What are the immediate steps to take and potential treatments for a patient experiencing vaginal bleeding?

Immediate Management of Vaginal Bleeding

For patients presenting with vaginal bleeding, immediately assess hemodynamic stability and initiate resuscitation with IV access and fluid replacement if signs of shock are present, while simultaneously determining pregnancy status and identifying the bleeding source to guide urgent intervention. 1

Initial Stabilization and Assessment

Hemodynamic Evaluation

• Establish large-bore IV access immediately for any patient with signs of hemorrhagic shock (tachycardia, hypotension, altered mental status) 2
• Target systolic blood pressure of 80-100 mmHg until bleeding is controlled in patients without brain injury 3, 1, 2
• Administer crystalloid fluids initially, followed by blood products if severe hypovolemia or ongoing hemorrhage is evident 4, 2
• Do not rely on single hemoglobin/hematocrit measurements as isolated markers for bleeding severity—these lag behind actual blood loss 3, 4
• Measure serum lactate and base deficit to accurately estimate and monitor the extent of bleeding and shock 3, 4, 2

Critical First Steps

• Determine pregnancy status immediately with urine or serum β-hCG test for all women of reproductive age 1, 2
• Minimize elapsed time between presentation and definitive intervention—delays worsen outcomes in patients requiring urgent bleeding control 3, 1, 2

Management Based on Hemodynamic Status

Unstable Patients (Hemorrhagic Shock)

Patients with hemorrhagic shock and an identified bleeding source require immediate bleeding control procedures unless initial resuscitation is successful 3, 1, 2

• Proceed directly to surgical intervention if vaginal or cervical trauma is clearly identified—do not delay for extensive imaging 2
• Perform rapid focused assessment with sonography (E-FAST) to identify potential sources of bleeding 1, 2
• Obtain pelvic X-ray only if pelvic trauma is suspected and urgent intervention is needed to stabilize vital signs 1, 2
• When E-FAST and chest X-ray rule out extra-pelvic causes, consider angiography to visualize active arterial bleeding 1
• For pelvic trauma with bleeding, apply external pelvic compression immediately using pelvic binders placed around the greater trochanters 1
• If pelvic ring disruption is present, perform immediate pelvic ring closure and stabilization, followed by angiographic embolization or surgical bleeding control 3, 1

Stable Patients

For hemodynamically stable patients, perform thorough diagnostic evaluation before intervention 1

• Obtain transvaginal ultrasound as the standard test to assess for retained products of conception, arteriovenous malformation, or other complications 4
• Perform thoraco-abdomino-pelvic CT scan with IV contrast when hemodynamic status allows, if trauma is suspected or bleeding source remains unclear 1, 2
• Skip pelvic X-ray in stable patients—proceed directly to CT scan with contrast if imaging is needed 1, 2
• For early pregnancy patients, obtain pelvic ultrasound to evaluate for intrauterine or ectopic pregnancy (prevalence up to 13% in symptomatic ED patients) 1
• Perform transvaginal ultrasound even when β-hCG is below traditional discriminatory thresholds—do not defer based solely on β-hCG levels 1

Pharmacological Management

Hemostatic Agents

• Consider tranexamic acid 10-15 mg/kg followed by infusion of 1-5 mg/kg/h in patients with significant bleeding 3, 4
• For contraceptive-related bleeding irregularities, consider NSAIDs for 5-7 days as first-line medical treatment 3
• Hormonal treatment with combined oral contraceptives or estrogen (10-20 days) may be used if medically eligible 3

Special Considerations for Pregnant Patients

• Evaluate for ectopic pregnancy in all pregnant patients with vaginal bleeding 1
• Consider anti-D immunoglobulin for Rh-negative women with threatened abortion, complete abortion, or ectopic pregnancy 1
• Arrange follow-up within 24-48 hours for pregnant patients with threatened abortion 1

Damage Control Approach

A damage control surgical approach is essential in severely injured patients with deep hemorrhagic shock and signs of ongoing bleeding 3, 1

• Use packing, direct surgical bleeding control, and local hemostatic procedures for abdominal bleeding 3
• In exsanguinating patients, aortic cross-clamping may be employed as an adjunct 3
• For pelvic injuries, perform pre-peritoneal packing to decrease the need for embolization and provide crucial time for selective hemorrhage management 3
• Remove packs preferably only after 48 hours to lower the risk of re-bleeding 3

Critical Pitfalls to Avoid

• Never delay surgical intervention in unstable patients for extensive diagnostic workup 2
• Do not discharge patients with unexplained heavy bleeding without ensuring concrete follow-up plans within 24-48 hours 1, 2
• Avoid relying solely on blood pressure as an indicator of blood loss—some patients compensate well despite significant hemorrhage 4, 2
• Do not assume non-pregnancy without testing—always obtain β-hCG in reproductive-age women 1, 2
• Consider the possibility of ectopic pregnancy even after presumed miscarriage, especially if initial diagnosis was not confirmed by ultrasound 4

Disposition

• Admit patients with heavy bleeding, hemodynamic instability, or requiring surgical intervention 4
• Ensure concrete follow-up plans are in place before discharge for all patients 1
• Refer to gynecology for further evaluation and treatment in most cases requiring outpatient management 5, 6