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Vaginal Bleeding

Pregnant or not? Stable or not? Those two answers run the show.

Open full pathway
Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

  1. Two questions: pregnant or not, stable or not.
  2. Resuscitate shock first. TXA within 3 h of PPH (WOMAN).
  3. No digital exam until previa is excluded by US.

2 · Escalate now if

  • Any bleeding with positive hCG and pain
  • Painless bright-red bleeding in later pregnancy (previa)
  • Painful rigid uterus with fetal distress (abruption)
  • Postpartum bleeding saturating pads rapidly
  • Orthostatic symptoms or hemodynamic instability
  • Bleeding on anticoagulation or with known bleeding disorder

3 · Immediate workup

  • Urine/serum hCG immediately in all patients of childbearing potential
  • POCUS; pad counting for quantification

4 · Don’t miss

  • Hemorrhagic shock from any source
    Resuscitate before diagnosing: two IVs, crossmatch. TXA within 3 h of PPH (WOMAN trial); TXA is also used for selected non-pregnant heavy bleeding.
  • Ectopic pregnancy
    Bleeding + pain + positive hCG — transvaginal US urgently.
  • Placenta previa
    Painless bright-red bleeding in later pregnancy — NO digital vaginal exam; US first.
  • Placental abruption
    Painful woody uterus, fetal distress — obstetric emergency, deliver.
  • Postpartum hemorrhage
    Uterine atony > retained tissue > trauma; uterotonics + bimanual compression pathway.

5 · Disposition lane

Admit

Ectopic per criteria, symptomatic miscarriage needing care, moderate bleeding with anemia, anticoagulation reversal issues.

Emergency obstetrics / OR / ICU

Placenta previa or abruption in viable pregnancy, postpartum hemorrhage, shock of any source, molar pregnancy.