What is the management approach for a female of reproductive age presenting with bleeding, uterine enlargement, and a ruptured bowel?

Management of Bleeding with Enlarged Uterus and Ruptured Bowel

In a reproductive-age female presenting with bleeding, uterine enlargement, and ruptured bowel, immediate resuscitation with simultaneous hemorrhage control takes absolute priority—perform E-FAST to identify bleeding sources, stabilize hemodynamics with aggressive fluid resuscitation and blood products, and proceed urgently to exploratory laparotomy for definitive surgical control of both bowel perforation and bleeding sources. 1

Immediate Resuscitation and Stabilization

Airway and Breathing

• Establish two large-bore (14-16 gauge) intravenous lines immediately for aggressive fluid resuscitation in this critically injured patient 2
• Administer supplemental oxygen to maintain maternal oxygen saturation >95% to ensure adequate tissue oxygenation 2
• Insert a nasogastric tube if the patient is semiconscious or has altered mental status to prevent aspiration of gastric contents 2

Circulation and Hemorrhage Control

• Initiate massive transfusion protocol with 1:1:1 ratio of packed RBCs, fresh frozen plasma, and platelets for massive hemorrhage (>1500 mL blood loss) 3
• Transfuse O-negative blood immediately until cross-matched blood becomes available to avoid delays in resuscitation 2
• Administer tranexamic acid 1 g intravenously over 10 minutes immediately, as it reduces bleeding-related mortality when given within 3 hours, with effectiveness declining by approximately 10% for every 15 minutes of delay 4
• Avoid vasopressors unless hypotension is intractable and unresponsive to fluid resuscitation, as they adversely affect tissue perfusion 2

Diagnostic Imaging Algorithm

Hemodynamically Unstable Patients

• Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) immediately at bedside to identify intraperitoneal bleeding and guide urgent intervention decisions 1, 2
• E-FAST has 97% positive predictive value for intra-abdominal bleeding and 97% negative predictive value in patients with shock 1
• Abundant hemoperitoneum (3 positive E-FAST sites) indicates need for urgent laparotomy with 61% rate of appropriate surgical intervention 1
• Obtain portable chest X-ray and pelvic X-ray at bedside to rule out thoracic bleeding sources 1
• Do NOT delay surgery for CT scanning in hemodynamically unstable patients—proceed directly to operating room based on E-FAST findings 1

Hemodynamically Stable Patients

• Perform thoraco-abdomino-pelvic CT scan with intravenous contrast to obtain complete inventory of all injuries including bowel perforation, intra-abdominal bleeding sources, and uterine pathology 1
• CT allows identification of active bleeding sources and guides subsequent interventional or surgical management 1

Surgical Management

Exploratory Laparotomy Indications

• Proceed immediately to exploratory laparotomy for ruptured bowel with peritoneal contamination, as this is a surgical emergency requiring definitive repair 1
• Laparotomy is indicated when E-FAST demonstrates abundant hemoperitoneum (3 positive sites) in unstable patients 1
• Control bleeding and address perineal/peritoneal contamination as primary objectives in complex pelvic trauma 1

Intraoperative Priorities

1. Control hemorrhage first—identify and control all bleeding sources including uterine, bowel mesenteric, and pelvic vascular injuries 1
2. Repair bowel perforation and perform thorough debridement to prevent sepsis 1
3. Assess uterus for rupture or injury—if uterine rupture is present, repair or hysterectomy may be necessary depending on extent of injury 1
4. Perform comprehensive exploration for associated injuries to liver, spleen, kidneys, and other pelvic organs 1

Adjunctive Hemorrhage Control

Angiographic Embolization

• Consider angiographic embolization for ongoing pelvic bleeding after bowel repair if patient stabilizes hemodynamically and bleeding source is not surgically accessible 1
• Non-selective bilateral internal iliac artery embolization should be performed in hemodynamically unstable patients with multiple bleeding targets 1
• Time-to-successful embolization is independently associated with mortality—mortality increases from 16% to 64% if embolization requires >60 minutes 1
• Embolization can be performed with pelvic stabilization devices in place (binders or external fixators) 1

Coagulation Management

• Obtain coagulation panel including fibrinogen level, as pregnant trauma patients are at high risk for hypofibrinogenemia 2
• Replace fibrinogen with cryoprecipitate or fibrinogen concentrate if levels <2-3 g/L with ongoing bleeding 4
• Platelet transfusion is indicated if platelet count <75 × 10⁹/L or blood loss exceeds 5000 mL 4

Critical Pitfalls to Avoid

• Never perform digital vaginal examination before imaging excludes vascular abnormalities or placental complications, as this risks catastrophic hemorrhage 3
• Do not delay surgical intervention for CT scanning in hemodynamically unstable patients—E-FAST and bedside X-rays provide sufficient information for urgent operative decisions 1
• Do not inflate abdominal portion of anti-shock trousers, as this may reduce pelvic and uterine perfusion 2
• Avoid aggressive sharp curettage if retained products are suspected, as this could perforate a thinned uterine wall or worsen bleeding from vascular abnormalities 3

Multidisciplinary Coordination

• Transfer to a trauma center with obstetric, general surgery, and interventional radiology capabilities immediately 1, 2
• Complex pelvic trauma with bowel injury requires coordinated care from trauma surgery, gynecology, and potentially colorectal surgery 1
• Maintain arterial access port with anti-reflux valve for 24 hours post-embolization to allow repeat angiography if hemorrhage recurs 1