What is the appropriate emergency department management of a patient presenting with vaginal bleeding, including initial stabilization, assessment for pregnancy, and treatment for both pregnant and non‑pregnant women?

Emergency Department Management of Vaginal Bleeding

All patients presenting with vaginal bleeding require immediate pregnancy testing with urine or serum β-hCG, followed by hemodynamic assessment and risk stratification based on pregnancy status, with pregnant patients requiring urgent ultrasound to exclude life-threatening ectopic pregnancy. 1, 2

Initial Stabilization and Assessment

Immediate Priorities

• Assess hemodynamic stability first by obtaining vital signs including blood pressure, heart rate, and evaluating for signs of hemorrhagic shock. 2
• Establish IV access and initiate fluid resuscitation in unstable patients, with blood products administered immediately if hemorrhagic shock is present. 1
• Obtain quantitative β-hCG on all patients immediately to determine pregnancy status, as this fundamentally changes the diagnostic and treatment algorithm. 1, 2
• Determine Rh status urgently, as anti-D immunoglobulin may be indicated for Rh-negative women with threatened abortion, complete abortion, or ectopic pregnancy. 1, 2

Hemodynamically Unstable Patients

• Patients in hemorrhagic shock require immediate resuscitation with blood products targeting hemoglobin 7-9 g/dL while simultaneously pursuing definitive hemorrhage control. 3
• Consider permissive hypotension targeting systolic blood pressure 80-100 mmHg until bleeding is controlled, particularly in trauma contexts. 1, 3
• Perform E-FAST immediately to identify potential sources of bleeding and guide intervention decisions. 1
• If trauma-related, apply external pelvic compression using pelvic binders placed around the great trochanters as soon as possible. 1

Pregnant Patients

Diagnostic Approach

• Perform transvaginal ultrasound immediately as the primary diagnostic tool, regardless of β-hCG level, as this is the most critical step to exclude ectopic pregnancy. 2
• Do not defer ultrasound based solely on β-hCG levels below traditional discriminatory thresholds, as up to 36% of ectopic pregnancies present with β-hCG <1,000 mIU/mL and ultrasound can detect intrauterine pregnancy at these low levels. 2
• Ectopic pregnancy prevalence reaches 13% in symptomatic ED patients and remains the leading cause of maternal death in the first trimester. 2

Ultrasound Interpretation

• Gestational sac with yolk sac or fetal pole confirms intrauterine pregnancy and essentially rules out ectopic pregnancy (except rare heterotopic pregnancy). 2
• For indeterminate ultrasound findings (pregnancy of unknown location):
  • β-hCG <1,000 mIU/mL: approximately 15% ectopic pregnancy rate 2
  • β-hCG >1,000 mIU/mL: approximately 2% ectopic pregnancy rate 2
  • β-hCG >2,000 mIU/mL with no IUP: 57% ectopic pregnancy rate 2
  • Overall, 7-20% of pregnancies of unknown location will ultimately be ectopic 2

Physical Examination Considerations

• Perform speculum examination to assess for cervical lesions, polyps, inflammation, or active bleeding source. 2
• Avoid digital bimanual examination until ultrasound excludes placenta previa in patients beyond first trimester, as examination before imaging can precipitate catastrophic hemorrhage. 2

Management Based on Findings

For confirmed ectopic pregnancy or high suspicion:

• Hemodynamically unstable patients require immediate surgical intervention. 1
• Stable patients may be candidates for medical management or surgical intervention based on clinical parameters. 2

For pregnancy of unknown location:

• Arrange serial β-hCG measurements every 48 hours (normal IUP increases by at least 53% over 48 hours, though this has limited sensitivity of 36% and specificity of 63%). 2
• Repeat ultrasound when β-hCG reaches discriminatory threshold to establish diagnosis. 2
• Approximately 80-93% will resolve as early or failed intrauterine pregnancies. 2

For threatened abortion:

• Arrange follow-up within 24-48 hours with concrete plans in place before discharge. 1, 2

Non-Pregnant Patients

Hemodynamically Stable Patients

• Perform thoraco-abdomino-pelvic CT scan with intravenous contrast when hemodynamic status allows. 1
• Pelvic X-ray is not necessary for stable patients; proceed directly to CT scan with contrast. 1
• Perform speculum examination to identify cervical or vaginal sources of bleeding. 4
• Consider structural causes (fibroids, polyps), infectious etiologies (gonorrhea, chlamydia), hormonal causes (anovulatory bleeding), or malignancy. 4

Hemodynamically Unstable Patients

• Obtain pelvic X-ray upon arrival for patients requiring urgent intervention to stabilize vital signs. 1
• Perform E-FAST to identify potential sources of bleeding. 1
• When E-FAST and chest X-ray rule out extra-pelvic causes of hemorrhagic shock, proceed to angiography to visualize active arterial bleeding. 1
• If E-FAST shows abundant hemoperitoneum (≥3 positive sites), emergency laparotomy is indicated with 61% probability of intra-abdominal injury requiring surgical control. 3

Trauma-Related Vaginal Bleeding

Pelvic Trauma Management

• Apply external pelvic compression immediately using pelvic binders placed around the great trochanters. 1
• For persistently hypotensive patients despite pelvic stabilization, ongoing hypotension confirms arterial bleeding requiring angiography. 3
• Proceed directly to angiographic embolization after ensuring pelvic binder is properly applied, as 73% of non-responders to initial resuscitation have arterial bleeding requiring embolization. 3
• Angiography achieves hemorrhage control with 73-97% success rates and is the definitive treatment for arterial pelvic bleeding. 3
• Do not perform laparotomy for isolated pelvic bleeding, as non-therapeutic laparotomy dramatically increases mortality. 3

Adjunctive Measures

• Administer tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion to prevent fibrinolysis. 3
• Monitor serum lactate and base deficit to assess adequacy of resuscitation. 3
• Obtain baseline platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels if significant bleeding is present. 2

Critical Pitfalls to Avoid

• Never defer ultrasound based solely on low β-hCG levels in pregnant patients, as ultrasound may initially miss up to 74% of ectopic pregnancies, making this a potentially fatal error. 2
• Do not rely on absence of risk factors to exclude ectopic pregnancy. 2
• Do not delay angiography for additional imaging in persistently hypotensive trauma patients, as mortality increases approximately 1% every 3 minutes of delay. 3
• Do not remove pelvic binder prematurely, as mechanical stabilization must be maintained until definitive hemorrhage control is achieved. 3
• Avoid digital examination before ultrasound in patients beyond first trimester to prevent catastrophic hemorrhage from placenta previa. 2
• Ensure all hemodynamically stable patients have concrete follow-up plans before discharge, as delayed diagnosis of ectopic pregnancy can be fatal. 2
• Do not perform CT scan in unstable patients, as this delays definitive treatment; proceed directly to angiography or operating room based on E-FAST findings. 3