Patient with vaginal bleeding…
July 26, 2013

Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , trackback

Your radio goes off and a panicked paramedic reports that they are en route with a 42-year-old woman who is having profuse vaginal bleeding and appears very ill. She is pale, tachycardic, and hypotensive. She has a history of fibroids. She has been bleeding heavily for 3 days, and the bleeding has acutely increased in the past few hours. The on-call gynecologist is delivering a baby at the hospital across town, and you will have to stabilize this patient and manage her on your own for a few hours…

How would you manage this patient?

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1. Eak - July 28, 2013

First, the emergency physician should evaluate airway, breathing, and circulation. This patient has circulation problem – At least grade 3 hemorrhage. Intravenous normal saline solution should be vigorously given at least 2,000 ml. Oxygen cannular should be given. At the same time, the patient blood should be checked for hematocrit, platelets, coagulation studies, and thyroid-stimulating hormone (if suspected the endocrine disorder). Also, the pregnancy test should also be checked because she is in reproductive age. Group O, low-titer, and Rh-negative should be reserved if the emergent blood transfusion is indicated. Since she has severe, persistent bleeding with unstable hemodynamics, dilatational and curettage is indicated. Whereas the uterine packing should be avoided because of risk of infection. For the conjugated estrogens may be used in the emergent treatment of life-threathening hemorrhage if the bleeding is not caused by pregnancy or tumor. While all management is in the process, we should determine the cause of bleeding that requires immediate attention. The most possible cause in this case is bleeding from fibroids. The others may be neoplasia or dysfunctional uterine bleeding.

2. Chris Stahmer - August 1, 2013

Eak is off to a great start. I would also add the ever present two large bore ivs and cardiac monitor. However, a two liter NS bolus may be deleterious considering this hemodynamic description. I would strongly consider going to an immediate O – transfusion pending type and cross match available blood. If the bleeding is as brisk as I am currently imagining then considering temporary vaginal packing while awaiting the OR may or may not be of any benefit depending on what is found during her pelvic exam.

3. rajesh - August 1, 2013

1. Assess airway if intubation is indicated then intubate and ventilate, if not then start O2 via face mask or nasal prongs.
2. Circulation – Patient is actively bleeding, so 2 large bore cannula is secured and samples collected for complete blood haemogram, coagulation profile, CPK, blood culture and sensitivity ,blood grouping, typing and cross matching for 2 PRBC and FFP. ABG is also done to know the acidosis.Iv fluids are started but as quickly as the blood can be procured the better is the outcome.
3. Tranexamic acid injection 1 gram is given.
4. Bedside sonograph of abdomen and pelvis is needed to rule out other causes of bleeding PV.
5. Since the cause for her severe bleeding can be DUB thus anesthetic evaluation is taken and OT is kept ready so time is preserved.
6. Vaginal packing can be done.
7. Broad spectrum antibiotics coverage.
d and c should not be attempted since this may worsen her condition.
Differential diagnosis:
Septic shock with DIC.
Endometrial cancer.

4. joncheah - August 1, 2013

preparation :
i-room – resuscitation preferably/gowns/gloves
ii-equipment – get 2 large saline bags (warmed) with pressure pumps
cardiac monitorin/NIBP
Gynaecology trolley to do an inspection
bedside qualitative HCG strips to test urine/blood
O-ve Blood (if the hospital has massive transfusion protocol get ready to activate after ax)
iii. staffing – nurses/junior residents/doctors

Assess ABCs.

Airway – consider intubating if GCS consider coagulopathy from liver disease
——> history of fibroids may be red herring (so MUST Exclude pregnancy esp ectopic)

–start by assessing degree of shock she has
–main aim is to exclude pregnancy (occult placenta abruptio/massive miscarriage/ectopic) by bedside serum HCG : if negative will move on to do bedside USS to assess pelvis
–consider giving blood EARLY if NO contraindications (i.e Jehovah’s witness)
–give 1gram of TRANEXAMIC ACID IV
–Consider ethylestradione if pregnancy excluded

VIsual inspection (gentle speculum to assess source)
EXCLUDE ARTERIAL lacerations of genitalia (post coital/trauma)
consider removing products of POS stuck in os (can cause concomitant vagal stimuli and HYPOTENSION)

Urinary Catheter should be inserted to measure urine volume collapse the bladder

5. Dr Anusha Chari - August 1, 2013

Place the patient in a monitored bed, two large bore PIVs, O2 by NC. Draw labs, incl type and screen, Rh, Cbc, coags, UHCG. If clinically obvious massive bleed, type and cross for 4-6 units. Initiate premarin IV. Consult on call Ob-gyn. Peform quick pelvic exam. Bedside transabd ultrasound. If bleeding persists despite above and pt doesnt stabilize, consider packing vaginal vault,Massive transfusion incl. init of other products ffp etc

6. Shayne Calleja - August 1, 2013

Impression: abnormal uterine bleeding
IVF: fluid challenge with 500cc to 1 L of PNSS then run remaining in 2 hours
– another iv line with PLR 1L for 6 hours
– give plasma expanders while waiting for properly typed and cross-matched fresh whole blood
CBC with platelet count
Blood typing
Sodium, potassium, calcium and albumin
Pregnancy test ( serum beta HCG)
Chest xray
12-lead ecg
Blood sugar monitoring

-tranexamic acid 500 ng iv q8 hours
– vitamin k 1 amp iv stat dose then q8
– facilitate blood transfusion
– start iv antibiotics
Immediately ask the help of a gynecologist for possible pelvic explore lap to search for the possible cause ofAUB.
– vital signs monitoring q15min until stable.

7. Adel Noman - August 2, 2013

according to this case IT LOOK IN MODERET STAGE of hemorrage. first we should start with ABC.keep the patient lying and give O2 by mask,start FAST on the road with Fluids Normal saline 2L infusid throught big cannula 14gage in the first 1/2 hour and up to 10L. if need to colloid and blood transfusion. take blood sample for CBC,Coagulation study,sugar, renal function test ,and for blood group and cross maching,and for antibody formation.follow up vital signs and response to fluid.we should have contact with the hospital to contact with the obstetrician,and anasthesiolog
the most common cause of PPH IS 1) uterine atony,so we need to check the uterus from external examination if bulgy lower abdomen .if yes give Oxytocin amp .
2)Retained placent in uterous this need U/SOUND to diagnose it.
3)Trauma in external gentalia.this need to check of the site by inspection and direct repair it and direct pressure.
4)bleeding tendency.

8. Dr. Masood. - August 2, 2013

stabilize her hemodynamically.
send the routine labs; cbc, electrolytes including RBS, BUN, Creatinine.
plus PT,APTT, blood group and her rhesus status
Emergency pelvic U/S to r/o miscarriage or ectopic pregnancy.
Give her transamine injections to control bleeding also simultaneously.
Arrange for blood while giving her normal saline or dextrose with normal saline.

Diagnosis: Menorrhagia sec. to threatened abortion / incomplete abortion /ectopic pregnancy versus versus Dysfunctional uterine bleeding

9. Rachael N.K - August 2, 2013

The emergency physician should start by a quick assessment of airway, breathing and circulation.
Since the patient is pale, and hypotensive due to hemorrhage, intravenous normal saline should be given to expand the volume while blood samples for group and cross match to determine blood group, complete blood count should drawn in order to check packed cell volume, hemoglobin levels and in preparation for transfusion if indicated.Other tests include Either urine or Serum beta Human chorionic gonadotropin hormone levels should be assessed to rule out early pregnancy complications as cause of hemorrhage.
The airway should be supported and oxygen given by mask
A quick focused examination should be performed to determine the source of bleeding with emphasis on the abdominal and vaginal(speculum) to determine source of bleeding.
if the cause of bleeding is due to incomplete abortion, evacuation is indicated, if the cause is fibroids then intravenous estrogen four hourly for 24 hours followed by dilatation and curettage if ineffective.
definitive management will depend on underlying cause of hemorrhage which will be determined once bleeding has ceased and patient hemodynamic status has stabilized. This is when the secondary survey will be done with performance of head to toe exam

10. GS - August 2, 2013

ABC’s// type x match 4 u pRBC’s, CBC, Coag’s, INR, B-HCG, Fluids NS Wide Open, pressors @ need, O neg blood, FFP, Vit. K , ergotamine.

11. siva - August 5, 2013

after the initial care trying to stabilize the patient, I would prefer to go for intracavitary radio-therapy, if not, uterine artery embolization.

12. Dr. Brown - August 6, 2013

I would ask the EMS personnel to start two IV 18ga are larger. I would also ask the EMS to draw blood for type and cross match, CBC, PT, PTT, hang RL. Up on arrival I would order the test stat. Tale a history and examine the patient. Get and US of the pelvis do a pelvic exam. Transfuse the patient if the is short of breath, pale skin, hgb less than 8. hct less than 30, patient has air hunger. Try to precisely identify the cause and site of bleeding. Alert OR team to stand by if exam the tests indicate. I may try to suppress the bleeding with estrogen or progesterone as indicated by exam results.

13. Suresh Naidu a/l Nook Naidu - August 6, 2013

quick ABC as usual
TACHYCARDIC AND HYPOTENSIVE…that makes her C in trouble. oxygen and saline en route if possible…and meanwhile prepare to receive the patient …maybe emergency o blood group.. On arrival to ED ..reasses ABC…Draw blood for CBC, electrlytes group cross match, blood gas, urine for UPT,; Analgesic for pain, start group emergency uncrossmatched blood depending on situation, quick bed side ultrasongraphy …IV tranexamic acid stat and infusion. Update the gynes/obs on call…ask for input if needed…. for cxr or hormones if no contraindication

14. Dr Waheeb - August 15, 2013

Meanwhile be arrived to ED I need to :
1- Prepare me & staff ( gloves , gowns
2- prepare monitoring bed & equipments ( crash card , fluids , airway equipments , bloods – o negative )
3- activate blood bank pt may need massive BTF
4- activate OR

1- recheck VS & ABC stabilization
– Monitoring bed with cardiac monitor & pulse OX
– oxygen 100% high flow by non rebreathing mask if pt no need control by ETT
– tow large IV line NO 16 & taking blood sample for CBC , 6 typing & Cross matching , hCG, ABG, Lactate, Coagulation profile, RFT
– start 2 L NS bolus & one unit O neg packed RBCs
-bed side FAST US & pelvic US to exclude ectopic or intrauterine pregnancy
– Folly’s catheterization and urine pregnancy test
– vaginal exam and backing by compression
Frequent assess of VS & level of consciousness for any improvement or deterioration and correct it at any
Meanwhile waiting Gyn&Obs need to exclude ectopic pregnancy or early bleeding of pregnancy
If negative may can add estrogen IV to resuscitation with Gyn consultation

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