Abdomen, Pelvis, and Perineun

Management and Determining the Cause

Chief Complaint: Vaginal Bleeding

Patient Unstable

Hemodynamic instability refers to a state in which the circulatory system fails to provide adequate blood flow to organs and tissues, leading to insufficient oxygen delivery and potential organ dysfunction.

The signs and symptoms of hemodynamic instability include:

1. Vital Signs Abnormalities

Hypotension: Systolic blood pressure < 90 mmHg or a significant drop from baseline.
Tachycardia: Heart rate > 100 beats per minute.
Bradycardia (less common): Heart rate < 60 beats per minute, typically in severe cases.
Respiratory distress: Tachypnea (respiratory rate > 20 breaths per minute) or labored breathing.
Hypoxia: Low oxygen saturation (SpO2) < 90%.

2. Signs of Poor Organ Perfusion

Altered mental status: Confusion, agitation, lethargy, or unresponsiveness.
Cold, clammy skin: Due to vasoconstriction and poor peripheral perfusion.
Decreased urine output: Oliguria (< 0.5 mL/kg/hr) or anuria.
Weak or thready pulse: Indicative of reduced cardiac output.

3. Objective Findings

Elevated lactate levels: Reflecting tissue hypoperfusion.
Metabolic acidosis: Low bicarbonate or a high anion gap.
Decreased mixed venous oxygen saturation (SvO2): Suggests inadequate oxygen delivery or increased oxygen extraction.

4. Specific Clinical Manifestations

Chest pain or discomfort: May indicate myocardial ischemia or infarction.
Signs of shock:
- Hypovolemic shock: Signs of volume loss (e.g., bleeding, dehydration).
- Cardiogenic shock: Pulmonary edema, jugular venous distension.
- Septic shock: Fever, warm skin (early stages), or cold skin (late stages).
- Obstructive shock: Signs of tamponade, tension pneumothorax, or pulmonary embolism.

Immediate Action

++++++++++++++++++++++++

## Diagnostic Evaluation

To determine the cause of bleeding, the following tests may be conducted:

- Blood tests (complete blood count, coagulation profile, thyroid function)[5]
- Hormone level tests[5]
- Pelvic ultrasound or transvaginal ultrasound[5]
- Endometrial biopsy, if indicated[1]

## Medical Management

For most cases of acute abnormal uterine bleeding (AUB), medical management is the first-line treatment:

**Hormonal Options:**
- IV conjugated equine estrogen (for severe acute bleeding)[1][2]
- Combined oral contraceptives[1][2]
- Oral progestins[1][2]
- Levonorgestrel intrauterine system (for long-term management)[2]

**Non-hormonal Options:**
- Tranexamic acid[1][2][3]
- Nonsteroidal anti-inflammatory drugs (NSAIDs)[3][4]

**Other Treatments:**
- Iron supplementation for anemia[1][3]
- Antibiotics for infections[3]

## Surgical Management

Surgical intervention may be necessary in certain situations:

- Hemodynamic instability[1][2]
- Failure of medical management[1][2]
- Contraindications to medical therapy[1]
- Specific underlying conditions (e.g., fibroids, polyps)[2]

**Surgical options include:**
- Dilation and curettage (D&C)[1][2][4]
- Endometrial ablation[2][4]
- Uterine artery embolization (for fibroids)[4]
- Hysteroscopy with polypectomy or myomectomy[2]
- Hysterectomy (for those who no longer desire fertility)[1][4]

## Long-term Management

After controlling acute bleeding, focus shifts to preventing recurrence:

- Hormonal treatments (e.g., oral contraceptives, levonorgestrel IUD)[2][4]
- Addressing underlying causes (e.g., thyroid disorders, bleeding disorders)[1]
- Regular follow-up to monitor treatment efficacy[3]

Remember, the specific management plan should be tailored to each patient's individual circumstances, considering factors such as the severity of bleeding, underlying cause, and patient preferences.

Citations:
[1] https://www.ncbi.nlm.nih.gov/books/NBK470230/
[2] https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women
[3] https://medlineplus.gov/ency/article/007496.htm
[4] https://www.mayoclinic.org/diseases-conditions/menorrhagia/diagnosis-treatment/drc-20352834
[5] https://www.radiologyinfo.org/en/info/vaginalbleeding
[6] https://www.aafp.org/pubs/afp/issues/2012/0101/p35.html
[7] https://my.clevelandclinic.org/health/diseases/15428-uterine-bleeding-abnormal-uterine-bleeding

Pivotal Assessment	Finding
History	Mid-cycle spotting

The management of vaginal bleeding depends on several factors, including the underlying cause, severity of bleeding, patient's age, and desire for future fertility.