement
    • Avoid in patients taking CYP3A4 inhibitors (e.g., macrolide antibiotics, protease inhibitors)

Monitoring and Assessment

• Quantify blood loss using gravimetric and direct measurement methods 5
• Monitor vital signs, uterine tone, and hemoglobin levels
• Target fibrinogen level ≥1.5 g/L in women with bleeding disorders 1

Management Based on Etiology

Postpartum Hemorrhage

1. Administer TXA 1 g IV immediately 1
2. Initiate oxytocin infusion (10-40 units in 1000 mL) 3
3. Perform active management of third stage of labor with uterotonics 1
4. Consider methylergonovine if no contraindications exist 4
5. Monitor for 72 hours in women with bleeding disorders 1

Uterine Fibroids

1. For acute bleeding, administer TXA as first-line therapy 1
2. Consider hormonal options for long-term management:
   • Levonorgestrel-releasing IUD (reduces bleeding and fibroid diameter) 1, 6
   • Progestin-only contraceptives (safe option with no increased thrombosis risk) 6
3. Surgical options if medical management fails:
   • Myomectomy (laparoscopic or open) 1
   • MR-guided focused ultrasound surgery for selected patients 1

Abnormal Uterine Bleeding (Non-pregnancy related)

1. Administer TXA for acute episodes 7, 8
2. For long-term management:
   • Levonorgestrel IUD (reduces menstrual flow by 65-85%) 8
   • Oral contraceptives (decrease menstrual flow by approximately 50%) 8
   • NSAIDs (decrease bleeding by 30-50%) 8

Special Considerations

Patients with Bleeding Disorders

• Target fibrinogen level ≥1.5 g/L for vaginal delivery or cesarean section 1
• Early use of TXA in case of postpartum bleeding 1
• Consider thromboprophylaxis in patients with dysfibrinogenemia type 3B 1

Peripartum Anticoagulation Management

• For women on therapeutic anticoagulation, schedule delivery with prior discontinuation of anticoagulants 1
• For women on prophylactic-dose LMWH, consider cessation at onset of spontaneous labor 1
• Avoid neuraxial anesthesia until at least 24 hours after last dose of therapeutic LMWH 1

Pitfalls and Caveats

• Do not delay TXA administration - efficacy decreases by 10% for every 15-minute delay, with no benefit after 3 hours 1
• Avoid TXA in women with clear contraindications to antifibrinolytic therapy (e.g., known thromboembolic events) 1
• For cesarean deliveries, studies show TXA (1 g IV) before skin incision reduces blood loss from 616.5 mL to 436.5 mL 5
• Avoid direct thrombin and anti-Xa inhibitors during pregnancy 1
• Be cautious with methylergonovine in patients taking medications that inhibit CYP3A4 4

By following this algorithmic approach to intrauterine bleeding management, clinicians can effectively reduce morbidity and mortality while preserving quality of life for patients experiencing this potentially life-threatening condition.