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Emergency and Acute Medicine: Vaginal Bleeding
Vaginal bleeding is a common emergency department presentation with causes ranging from benign to life-threatening. A critical principle is that any woman of reproductive age must be assumed pregnant until proven otherwise, regardless of menstrual or sexual history. The differential diagnosis is broad and is best approached by categorizing causes into pregnancy-related and nonpregnancy-related conditions.
In pregnancy, causes vary by gestational age. In early pregnancy, serious conditions include Ectopic pregnancy, which occurs in about 2% of pregnancies and can be life-threatening, as well as various forms of abortion (threatened, incomplete, complete, missed, inevitable, or septic). Other causes include molar pregnancy and trauma. In later pregnancy, vaginal bleeding may be due to Placenta previa, Placental abruption, labor, or trauma. In the immediate postpartum period, life-threatening causes include postpartum hemorrhage, uterine inversion, retained placenta, and infection such as endometritis.
In nonpregnant patients, vaginal bleeding is most commonly due to dysfunctional uterine bleeding (DUB), often related to anovulation. Structural causes include uterine fibroids (leiomyomas), cervical or endometrial polyps, and pelvic tumors. Postmenopausal bleeding is particularly concerning and most commonly due to endometrial atrophy, though malignancy must always be considered. Less common causes include bleeding disorders such as Von Willebrand disease, infections, trauma, or foreign bodies.
Patients may present with symptoms of blood loss such as lightheadedness, fatigue, weakness, or syncope. A detailed history should assess the duration and quantity of bleeding, last menstrual period, pregnancy status, prior ectopic pregnancy, and passage of clots or tissue. Estimating blood loss can be aided by noting that a tampon holds about 5 mL and a pad 5–15 mL. Physical examination should include vital signs to assess hemodynamic stability, abdominal exam for masses or tenderness, and a pelvic exam to identify the source of bleeding and determine whether the cervical os is open or closed. Altered mental status may indicate severe blood loss.
The essential workup begins with a pregnancy test in all women of childbearing potential. In early pregnancy, evaluation includes quantitative β-hCG, ultrasound to confirm intrauterine pregnancy, hematocrit, and blood type with Rh status. Ultrasound findings must be interpreted in the context of β-hCG levels, using the discriminatory zone (≈1,000–1,500 mIU/mL for transvaginal ultrasound). In later pregnancy, fetal heart tones, ultrasound, and coagulation studies may be required, especially in suspected placental abruption. In postpartum patients, ultrasound helps identify retained products of conception.
Management priorities focus on stabilization. Patients with significant bleeding or hypotension require immediate resuscitation with oxygen, cardiac monitoring, and two large-bore IV lines for fluid resuscitation. Blood transfusion may be necessary if instability persists. In pregnant patients, positioning in the left lateral decubitus position helps prevent vena cava compression.
Treatment depends on the underlying cause. In early pregnancy, confirmed ectopic pregnancy may be managed with methotrexate or surgery depending on stability. Threatened miscarriage with confirmed intrauterine pregnancy can often be managed outpatient with close follow-up. Incomplete or septic abortions require obstetric consultation, with septic cases needing IV antibiotics and admission. In later pregnancy, placenta previa and placental abruption require urgent obstetric management and possible delivery. Postpartum hemorrhage may require uterine massage, removal of retained placenta, or surgical intervention.
In nonpregnant patients, treatment of DUB may include hormonal therapy such as medroxyprogesterone or combined oral contraceptives. Severe bleeding may be treated with intravenous conjugated estrogens. Structural causes require gynecologic evaluation, imaging, and sometimes surgical management.
Disposition depends on stability and diagnosis. Admission is required for unstable patients, ectopic pregnancy not meeting outpatient criteria, placental abruption, septic abortion, postpartum hemorrhage, or significant comorbidities. Stable patients with confirmed intrauterine pregnancy or mild nonpregnancy-related bleeding may be discharged with close follow-up, typically within 48 hours.
Key clinical pearls include always ruling out ectopic pregnancy in first-trimester bleeding, recognizing that menstrual history does not exclude pregnancy, and maintaining a high index of suspicion for life-threatening causes. Clear return precautions are essential, including worsening bleeding, abdominal pain, fever, dizziness, or syncope.
Vaginal bleeding is a common emergency department presentation with causes ranging from benign to life-threatening. A critical principle is that any woman of reproductive age must be assumed pregnant until proven otherwise, regardless of menstrual or sexual history. The differential diagnosis is broad and is best approached by categorizing causes into pregnancy-related and nonpregnancy-related conditions.
In pregnancy, causes vary by gestational age. In early pregnancy, serious conditions include Ectopic pregnancy, which occurs in about 2% of pregnancies and can be life-threatening, as well as various forms of abortion (threatened, incomplete, complete, missed, inevitable, or septic). Other causes include molar pregnancy and trauma. In later pregnancy, vaginal bleeding may be due to Placenta previa, Placental abruption, labor, or trauma. In the immediate postpartum period, life-threatening causes include postpartum hemorrhage, uterine inversion, retained placenta, and infection such as endometritis.
In nonpregnant patients, vaginal bleeding is most commonly due to dysfunctional uterine bleeding (DUB), often related to anovulation. Structural causes include uterine fibroids (leiomyomas), cervical or endometrial polyps, and pelvic tumors. Postmenopausal bleeding is particularly concerning and most commonly due to endometrial atrophy, though malignancy must always be considered. Less common causes include bleeding disorders such as Von Willebrand disease, infections, trauma, or foreign bodies.
Patients may present with symptoms of blood loss such as lightheadedness, fatigue, weakness, or syncope. A detailed history should assess the duration and quantity of bleeding, last menstrual period, pregnancy status, prior ectopic pregnancy, and passage of clots or tissue. Estimating blood loss can be aided by noting that a tampon holds about 5 mL and a pad 5–15 mL. Physical examination should include vital signs to assess hemodynamic stability, abdominal exam for masses or tenderness, and a pelvic exam to identify the source of bleeding and determine whether the cervical os is open or closed. Altered mental status may indicate severe blood loss.
The essential workup begins with a pregnancy test in all women of childbearing potential. In early pregnancy, evaluation includes quantitative β-hCG, ultrasound to confirm intrauterine pregnancy, hematocrit, and blood type with Rh status. Ultrasound findings must be interpreted in the context of β-hCG levels, using the discriminatory zone (≈1,000–1,500 mIU/mL for transvaginal ultrasound). In later pregnancy, fetal heart tones, ultrasound, and coagulation studies may be required, especially in suspected placental abruption. In postpartum patients, ultrasound helps identify retained products of conception.
Management priorities focus on stabilization. Patients with significant bleeding or hypotension require immediate resuscitation with oxygen, cardiac monitoring, and two large-bore IV lines for fluid resuscitation. Blood transfusion may be necessary if instability persists. In pregnant patients, positioning in the left lateral decubitus position helps prevent vena cava compression.
Treatment depends on the underlying cause. In early pregnancy, confirmed ectopic pregnancy may be managed with methotrexate or surgery depending on stability. Threatened miscarriage with confirmed intrauterine pregnancy can often be managed outpatient with close follow-up. Incomplete or septic abortions require obstetric consultation, with septic cases needing IV antibiotics and admission. In later pregnancy, placenta previa and placental abruption require urgent obstetric management and possible delivery. Postpartum hemorrhage may require uterine massage, removal of retained placenta, or surgical intervention.
In nonpregnant patients, treatment of DUB may include hormonal therapy such as medroxyprogesterone or combined oral contraceptives. Severe bleeding may be treated with intravenous conjugated estrogens. Structural causes require gynecologic evaluation, imaging, and sometimes surgical management.
Disposition depends on stability and diagnosis. Admission is required for unstable patients, ectopic pregnancy not meeting outpatient criteria, placental abruption, septic abortion, postpartum hemorrhage, or significant comorbidities. Stable patients with confirmed intrauterine pregnancy or mild nonpregnancy-related bleeding may be discharged with close follow-up, typically within 48 hours.
Key clinical pearls include always ruling out ectopic pregnancy in first-trimester bleeding, recognizing that menstrual history does not exclude pregnancy, and maintaining a high index of suspicion for life-threatening causes. Clear return precautions are essential, including worsening bleeding, abdominal pain, fever, dizziness, or syncope.
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