What is the treatment for vaginal bleeding?

Treatment for Vaginal Bleeding

The treatment for vaginal bleeding depends on the cause, with immediate assessment of hemodynamic stability and prompt intervention for unstable patients being the priority. 1

Initial Assessment

Hemodynamic Stability

• Assess vital signs (blood pressure, heart rate)
• Check for signs of shock
• Evaluate blood loss severity

Diagnostic Approach

1. Imaging:

   • Transabdominal ultrasound is the preferred initial imaging for pregnant patients with vaginal bleeding 1
   • Transvaginal ultrasound is frequently necessary when transabdominal is inconclusive 1
   • For trauma-related bleeding, FAST (Focused Assessment with Sonography for Trauma) should be employed 1

2. Laboratory Tests:

   • Complete blood count
   • Coagulation profile
   • Serum lactate and base deficit to estimate blood loss severity 1
   • Pregnancy test for reproductive-age women

Treatment Algorithm

For Hemodynamically Unstable Patients:

1. Immediate resuscitation:

   • Establish large-bore IV access
   • Crystalloid fluid resuscitation initially 1
   • Target systolic blood pressure of 80-100 mmHg until bleeding is controlled 1

2. Bleeding control:

   • For trauma-related bleeding: immediate surgical intervention or angiographic embolization 1
   • For pregnancy-related bleeding: emergent endoscopic therapy if variceal bleeding 1
   • For obstetric hemorrhage: uterotonic agents, surgical intervention if needed

For Hemodynamically Stable Patients:

Pregnancy-Related Bleeding:

1. Second/Third Trimester Bleeding:

   • For placenta previa: bed rest, avoid vaginal examinations, prepare for possible cesarean delivery 1
   • For vasa previa: hospitalization and planned cesarean delivery 1
   • For placental abruption: close monitoring, possible delivery depending on gestational age and severity

2. Variceal Bleeding in Pregnancy:

   • Non-selective beta-blockers (propranolol preferred) 1
   • Endoscopic variceal ligation for medium/large varices 1
   • For active bleeding: octreotide (avoid terlipressin) and cephalosporin prophylaxis 1

Non-Pregnancy Related Bleeding:

1. Hormonal Management:

   • Medroxyprogesterone acetate for abnormal uterine bleeding 2, 3
   • Combined oral contraceptives for acute abnormal bleeding 3
   • Levonorgestrel-releasing intrauterine system for heavy menstrual bleeding 3

2. Non-Hormonal Options:

   • Tranexamic acid (10-15 mg/kg followed by infusion of 1-5 mg/kg/h) 1, 3
   • NSAIDs may be used with hormonal methods to decrease menstrual bleeding 3

3. Surgical Options:

   • For structural causes (fibroids, polyps): consider surgical removal
   • For persistent heavy bleeding: endometrial ablation or hysterectomy may be considered

Special Considerations

Trauma-Related Bleeding

• Early bleeding control using packing, direct surgical control, and local hemostatic procedures 1
• Damage control surgery for severely injured patients with hemorrhagic shock 1
• For pelvic fractures: immediate pelvic ring closure and stabilization 1, 4

Coagulopathy

• Fresh frozen plasma, platelets, and other blood products as needed
• Antifibrinolytic agents may be considered 1

Medication Side Effects

• Monitor for fluid retention with progestational drugs 2
• Be aware that hormonal treatments may mask onset of menopause 2
• For patients with history of depression, carefully monitor when using progestins 2

Pitfalls to Avoid

• Delaying intervention in unstable patients
• Failing to consider non-functional causes of irregular bleeding 2
• Overlooking potential malignancy in cases of persistent abnormal bleeding 2
• Single hematocrit measurements should not be used as the sole marker for bleeding severity 1

Remember that vaginal bleeding can be the first sign of serious conditions including cancer, bleeding disorders, and pregnancy complications, making prompt and appropriate evaluation and management essential.