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…
The bleeding 42-year-old woman was quite ill upon arrival to the ED, with blood pressure of 96/52 mm Hg, heart rate of 124 beats/min, respiratory rate of 17 breaths/ min and oxygen saturation of 97% on room air. Two large-bore peripheral IVs were placed, and fluid resuscitation with normal saline boluses was started. On physical exam, she was bleeding heavily from the cervical os, and her uterus was large, firm, and irregularly shaped. A pregnancy test was negative. You started treatment with conjugated equine estrogen 25 mg IV. Her initial CBC showed a hemoglobin of 6.8 g/dL, and she was transfused with 2 units of packed red blood cells. After receiving the normal saline boluses and packed red blood cells, there was improvement in her vital signs. Her bleeding began to slow, and after a second dose of IV estrogen 4 hours later, the bleeding stopped completely and she was admitted to the gynecology service in stable condition. As the patient had completed child-bearing and had had little success with medical management of her heavy bleeding in the past, she elected for hysterectomy, which was performed the next day.
Congratulations to Chris Stahmer, Anusha Chari, Joncheah, Shayne Calleja, and Rachael N.K. ? this month?s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Emergency Department Management Of Vaginal Bleeding In The Nonpregnant Patient. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!