What is the treatment for vaginal bleeding?

Treatment for Vaginal Bleeding

The treatment for vaginal bleeding depends critically on pregnancy status and hemodynamic stability—immediately assess both before any intervention, and in pregnant patients with second/third trimester bleeding, perform ultrasound imaging BEFORE any digital pelvic examination to prevent catastrophic hemorrhage from placental abnormalities. 1

Immediate Assessment Priority

• Determine pregnancy status first through urine or serum beta-hCG testing, as this fundamentally changes the entire diagnostic and therapeutic approach 1
• Assess hemodynamic stability immediately—unstable patients require urgent procedural management including uterine aspiration, dilation and evacuation, or surgical removal of ectopic pregnancy 2
• Obtain quantitative beta-hCG level regardless of ultrasound findings in all pregnant patients 1

Critical Safety Rule for Pregnant Patients

• Never perform digital pelvic examination before ultrasound in second and third trimester bleeding—this can precipitate catastrophic hemorrhage with placenta previa or vasa previa 1, 3
• Transvaginal ultrasound is both accurate and safe for diagnosis of placenta previa, contrary to outdated concerns 4
• Speculum examination to assess cervical lesions, polyps, or inflammation should only occur after placental abnormalities are excluded 1

Diagnostic Imaging Approach

For Second and Third Trimester Bleeding

• Transabdominal ultrasound is the preferred initial screening tool for placenta previa, evaluating the placenta, inferior placental margin, placental cord insertion, and cervix from external to internal os 4
• Transvaginal ultrasound is frequently necessary when transabdominal imaging is inconclusive or inadequate, providing superior visualization of the lower uterine segment and cervix 4
• Doppler velocimetry ultrasound is invaluable for identifying vasa previa—vessels overlying the internal cervical os can be subtle and require color/spectral Doppler to distinguish fetal from maternal vessels 4
• Transperineal or transrectal ultrasound serves as alternative when transvaginal approach is declined or unsuccessful 4

For First Trimester Bleeding

• Transvaginal ultrasound provides better resolution than transabdominal for early pregnancy evaluation 1, 3
• If intrauterine pregnancy is confirmed, ectopic pregnancy is essentially ruled out except in rare heterotopic cases 1, 3
• Repeat ultrasound when beta-hCG reaches 1,500-2,000 mIU/mL (discriminatory threshold), at which point normal intrauterine pregnancy must show gestational sac 3

Treatment Based on Diagnosis

Pregnancy-Related Bleeding

For subchorionic hemorrhage with viable pregnancy:

• Schedule follow-up ultrasound in 1-2 weeks 1, 3

For pregnancy of unknown location:

• Continue serial beta-hCG measurements every 48 hours until diagnosis is established 1, 3
• Approximately 7-20% will be ectopic pregnancies requiring close monitoring 1, 3
• Confirmed or suspected ectopic pregnancy requires immediate specialist consultation 1

For second/third trimester pathologic bleeding:

• May require hospitalization and/or delivery 1
• Placenta previa, vasa previa, placental abruption, or uterine rupture require immediate specialist consultation 1

For secondary amenorrhea with bleeding:

• Progesterone Capsules 400 mg daily at bedtime for 10 days induces withdrawal bleeding in 73.8-76.8% of women 5
• Alternative dosing: 300 mg daily for 10 days 5

For prevention of endometrial hyperplasia in postmenopausal women on estrogen:

• Progesterone Capsules 200 mg daily at bedtime for 12 continuous days per 28-day cycle reduces hyperplasia risk from 64% to 6% 5

Unstable Patients

• Clinically unstable patients require urgent procedural management regardless of etiology 2
• Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids 2

Prepubertal Girls

• Never force examination—this is always contraindicated 6
• Never perform digital vaginal examination in prepubertal children as this is inappropriate and traumatic 6
• If child is reluctant or extent of injury cannot be determined, examination under anesthesia with vaginoscopy is recommended 7
• Assess for signs of trauma, discharge, lesions, and masses during external examination only 6
• Palpable abdominal mass is a red flag requiring additional investigation 6

Critical Pitfalls to Avoid

• Ultrasound misses up to 50% of placental abruptions, so clinical correlation is essential—do not rely solely on imaging 1, 3
• In pregnancy of unknown location, 7-20% will be ectopic pregnancies, making serial beta-hCG mandatory 1
• Progesterone Capsules cause drowsiness and dizziness—must be taken at bedtime with water while standing 5
• Some women experience extreme dizziness, blurred vision, difficulty speaking, or difficulty walking with progesterone—discuss with provider immediately if these occur 5
• Progesterone Capsules contain peanut oil and are contraindicated in peanut allergy 5

Systemic Causes Requiring Evaluation

• Evaluate clotting system (platelets and clotting factors) to rule out hematologic disorders 8
• Consider endocrine disease, renal insufficiency, hepatic abnormalities, and vasculitis with detailed history and targeted examination 8
• Assess for nutritional deficiencies or adverse drug reactions that may contribute to bleeding 8
• History of infertility and progesterone treatment during pregnancy is significantly associated with bleeding episodes 9