Unstable Patients

Life threatening acute vaginal bleeding is rare in non-pregnant patients^2,13,21 but can occur, particularly in the context of trauma or a uterine arteriovenous malformation.¹⁷ Patients should have initial resuscitation as per any other unstable bleeding patient:

• ABCDE assessment and interventions including activation of major transfusion protocol if indicated.¹⁷
• Urgent ED gynaecology referral.^4,17,21
• First line treatment for vaginal bleeding in unstable, non-pregnant patients is with high dose IV oestrogen to promote rapid endometrial regrowth.^17,21
  • Although first line treatment, this may not be immediately available in ED. In addition, ED practitioners are unlikely to be familiar with IV oestrogen and so this treatment should be led by the gynaecology team.
• Rarely, uterine tamponade may be required for uncontrolled uterine bleeding.
  • Specific devices are available for controlling uterine haemorrhage, e.g. Bakri Balloon, but they may not be available in the ED.
  • If these are not available, pass a foley catheter through the cervix and inflate the balloon^4,13,17 or alternatively pack the uterus with long continuous gauze.¹³ This must be done with a speculum, under sterile conditions⁴ and with sufficient analgesia.
  • If it is not possible to visualise the cervix due to ongoing bleeding, or the bleeding is from the vagina itself, the vaginal vault can be packed with either commercially available vaginal packing or lubricated continuous gauze.⁴ The gauze may be soaked in tranexamic acid as an adjunct.⁴
• If other interventions are unsuccessful, there may be a role for IV tranexamic acid.¹⁷