How do I manage a woman presenting to the emergency department with vaginal bleeding?

Management of Vaginal Bleeding in the Emergency Department

The immediate priority is to assess hemodynamic stability and determine pregnancy status, as these two factors dictate all subsequent management decisions. 1

Initial Assessment and Stabilization

Hemodynamic Assessment

• Check vital signs immediately to identify hemorrhagic shock: systolic BP <90 mmHg, heart rate >100 bpm, signs of hypoperfusion (altered mental status, cool/clammy skin, decreased capillary refill). 2
• Establish IV access immediately in all patients with active bleeding. 1
• Monitor serum lactate and base deficit to estimate bleeding severity and tissue hypoperfusion—do not rely on single hematocrit measurements alone. 2

Pregnancy Status Determination

• Obtain urine or serum β-hCG test on all women of reproductive age presenting with vaginal bleeding, as ectopic pregnancy prevalence reaches 13% in symptomatic ED patients. 2, 1

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Unstable Patients (Hemorrhagic Shock)

Patients in hemorrhagic shock with vaginal bleeding require immediate resuscitation and bleeding control—do not delay for extensive imaging. 2, 1

Immediate Resuscitation

• Begin fluid resuscitation with crystalloids targeting systolic BP 80-100 mmHg until bleeding is controlled. 2
• Transfuse packed red blood cells if Hb <7 g/dL, targeting Hb 7-9 g/dL to avoid worsening coagulopathy through over-resuscitation. 3
• Avoid excessive fluid administration while bleeding is uncontrolled, as this exacerbates coagulopathy. 3, 4

Rapid Diagnostic Approach

• Perform focused assessment with sonography (E-FAST) at bedside to identify potential intra-abdominal or pelvic sources of bleeding. 1
• Obtain pelvic X-ray if trauma mechanism is present to identify pelvic fractures. 1
• If E-FAST and chest X-ray rule out extra-pelvic hemorrhage, proceed directly to angiography to visualize active arterial bleeding. 1

Bleeding Control

• Patients with identified bleeding source and hemorrhagic shock require immediate surgical intervention unless initial resuscitation successfully stabilizes them. 2, 1
• For pelvic trauma with ring disruption: apply external pelvic binder around the greater trochanters immediately, followed by pelvic ring closure/stabilization and angiographic embolization or surgical packing. 2, 1
• Damage control surgery principles apply if patient demonstrates ongoing hemorrhagic shock, coagulopathy, hypothermia, or acidosis. 2

Critical Pitfall: Do not delay definitive bleeding control for prolonged diagnostic workup in unstable patients—minimizing time between injury and intervention is essential for survival. 2, 1, 4

For Hemodynamically Stable Patients

Pregnancy-Related Bleeding

For pregnant patients, transvaginal ultrasound is the primary diagnostic tool and should be performed regardless of β-hCG level. 2, 1

• Perform transvaginal ultrasound even when β-hCG is below traditional discriminatory thresholds (historically 1,000-1,500 mIU/mL), as this still provides valuable risk stratification. 2, 1
• Bedside ultrasound by emergency physicians can expedite diagnosis when available. 1
• Ultrasound findings guide management:
  • Intrauterine pregnancy (IUP) with yolk sac or fetal pole: threatened abortion—arrange follow-up within 24-48 hours. 2, 1
  • No IUP visualized with β-hCG >1,000 mIU/mL: high suspicion for ectopic pregnancy—requires urgent gynecology consultation. 2
  • Indeterminate ultrasound: risk of ectopic pregnancy is 15% if β-hCG <1,000 mIU/mL versus 2% if β-hCG >1,000 mIU/mL. 2

Special consideration: Administer anti-D immunoglobulin to Rh-negative women with threatened abortion, complete abortion, or ectopic pregnancy. 1

Non-Pregnancy-Related Bleeding

• Obtain thoraco-abdomino-pelvic CT scan with IV contrast when hemodynamic status allows—skip pelvic X-ray and proceed directly to CT. 1
• Complete blood count, coagulation studies, and type/cross-match if bleeding is significant. 2
• Consider gynecologic causes: cervical lesions, uterine pathology, coagulopathy, malignancy.

Follow-Up and Disposition

• Ensure concrete follow-up plans within 24-48 hours for pregnant patients with threatened abortion before discharge. 1
• Patients with indeterminate ultrasound require serial β-hCG monitoring and repeat imaging.
• Unstable patients or those requiring procedural intervention need admission.

Key Principle: The presence of hemorrhagic shock (Class III-IV hemorrhage per ATLS classification: >1,500 mL blood loss, BP decreased, HR >120 bpm) mandates immediate bleeding control over diagnostic evaluation. 2 In contrast, stable patients benefit from systematic diagnostic workup to identify the bleeding source before intervention. 2, 1