IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS
ABNORMAL VAGINAL BLEEDING
See Table 38–1. Patients with active vaginal bleeding are at risk of exsanguination and require immediate evaluation and treatment.
Table 38–1.Causes of abnormal vaginal bleeding. ||Download (.pdf) Table 38–1. Causes of abnormal vaginal bleeding.
Premenarcheal Vaginal Bleeding
Tumor (vaginal, uterine)
Reproductive Age Bleeding
Variations in normal cycle
Hypermenorrhea (excessive bleeding at time of period)
Polymenorrhea (menstrual periods <21 d apart)
Metrorrhagia (irregular period)
Pregnancy (including ectopic)
Endocrine abnormality (idiopathic, estrogens, thyroid)
Coagulopathy (factor VIII deficiency, von Willebrand disease)
Malignant neoplasm or polyps (cervical, vaginal, uterine)
Myoma of uterus
Carcinoma (cervical, uterine)
Emergency Evaluation and Treatment
A. Assess for Hemodynamic Instability
Examine the patient for hypotension or tachycardia due to depletion of intravascular volume.
If blood pressure and pulse are normal in the supine position, measure them in the sitting position. If they are still normal, measure them in the standing position to detect more subtle volume depletion. Supine or postural hypotension can indicate life-threatening hemorrhage.
Tachycardia while the patient is resting or when he or she assumes the upright posture also may indicate vascular depletion; however, it is important to recognize that a pregnant woman in her third trimester may have a normal resting heart rate that is faster than her nonpregnant state.
3. Poor peripheral perfusion
Cool, mottled skin, and delayed capillary refill may indicate significant volume loss.
B. Treat Shock, If Present
Insert at least two large-bore (≥16-gauge) intravenous (IV) catheters. A central venous catheter may be preferable if peripheral venous access is not readily obtainable. Intraosseous access is an acceptable alternative (Chapter 8).
Determine the amount of blood loss and draw blood for (a) typing and cross-matching (reserve 4 units of fresh frozen plasma and 2–4 units of packed red cells), (b) platelet count, prothrombin time, and partial thromboplastin time to uncover any bleeding abnormality, (c) complete blood count (CBC), (d) renal function tests and measurement of serum electrolytes, and (e) blood gas measurements and pH (useful in assessing adequacy of ventilation and perfusion).
Insert a Foley catheter.
If the patient is of childbearing age, obtain a serum or urinary pregnancy test.
Begin rapid infusion of crystalloid solution (Ringer’s solution or normal saline), the rate depending on vital signs (eg, 200–1000 mL/h), to restore intravascular volume and maintain blood pressure until compatible blood becomes available for transfusion.