What is the initial management of vaginal bleeding in the emergency department (ED)?

Initial Management of Vaginal Bleeding in the Emergency Department

Immediately assess hemodynamic stability and pregnancy status—these two factors determine your entire management pathway and must be established within minutes of patient arrival. 1

Immediate Stabilization (First 5 Minutes)

For hemodynamically unstable patients with vaginal bleeding, establish large-bore IV access and initiate aggressive fluid resuscitation with crystalloids, followed by blood products if needed. 1 The time between presentation and intervention must be minimized to reduce mortality. 1

• Patients in hemorrhagic shock with an identified bleeding source require immediate surgical bleeding control unless initial resuscitation succeeds 1
• Target systolic blood pressure of 80-100 mmHg may be appropriate until bleeding is controlled (though this applies primarily to trauma contexts) 2

Pregnancy Status Determination

Obtain urine or serum β-hCG immediately on all women of reproductive age—this single test fundamentally changes your diagnostic and therapeutic approach. 1

If Pregnancy Test is Positive (Early Pregnancy):

Perform pelvic ultrasound urgently to differentiate intrauterine pregnancy from ectopic pregnancy, as ectopic pregnancy occurs in up to 13% of symptomatic ED patients. 2, 1

• Transvaginal ultrasound is preferred and should be performed even when β-hCG is below traditional discriminatory thresholds, as it can still identify intrauterine or ectopic pregnancies 2
• Bedside ultrasound by emergency physicians expedites diagnosis when available 2
• Critical pitfall: Do not defer ultrasound based solely on β-hCG levels—modest diagnostic performance still provides valuable information for risk stratification 2

For Rh-negative women with threatened abortion, complete abortion, or ectopic pregnancy, administer anti-D immunoglobulin. 1

Clinically unstable pregnant patients require immediate procedural management: uterine aspiration, dilation and evacuation, or surgical removal of ectopic pregnancy. 3

• Septic abortion demands prompt procedural management plus IV antibiotics and fluids 3

If Pregnancy Test is Negative (Non-Pregnant):

Approach based on hemodynamic stability—unstable patients require immediate intervention while stable patients can undergo systematic evaluation. 4, 5

Diagnostic Workup by Stability Status

Hemodynamically Unstable Patients:

Perform rapid focused assessment with sonography (E-FAST) to identify bleeding sources. 1

• If E-FAST and chest X-ray exclude extra-pelvic causes, proceed to angiography to visualize active arterial bleeding 1
• Pelvic X-ray should be obtained for unstable patients requiring urgent stabilization 1

Hemodynamically Stable Patients:

Obtain thoraco-abdomino-pelvic CT scan with IV contrast—skip pelvic X-ray and proceed directly to CT. 1

• For stable pregnant patients with early pregnancy bleeding, pelvic ultrasound is the primary imaging modality 1
• Laboratory evaluation should include complete blood count, coagulation studies, and consideration of bleeding disorders based on history 6

Special Considerations for Pelvic Trauma

If vaginal bleeding occurs with pelvic trauma, apply external pelvic compression immediately using pelvic binders placed around the greater trochanters. 1

• Patients with pelvic ring disruption in hemorrhagic shock require immediate pelvic ring closure and stabilization 2, 1
• Following stabilization, proceed with angiographic embolization or surgical bleeding control as needed 2, 1
• Damage control surgery is essential for severely injured patients with ongoing bleeding 1

Acute Medical Management for Non-Pregnant Patients

For heavy vaginal bleeding without hemodynamic instability, initiate high-dose hormonal therapy to temporize bleeding until gynecologic follow-up. 5

• Combined oral contraceptives or high-dose progestins can be used 5
• Tranexamic acid may be considered as an antifibrinolytic agent 5
• Critical pitfall: Emergency physicians should initiate treatment rather than simply referring to gynecology—acute bleeding episodes require immediate temporizing measures 5

Age-Specific Considerations

Patient age significantly narrows the differential diagnosis and guides workup intensity. 6

• Prepubertal girls with vaginal bleeding require careful evaluation for trauma, foreign body, or abuse 5
• Reproductive-age women: consider structural causes (fibroids, polyps), anovulatory bleeding, and coagulopathy 6, 5
• Postmenopausal bleeding mandates evaluation for malignancy 4

Mandatory Gynecology Consultation/Follow-up

All patients with vaginal bleeding require timely gynecologic follow-up, even if stabilized in the ED. 4, 5

• Arrange follow-up within 24-48 hours for pregnant patients with threatened abortion 2
• Non-pregnant patients with ongoing bleeding need outpatient gynecology within 1-2 weeks 5
• Critical pitfall: ED patients often have difficulty arranging follow-up—ensure concrete plans are in place before discharge 2

Common Pitfalls to Avoid

• Failing to obtain pregnancy test on all reproductive-age women 1
• Deferring ultrasound in pregnant patients based solely on β-hCG thresholds 2
• Performing non-therapeutic laparotomy in pelvic trauma patients—this increases mortality 2
• Discharging patients without initiating temporizing treatment or ensuring follow-up 5
• Missing coagulopathy or systemic illness as underlying cause 4