What is the standard of care for a 30‑year‑old woman at 10 weeks gestation presenting to the emergency department with hematemesis?

Management of Hematemesis in a 30-Year-Old Woman at 10 Weeks Gestation

The standard of care is immediate hemodynamic assessment and resuscitation, followed by urgent upper endoscopy to diagnose and treat the bleeding source, while maintaining awareness of pregnancy-specific coagulation changes and avoiding teratogenic medications. 1

Immediate Assessment and Stabilization

Hemodynamic Evaluation

• Calculate the Shock Index (heart rate ÷ systolic blood pressure): a value >1 indicates hemodynamic instability requiring immediate aggressive resuscitation. 2
• Assess for signs of hypovolemia including tachycardia, hypotension, altered mental status, and decreased urine output. 2
• Obtain venous blood gas for rapid hemoglobin measurement and lactate level; lactate >2 mmol/L indicates tissue hypoperfusion and shock. 3, 2

Laboratory Workup

• Draw urgent complete blood count, coagulation studies (PT/APTT), fibrinogen level, type and screen, and liver function tests. 3, 2
• Recognize that pregnancy at 10 weeks already exhibits hypercoagulable changes including elevated factor VIII, von Willebrand factor, fibrinogen, and increased thrombin generation, though these changes are less pronounced than in the third trimester. 4
• Use PT ratio and APTT ratio ≥1.5 as the threshold for coagulopathy rather than absolute values, as coagulation times are physiologically shortened in pregnancy. 2

Resuscitation Protocol

• Initiate two large-bore IV lines and begin resuscitation with warm crystalloid solutions (normal saline or lactated Ringer's). 5
• Administer oxygen to maintain arterial saturation ≥95%. 5
• Transfuse packed red blood cells if hemoglobin falls below 7.0 g/dL, or consider transfusion at 7.0-8.0 g/dL if the patient has ongoing bleeding or hemodynamic instability. 2
• Transfuse one unit at a time and recheck hemoglobin before each subsequent unit unless there is active hemorrhage. 2

Upper GI Bleeding-Specific Management

Diagnostic Approach

• Perform urgent upper endoscopy once the patient is hemodynamically stable or stabilized with resuscitation; endoscopy is both diagnostic and therapeutic for upper GI bleeding. 1
• Place a large-bore orogastric tube and perform gastric lavage with copious fluid to clear the stomach and assess ongoing bleeding. 6
• Endoscopy should not be delayed in pregnant patients, as the diagnostic and therapeutic benefits outweigh radiation-free procedural risks at 10 weeks gestation. 1

Medical Therapy

• Initiate proton pump inhibitor therapy (e.g., pantoprazole 80 mg IV bolus followed by 8 mg/hour infusion) empirically while awaiting endoscopy. 6
• Avoid medications contraindicated in pregnancy; most PPIs are pregnancy category B or C and are considered safe. 1

Pregnancy-Specific Considerations at 10 Weeks

Coagulation Monitoring

• Do not assume normal hemostasis based on pregnancy alone; while pregnancy induces hypercoagulability, acute hemorrhage rapidly depletes clotting factors, particularly fibrinogen. 4
• Monitor fibrinogen levels closely if bleeding is severe; fibrinogen <2.0 g/L with ongoing bleeding requires replacement with cryoprecipitate or fibrinogen concentrate. 3, 2

Transfusion Thresholds in Active Bleeding

• In the setting of active hematemesis with hemodynamic instability or lactic acidosis, transfuse based on clinical status rather than waiting for hemoglobin to reach 7 g/dL, as hemoglobin remains falsely elevated during acute hemorrhage due to hemoconcentration. 2
• If massive transfusion is required (>4 units RBCs), administer fresh frozen plasma at a 1:1 ratio with RBCs after the fourth unit. 3, 5

Fetal Considerations

• At 10 weeks gestation, the fetus is in the first trimester; fetal hemostasis is immature but maternal resuscitation and hemodynamic stability are the priority for fetal survival. 4
• Avoid medications with known teratogenic effects during endoscopic procedures (consult anesthesia for safe sedation options). 1

Critical Pitfalls to Avoid

• Do not delay endoscopy due to pregnancy concerns; the maternal mortality risk from uncontrolled upper GI bleeding far exceeds any procedural risk to the fetus at 10 weeks. 1
• Do not rely on visual estimation of blood loss or wait for hemoglobin to drop before initiating transfusion in hemodynamically unstable patients, as blood loss is consistently underestimated and hemoglobin lags behind actual volume loss. 2
• Do not assume the patient has normal coagulation simply because she is pregnant; acute hemorrhage can rapidly induce coagulopathy despite baseline hypercoagulability. 4
• Do not administer methylergonovine or prostaglandin F2α, as these are obstetric hemorrhage medications not indicated for upper GI bleeding and have significant side effects. 5

Ongoing Monitoring

• Continue vital sign monitoring every 1-2 hours for the first 24 hours. 2
• Recheck hemoglobin 4-6 hours after initial assessment or sooner if clinical deterioration occurs. 2
• Monitor urine output as a marker of adequate tissue perfusion and volume status. 2
• Repeat coagulation studies if bleeding persists or if massive transfusion is required. 3