What is the immediate management for a patient with severe anemia?

Management of 35-Year-Old with AUB and Severe Anemia (ET 16mm)

This patient requires immediate packed red blood cell transfusion to address life-threatening severe anemia, followed by urgent gynecologic intervention to control the bleeding source. 1

Immediate Resuscitation

Transfuse 2-3 units of packed red blood cells immediately to address the critically low hemoglobin, with each unit expected to increase hemoglobin by approximately 1.5 g/dL, targeting an initial hemoglobin of 7-8 g/dL for stabilization. 1 This rapid correction is essential given the severity of anemia from ongoing uterine bleeding.

• Establish large-bore IV access (at least two catheters) to allow rapid volume expansion with crystalloids while preparing blood products. 2
• Initiate continuous cardiac monitoring as severe anemia carries extremely high risk of cardiac decompensation. 1
• Provide supplemental oxygen and monitor oxygen saturation continuously if respiratory distress is present. 1
• Insert urinary catheter and measure hourly urine output (target >30 mL/h) to monitor perfusion. 1

Transfusion Strategy

Use a restrictive transfusion threshold of Hb <7.0 g/dL as the trigger, but in this acute hemorrhagic scenario with ongoing bleeding, transfuse immediately without waiting for specific thresholds. 1 The patient's symptoms, hemodynamic stability, and ongoing blood loss should guide transfusion decisions rather than arbitrary hemoglobin numbers alone. 2

• Transfuse single units sequentially rather than multiple units simultaneously, reassessing after each unit to minimize transfusion-related complications. 1
• Target hemoglobin range of 7-9 g/dL after initial stabilization in this stable, non-cardiac patient. 2
• Monitor for transfusion reactions or volume overload during blood product administration. 1

Diagnostic Workup (Concurrent with Resuscitation)

Obtain complete blood count with differential to assess other cell lines and confirm severity of anemia. 1

• Check reticulocyte count (>10 × 10⁹/L indicates regenerative anemia), lactate dehydrogenase (LDH), indirect bilirubin, and haptoglobin levels to assess for hemolysis. 1
• Perform peripheral blood smear to look for schistocytes or other morphologic abnormalities. 1
• Obtain liver function tests and coagulation panel (PT/INR) to assess for coagulopathy. 1
• Check iron studies (ferritin, transferrin saturation) to identify absolute or functional iron deficiency. 2
• Consider direct antiglobulin test (Coombs) if hemolysis is suspected. 1
• Obtain pregnancy test to rule out pregnancy-related complications. 1

Gynecologic Management

Urgent gynecologic consultation is mandatory to address the bleeding source. The thickened endometrium (16mm) in the setting of severe anemia from AUB requires immediate intervention.

• Consider emergency endometrial sampling or dilation and curettage both for diagnosis and therapeutic hemostasis.
• High-dose progestins or tranexamic acid may be initiated to reduce bleeding while preparing for definitive management.
• Assess for structural causes (fibroids, polyps, adenomyosis) that may require surgical intervention.

Monitoring

Check hemoglobin levels daily until stable above 7-8 g/dL. 1

• Reassess volume status frequently during resuscitation to avoid fluid overload.
• Monitor for signs of ongoing bleeding (vital signs, urine output, clinical symptoms).

Iron Replacement (After Stabilization)

Initiate intravenous iron therapy once the patient is stabilized, as this is the treatment of choice for absolute iron deficiency in patients with complex medical disorders. 3 Oral iron is inadequate in the acute setting with ongoing blood loss.

Common Pitfalls to Avoid

Do not delay transfusion while waiting for laboratory confirmation of hemoglobin levels if the patient is symptomatic or hemodynamically unstable. 2

Avoid liberal transfusion strategies targeting Hb >10 g/dL, as this increases transfusion requirements without improving outcomes. 1

Do not overlook the need for urgent gynecologic intervention – transfusion alone without controlling the bleeding source will result in continued blood loss and transfusion dependence.

Implement diagnostic phlebotomy reduction strategy to minimize iatrogenic blood loss during hospitalization. 1