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Vaginal Bleeding

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

LearnQuick referenceClinical practice

Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobPregnant or not? Stable or not? Those two answers run the show.

  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.
  4. Anti-D depends on gestation and event: follow current obstetric guidance; it is not routinely required for every pregnancy loss before 12 weeks. Abruption is clinical.

Vaginal bleeding splits cleanly by pregnancy status.

In pregnancy: ectopic, miscarriage, molar, placenta previa (no vaginal exam!), abruption, and postpartum hemorrhage. Outside pregnancy: anovulatory bleeding, fibroids, cervicitis, malignancy — with coagulopathy and massive bleeding managed first.

Hemorrhagic shock from any source Critical

Key: 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 Critical

Key: Bleeding + pain + positive hCG — transvaginal US urgently.

Placenta previa Critical

Key: Painless bright-red bleeding in later pregnancy — NO digital vaginal exam; US first.

Placental abruption Critical

Key: Painful woody uterus, fetal distress — obstetric emergency, deliver.

Postpartum hemorrhage Critical

Key: Uterine atony > retained tissue > trauma; uterotonics + bimanual compression pathway.

Retained products / molar pregnancy Emergent

Key: US; molar = preeclampsia-before-20-weeks picture, oncology referral.

Anovulatory bleeding / fibroids / cervicitis Common

Key: Common non-pregnant causes; measure hemoglobin burden.

Bleeding disorder / anticoagulation Common

Key: vWD and coagulopathy hide in “heavy periods” — ask since menarche.

Tick what your patient has — the banner updates as you go.

Pregnant? LMP, contraception; volume of bleeding (pads/hour, clots, dizziness)

Pregnancy stage & prior ultrasounds; trauma (abruption)

Postpartum timing (atony vs retained tissue vs infection)

Non-pregnant

cycle pattern, intermenstrual or post-coital bleeding, anticoagulants, bleeding since menarche

Vitals & orthostatics; signs of shock

Abdomen

fundal height if pregnant, tenderness, contractions

Speculum exam (avoid digital if previa suspected) — source: cervix vs uterine

Postpartum

uterine tone, ongoing loss

Bedside

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

Labs

  • CBC, type & screen/crossmatch, Rh status (anti-D for Rh-negative unsensitized patients per pathway); Kleihauer-Betke only if significant fetomaternal hemorrhage is a question
  • Coagulation ± DIC panel in abruption/PPH; quantitative β-hCG; TSH for non-pregnant chronic patterns

Imaging

  • Transvaginal US in pregnancy: IUP vs ectopic, previa, abruption signs
  • US pelvis for non-pregnant structural causes
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Non-pregnant, hemodynamically stable, mild anemia with follow-up (gynecology ± iron therapy); threatened miscarriage with viable IUP and reliable care.

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.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Vaginal Bleeding:
    • 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. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Two questions run the show: pregnant or not, stable or not.
  • Painless bright-red third-trimester bleeding = previa until US says otherwise — no digital exam.
  • TXA reduces PPH death when given within 3 hours (WOMAN).
  • PALM-COEIN organizes non-pregnant AUB; coagulopathy (including vWD) hides in “heavy periods since menarche.”

Pitfalls

  • Never do a digital exam when previa is possible — ultrasound first, always. Speculum exam is for obstetrics once previa is excluded or in a controlled setting.
  • A normal early hematocrit reassures falsely — the bleed is ongoing.
  • Anti-D is event- and gestation-specific. ACOG 2024 suggests forgoing routine Rh testing/RhIg for abortion or pregnancy loss before 12 weeks; do not extend this to every ectopic, trauma, or later-pregnancy event. Follow the local obstetric pathway. Kleihauer-Betke quantifies fetomaternal hemorrhage when indicated.
  • Post-coital bleeding in an older patient = cervical cancer screen.
  • Postpartum “lochia” turning bright red with clots is a hemorrhage, not normal.
  • Ultrasound is insensitive for abruption — the diagnosis is clinical (painful woody uterus, fetal distress).
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Acute Pelvic Pain (Women)ShockAbdominal Pain

Selected guidance · source check 2026-09-07. These 2 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — vaginal bleeding
  • ACOG Practice Bulletins (previa, abruption, PPH)
  • WOMAN trial (Lancet 2017) — TXA in PPH; FIGO PALM-COEIN; RCOG guidance
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