What is the immediate management of vaginal bleeding in the emergency department?

Immediate Management of Vaginal Bleeding in the Emergency Department

Immediately establish large-bore IV access and begin aggressive fluid resuscitation with warmed blood products (not crystalloids alone) for any patient with active hemorrhage and signs of shock, while simultaneously identifying and controlling the bleeding source. 1

Initial Assessment and Stabilization

Hemodynamic Resuscitation

• Administer high-flow oxygen to all patients with active hemorrhage 1
• 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 2, 1
• Monitor serum lactate and base deficit continuously to track the extent of bleeding and shock; do not rely on single hematocrit measurements as they are misleading in acute hemorrhage 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1

Immediate Bleeding Control

• Patients with hemorrhagic shock and an identified bleeding source require immediate surgical bleeding control unless initial resuscitation is successful 2, 1
• Apply direct compression or packing to all accessible bleeding sites immediately 1
• For pelvic trauma with vaginal bleeding, apply external pelvic compression using pelvic binders placed around the great trochanters as soon as possible 2, 1
• Minimize elapsed time between presentation and definitive intervention to prevent complications 2

Diagnostic Approach Based on Hemodynamic Status

For Unstable Patients

• Do not delay surgical intervention for extensive imaging in actively hemorrhaging unstable patients 1, 3
• Perform focused assessment with sonography (E-FAST) only to rapidly identify free fluid or extra-pelvic causes of shock 2, 1
• Obtain pelvic X-ray only if pelvic trauma is suspected and the patient requires urgent intervention to stabilize vital signs 2, 3
• When E-FAST and chest X-ray rule out extra-pelvic causes of hemorrhagic shock, consider angiography to visualize active arterial bleeding 2

For Stable Patients

• Perform thoraco-abdomino-pelvic CT scan with intravenous contrast when hemodynamic status allows 2, 3
• Pelvic X-ray is not necessary for stable patients; proceed directly to CT scan with contrast 2, 3
• Determine pregnancy status with urine or serum β-hCG test for all patients of reproductive age 2

Pregnancy-Specific Considerations

Early Pregnancy Evaluation

• For early pregnancy patients with vaginal bleeding, obtain pelvic ultrasound to evaluate for intrauterine pregnancy or ectopic pregnancy, which has a prevalence as high as 13% in symptomatic ED patients 2
• Transvaginal ultrasound is preferred and should be performed even when β-hCG is below traditional discriminatory thresholds 2
• Do not defer ultrasound based solely on β-hCG levels, as modest diagnostic performance still provides valuable information for risk stratification 2
• Bedside ultrasound by emergency physicians can expedite diagnosis when available 2

Pregnancy-Related Management

• Consider administration of anti-D immunoglobulin for Rh-negative women with threatened abortion, complete abortion, or ectopic pregnancy 2
• Clinically unstable pregnant patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy 4
• Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids 4

Blood Product Administration and Coagulopathy Management

• Maintain hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 1
• Early infusion of fresh frozen plasma prevents dilutional coagulopathy 1
• Obtain baseline coagulation studies (PT, aPTT, Clauss fibrinogen) and cross-match, but do not delay transfusion for results 1

Critical Pitfalls to Avoid

• Never rely on wound dressings or topical agents alone to control active hemorrhage, as this delays definitive treatment and worsens outcomes 1
• Avoid excessive fluid resuscitation with crystalloids while bleeding is uncontrolled, as this dilutes clotting factors and worsens coagulopathy 1
• Avoid hyperventilation and excessive positive end-expiratory pressure in severely hypovolemic patients 1
• Do not discharge patients with unexplained heavy bleeding without concrete follow-up plans within 24-48 hours 1, 3
• Avoid delaying surgical intervention in unstable patients for extensive diagnostic workup 3

Disposition and Follow-Up

• Arrange follow-up within 24-48 hours for pregnant patients with threatened abortion 2
• Ensure concrete plans are in place for follow-up before discharge 2
• Most patients require referral to a gynecologist for further evaluation and treatment after initial emergency stabilization 5