What is the best treatment for heavy vaginal bleeding with active hemorrhage?

Treatment of Heavy Vaginal Bleeding with Active Hemorrhage

Immediate bleeding control through direct pressure, surgical intervention, or uterotonic agents (if obstetric cause) takes absolute priority, with resuscitation measures initiated simultaneously—do not delay definitive hemorrhage control for extensive diagnostic workup in unstable patients. 1, 2

Immediate Resuscitation and Stabilization

For any patient with active hemorrhage and signs of shock, establish large-bore IV access immediately and begin aggressive fluid resuscitation with warmed blood products as the primary resuscitation fluid, not crystalloids alone. 3

• Target systolic blood pressure of 80-100 mmHg until bleeding is definitively controlled—avoid aggressive normalization of blood pressure while hemorrhage continues, as this worsens coagulopathy 3, 2
• Administer high-flow oxygen to all patients with active hemorrhage 3
• Monitor serum lactate and base deficit continuously to track the extent of bleeding and shock 3
• Do not rely on single hematocrit measurements as they are misleading in acute hemorrhage 3
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 3

Immediate Bleeding Control Based on Source

Obstetric Hemorrhage (Postpartum or Pregnancy-Related)

Administer oxytocin 5-10 IU slowly IV or IM immediately, followed by continuous infusion not exceeding 40 IU total, as first-line treatment for uterine atony. 4, 5, 6

• Perform immediate manual uterine examination with antibiotic prophylaxis and uterine massage 5
• If oxytocin fails within 30 minutes, administer sulprostone as second-line agent 5
• Consider tranexamic acid 1 g IV (renewable once) if bleeding persists after sulprostone, though obstetric evidence is limited 7, 5, 8
• Intrauterine balloon tamponade should be performed if pharmacologic measures fail and before proceeding to surgery or interventional radiology 5, 6

Traumatic or Surgical Bleeding

Patients with hemorrhagic shock and an identified bleeding source require immediate surgical bleeding control unless initial resuscitation is successful—minimize time between presentation and definitive intervention. 3, 1, 2

• Apply direct compression or packing to all accessible bleeding sites immediately 3, 9
• For pelvic trauma with vaginal bleeding, apply external pelvic compression using pelvic binders placed around the great trochanters as soon as possible 1
• Patients with pelvic ring disruption in hemorrhagic shock require immediate pelvic ring closure and stabilization, followed by angiographic embolization or surgical packing if instability persists 3, 1
• Damage control surgery principles apply for severely injured patients with deep hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, or acidosis 3, 9

Diagnostic Approach During Active Hemorrhage

For Hemodynamically Unstable Patients

Do not delay surgical intervention for extensive imaging in actively hemorrhaging unstable patients—proceed directly to bleeding control. 1, 2

• Perform focused assessment with sonography (E-FAST) only to rapidly identify free fluid or extra-pelvic causes of shock 3, 1, 2
• Obtain pelvic X-ray only if pelvic trauma is suspected and patient requires urgent stabilization 1, 2
• Consider angiography when E-FAST and chest X-ray rule out extra-pelvic causes to visualize active arterial bleeding 1

For Hemodynamically Stable Patients

• Perform thoraco-abdomino-pelvic CT scan with IV contrast when hemodynamic status allows 1, 2
• Do not obtain pelvic X-ray in stable patients—proceed directly to CT with contrast 1, 2
• Obtain pregnancy test (urine or serum β-hCG) to rule out pregnancy-related complications 1, 2
• Perform transvaginal ultrasound for pregnant patients to evaluate for ectopic pregnancy or retained products 1

Blood Product Administration and Coagulopathy Management

Maintain hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage—administer RBCs, fibrinogen, and fresh frozen plasma without awaiting laboratory results in massive hemorrhage. 3, 5

• Early infusion of fresh frozen plasma prevents dilutional coagulopathy—do not resuscitate with crystalloids and red cells alone 3
• Obtain baseline coagulation studies (PT, aPTT, Clauss fibrinogen) and cross-match, but do not delay transfusion for results 3
• Consider near-patient testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available to guide component therapy 3
• Anticipate consumptive coagulopathy in obstetric hemorrhage (particularly placental abruption or amniotic fluid embolus), trauma with head injury, and sepsis 3

Antifibrinolytic Therapy

Tranexamic acid 10-15 mg/kg IV bolus followed by 1-5 mg/kg/h infusion may be considered in bleeding trauma patients, though obstetric evidence remains limited. 3, 7, 5

• Administer within 3 hours of injury onset for maximum benefit in trauma settings 3
• In obstetric hemorrhage, give 1 g IV (renewable once) if bleeding persists after uterotonic agents 5, 8
• Contraindicated in patients with active intravascular clotting or subarachnoid hemorrhage 7
• Infuse slowly (no more than 1 mL/minute) to avoid hypotension 7

Definitive Interventions for Refractory Bleeding

If hemorrhage is not controlled by pharmacological treatments and tamponade, proceed immediately to arterial embolization or surgery—do not delay definitive intervention. 5, 6

• Angiographic embolization is preferred for ongoing hemodynamic instability despite adequate pelvic stabilization in trauma 3
• Surgical options include uterine artery ligation, compression sutures, or hysterectomy for intractable obstetric hemorrhage 5, 6
• Hospital-to-hospital transfer for embolization is acceptable only after ruling out hemoperitoneum and if hemodynamic status allows 5

Critical Pitfalls to Avoid

• Never rely on wound dressings or topical agents alone to control active hemorrhage—this delays definitive treatment and worsens outcomes 9
• Avoid excessive fluid resuscitation with crystalloids while bleeding is uncontrolled, as this dilutes clotting factors and worsens coagulopathy 3, 9
• Do not perform dilation and curettage for presumed retained products without ultrasound confirmation, as uterine artery pseudoaneurysm can present with delayed postpartum bleeding and rupture during instrumentation 10
• Avoid hyperventilation and excessive positive end-expiratory pressure in severely hypovolemic patients 3
• Do not discharge patients with unexplained heavy bleeding without concrete follow-up plans within 24-48 hours 1, 2