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Category: Special Populations

Topic: Gynecology

Level: EMR

Next Unit: Female Reproductive System A&P

13 minute read

Gynecological emergencies may include

  • sexual assault,
  • infections and sexually transmitted diseases,
  • ectopic pregnancy, rupture, and internal hemorrhage,
  • and complications from GYN surgery.

Each of these can present as vaginal bleeding. There are, however, both innocuous causes of vaginal bleeding as well as serious causes.


Innocuous Causes of Vaginal Bleeding

  • dysfunctional uterine bleeding (hormonal causes),
  • vaginitis (yeast and other mild bacterial infections),
  • ovarian cysts,
  • irregular bleeding from oral contraceptives,
  • cervicitis (infection of the cervix), and
  • atrophic vaginitis (menopausal condition in which the tissue becomes thin and delicate).


Serious Causes of Vaginal Bleeding

  • uterine fibroids,
  • threatened miscarriage,
  • ectopic pregnancy,
  • ruptured ovarian cyst (although most are not "serious")
  • post-abortion and post-operative complications,
  • vaginal foreign body,
  • uterine foreign body (i.e., IUD),
  • sexually transmitted diseases (STDs),
  • sexual assault and trauma, and
  • GYN malignancies.

Both the innocuous and serious causes may be accompanied by itching or burning sensations, burning during urination, foul odors and discharge, abdominal pain, pain with intercourse, and even fever.


Designed for Blood Loss

The female physiology is designed, evolutionarily, for blood loss--that is, making as much blood via the bone marrow as the amount lost in the menstrual cycle. When does vaginal bleeding become life-threatening? Fudd's Law, tongue-in-cheek, states,

"If you push something hard enough, it will fall over."

Likewise, if a woman cannot make blood fast enough to keep up with what is lost, the outcome will be no different from any other hemorrhagic emergency.

Chronic bleeding from fibroids, although usually stable, can cross this line. The menstrual cycle is designed with bleeding a part of it, but any bleeding--acute or chronic--can result in hypovolemic shock if a balance of blood manufacture via the bone marrow (erythropoiesis) does not keep up with the amount of blood loss over time. Also, the maintenance of blood creation vs blood loss balance only works with chronic blood loss. Acute blood loss is always faster than erythropoiesis.


Postoperative Bleeding

In the postoperative period, any vaginal bleeding should be considered dangerous. The most common time for complications to ensue after GYN surgery is during the first post-op week. GYN surgeries include

  • hysterectomy,
  • laparoscopy,
  • appendectomy,
  • ovarian cystectomy,
  • removal of uterine fibroids (myomectomy),
  • endometriosis surgery,
  • tubal ligation, and
  • elective abortion.


Assessment of Vaginal Bleeding

Asking "How many pads or tampons were soaked each hour?" is the best way to estimate vaginal blood loss, which is the only objective quantitation. Patients often exaggerate the amount of bleeding they have, since blood spreads fairly wide on bedsheets, the site of which is disturbing to the patient. They will use words like "flooding," hemorrhage, and other references, which should be ignored in lieu of a pad or tampon count/hour (anything more than one per hour is too much).  


Psychological Impact of Vaginal Bleeding

Vaginal bleeding is often a difficult time for any woman, regardless of the cause, and may result in embarrassment, poor self-image, and withdrawal from social interactions until after resolution of the bleeding.

To wit:

a woman experiencing severe, life-threatening vaginal bleeding may be reluctant to call for help due to the personal nature of the anatomy involved.

Likewise, sexual assault, with its accompanying emotional lability, may delay a woman seeking care.


Management of Vaginal Bleeding

During vaginal bleeding, as with any bleeding, an assessment of the patient should be performed with a concentration on signs of shock and whether or not the patient presents with pain. If the patient is conscious and stable, a history can help direct the next steps by identifying risk factors such as recent surgery, pregnancy, and hormonal considerations.

Pain and bleeding in any reproductive-aged woman should always include suspicion of ectopic pregnancy.

In the field, because the causes of any life-threatening vaginal bleeding/hemorrhage are anatomically and functionally internal, there is not much you can do to stop it. You can't pack the vagina, and even this would not stop the bleeding (the packing would just fall out along with the accrued blood from behind it). 

Call to Action: TRANSPORT.

Instead, management of vaginal bleeding includes standard precautions as with any bleeding:

the administration of oxygen and proper patient positioning.

During gynecological emergencies, every effort should be made to protect patient privacy and modesty. Communication techniques should be applied. Because of the sensitive nature of pregnancy-related or sexual problems, one should try to get as much information as possible without making others present (often unavoidable) jump to conclusions that may make the emotional environment explosive, i.e., implications of infidelity or promiscuity. The EMS provider should always consider pregnancy and/or sexually transmitted diseases as the underlying cause.

Management of chronic vaginal bleeding may include pharmacological treatments, such as iron or folic acid, depending on the clinical condition (i.e., stability) of the patient. Such management can only be pursued once stability has been assured. Before that, management of acute vaginal bleeding with signs of hypovolemia (tachycardia, hypotension) requires rapid transport