What is the appropriate emergency department assessment and initial management for a woman presenting with acute vaginal bleeding, including hemodynamic stabilization, pregnancy testing, laboratory evaluation, imaging, and treatment of possible causes?

Emergency Department Evaluation of Vaginal Bleeding

Begin with immediate hemodynamic assessment and pregnancy testing, followed by a structured approach based on stability status—unstable patients require urgent intervention before complete diagnostic workup, while stable patients undergo systematic evaluation to identify the bleeding source.

Immediate Assessment and Stabilization

Primary Survey (ABCDE Approach)

• Assess airway patency and breathing adequacy immediately, as these are the most sensitive indicators of patient deterioration and must be secured before addressing bleeding 1, 2.
• Obtain vital signs within minutes of arrival and calculate shock index (heart rate ÷ systolic BP)—a value >1 indicates hemodynamic instability requiring immediate intervention 3.
• Apply two large-bore intravenous lines (18-gauge or larger) for volume resuscitation and blood product administration 4.

Critical Initial Laboratory Testing

• Obtain hemoglobin/hematocrit, coagulation parameters (PT/PTT/INR), fibrinogen, and blood typing with cross-match immediately 3.
• Measure serum lactate and base deficit as sensitive markers for estimating and monitoring the extent of bleeding and shock 5.
• Perform urine or serum β-hCG pregnancy testing on all women of reproductive age immediately—this is mandatory as it fundamentally changes the diagnostic and therapeutic approach 3.
• Note that single hematocrit measurements should not be used as an isolated marker for bleeding severity, as they lag behind acute blood loss 5.

Hemodynamic Resuscitation Strategy

For Hemodynamically Unstable Patients

• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL (use 9 g/dL threshold if massive bleeding or cardiovascular disease present) 5, 3.
• Target systolic blood pressure of 80-100 mmHg using permissive hypotension until major bleeding has been definitively controlled, as aggressive fluid resuscitation can worsen hemorrhage 5.
• Initiate crystalloid resuscitation immediately, with colloids added within prescribed limits for each solution 5.
• Administer tranexamic acid 1g IV over 10 minutes as soon as possible (ideally within 3 hours of symptom onset), followed by 1g infusion over 8 hours to prevent fibrinolysis 3.

Massive Transfusion Protocol

• Use FFP:pRBC ratio of at least 1:2 for massive hemorrhage, with high platelet:pRBC ratio 3.
• Target transfusion thresholds of hematocrit >25%, platelet count >50,000, and fibrinogen >120 mg/dl during active bleeding 5.

Diagnostic Algorithm Based on Stability

For Hemodynamically Unstable Patients

• Perform bedside E-FAST (Extended Focused Assessment with Sonography for Trauma) immediately to detect free fluid in peritoneal, pleural, and pericardial spaces—this has 97% positive predictive value for intra-abdominal bleeding 3, 6.
• Obtain pelvic X-ray and chest X-ray at the bedside, as these are the only imaging modalities compatible with ongoing resuscitation 3, 6.
• Do not delay for CT scanning if the patient remains hemodynamically unstable—proceed directly to definitive intervention (surgery or angioembolization) as each 3-minute delay increases mortality by approximately 1% 7.

For Hemodynamically Stable Patients

• Perform pelvic ultrasound to evaluate for ectopic pregnancy, ovarian pathology, and intrauterine abnormalities in pregnant or potentially pregnant patients 3.
• Obtain CT scan of abdomen/pelvis with IV contrast to identify bleeding sources, masses, or structural abnormalities—CT has 93.9% positive predictive value for detecting active bleeding 7.
• Consider endoscopic evaluation (hysteroscopy or colposcopy) if gynecologic source is suspected and patient remains stable.

Source-Specific Management

Trauma-Related Vaginal Bleeding

• Apply pelvic binder immediately if pelvic fracture is suspected, as this limits life-threatening venous and cancellous bone bleeding (80-90% of pelvic hemorrhage) 7.
• If E-FAST shows significant hemoperitoneum (≥3 positive sites), proceed to emergency laparotomy as this correlates with 61% probability of intra-abdominal injury requiring surgical control 7, 6.
• If E-FAST is negative or shows minimal free fluid with pelvic fracture, proceed to angiographic embolization for arterial bleeding control—success rate 73-97% 7.
• Perform preperitoneal pelvic packing (PPP) if angioembolization cannot be achieved within 60 minutes or if patient is in extremis—this can be completed in <20 minutes and controls both venous and arterial bleeding 7.

Gynecologic Causes

• For ectopic pregnancy with hemodynamic instability, proceed immediately to surgical intervention (laparoscopy or laparotomy) without delay for additional imaging 3.
• For suspected uterine hemorrhage in stable patients, consider medical management (tranexamic acid, hormonal therapy) before procedural interventions.
• For postpartum hemorrhage, initiate uterotonic agents (oxytocin, methylergonovine, carboprost) while preparing for potential surgical intervention.

Gastrointestinal Sources

• Do not assume vaginal bleeding is gynecologic in origin—always consider lower GI bleeding presenting as vaginal bleeding, especially in trauma or elderly patients 3.
• Perform upper endoscopy if clear diagnosis of lower GI bleeding is not possible, as up to 8% of patients with hematochezia have an upper GI source 5.
• For suspected anorectal varices with severe bleeding, maintain hemoglobin >7 g/dL and mean arterial pressure >65 mmHg while avoiding fluid overload 5.

Critical Pitfalls to Avoid

• Never delay definitive intervention for additional imaging in hemodynamically unstable patients—mortality increases significantly with each minute of delay 3, 7.
• Never remove pelvic binder prematurely in trauma patients, as it controls venous bleeding while arterial bleeding is addressed 7.
• Never perform CT scan on a patient becoming more unstable—proceed directly to intervention based on clinical findings and bedside imaging 7.
• Never assume isolated pelvic bleeding requires laparotomy—emergency laparotomy cannot control pelvic arterial bleeding and increases mortality; angioembolization or PPP is indicated 7.
• Approximately 20% of patients requiring ≥4 units transfusion have significant mortality risk—activate massive transfusion protocol early 3.
• Do not hyperventilate severely hypovolemic patients or apply excessive positive end-expiratory pressure, as this worsens hemodynamics 5.

Disposition and Monitoring

• Admit all hemodynamically unstable patients or those requiring transfusion to intensive care unit for continuous monitoring 3.
• Maintain arterial access port with anti-reflux valve for 24 hours after angioembolization to allow repeat intervention if hemorrhage recurs 5.
• Monitor serial hemoglobin, lactate, and base deficit to assess response to resuscitation and detect ongoing bleeding 5.