Massive Vaginal Bleeding

Case

A 29 year-old female with cervical cancer unexpectedly decompensates secondary to massive vaginal hemorrhage. Hypotension and SVT ensue. The standard approach to management is simple: place 2 large bore IV lines (with central access obtained, if needed), begin fluid and blood resuscitation, and reverse any coagulopathy.  The question that remains is: how would you achieve hemostasis?

Generally, educational resources discuss the approach to the vaginally-bleeding pregnant patient with two different algorithms: the stable patient and the unstable patient. But, what about the massively bleeding patient who is not pregnant?

Much of what allows us, as Emergency Medicine practitioners, to act quickly under pressure is pattern recognition, algorithms and useful tips. Below, I will highlight certain tricks of the trade for achieving hemostasis of the massively hemorrhaging vaginal bleeder.

Traditionally, we are taught that for uterine bleeding, tamponade can be achieved by:

  • visualizing the cervix with speculum
  • grasp cervix with ring forceps to stabilize
  • sterilize the cervix by swabbing three times with iodine
  • place a foley catheter into the cervical os using ring forceps
  • inflate the foley balloon up to 30cc

In theory, this seems simple. However many people cannot visualize the cervix with massive bleeding, let alone precisely place a foley catheter through a bleeding os.  We must also consider that bleeding may not be coming from the uterus. This is when packing the vagina becomes a feasible temporizing hemostatic option.

Tamponade

Supplies and Technique

Kerlix and Surgilube.

kerlix

surgilube

The patient should be positioned with hips and knees flexed with
the knees falling to the sides. Kerlix (preferred so that when it is removed, no piece is left in the vagina) should be thoroughly lubricated and manually placed into the vagina until no further gauze can be placed.

What if the patient is persistently bleeding?

If the patient continues to bleed massively, packing can be removed and new packing can be coated with either 5000 U of thrombin in 5cc of saline (placed on the end of the kerlix that will most closely abut the cervix).  Or, you can soak kerlix in acetone and pack the vaginal cavity to help stop bleeding.

In 1993, Pastor published two case reports of patients with massive oncologic vaginal bleed controlled with acetone soaked gauze in the European Journal of Gynecologic Oncology. While the mechanism of action is unknown, it is thought that the acetone acts as an astringent when applied topically to bleeding tumors. He noted:

  • immediate control of hemorrhage
  • no immediate side effects other than pain.
  • no long-term adverse effects

While this was the only study published of its kind, multiple GYN attendings I have spoken with have used this method with success, and have noted no serious adverse events.

Antibiotics

It is recommended that any patient who has vaginal packing in place be covered with IV broad-spectrum antibiotics to prevent infection (including toxic shock syndrome) from foreign body. Both aerobes and anaerobes should be covered by the choice of antibiotics. (Maier, RC). Generally, packing should be removed within 24-36 hours. For a review on toxic shock syndrome, please click here.

Tranexamic Acid (TXA)

While there are no randomized controlled trials looking at the utility of TXA in massive vaginal bleed, there have been a few small trials of TXA in post-partum bleeding. These small (N<500 total), poor quality studies did demonstrate a significant reduction in post-partum blood loss in women treated with TXA.

Currently, the London School of Hygiene & Tropical Medicine (University of London), is launching the WOMAN (World Maternal Antifibrinolytic) Trial, a randomized, double-blind, placebo-controlled trial among women with a clinical diagnosis of post-partum hemorrhage.

Primary outcomes of the WOMAN Trial will be the effect of early administration of TXA to women with PPH on:

  • death rates
  • hysterectomy rates
  • and other morbidities (surgical interventions, blood transfusion and risk of non-fatal vascular events)

Presently, TXA is approved by the United States Food and Drug Association  (2009) for treatment of menorrhagia.   While there are no specific ACOG guidelines on administration of TXA in massive vaginal bleeding, it has been noted that “TXA effectively reduces intraoperative bleeding and the need for transfusion in surgical patients and is likely effective for patients with acute abnormal uterine bleeding, although it has not been studied for this indication” (ACOG Guidelines).

Specifically, 10mg/kg IV (max 600mg) could be given, however ACOG cautions using TXA in patients with potential thromboembolic disease.

Conclusions

Patients with massive vaginal bleeding can rapidly decompensate, and part of resuscitation must include hemostasis. It is often difficult to determine the source of bleeding. Vaginal packing may be the most effective hemostatic temporizing measure that can be performed in the ED. Adjuncts to packing may include Kerlix soaked with thrombin or acetone. There are no specific recommendations for use of TXA, however it may be considered as a last line intervention in a decompensating patient.

Special thanks to Swami for also editing this paper.

Editorial note: If you found this article informative, consider also checking out this post from January 2014 which delves into the differential for vaginal bleeding as well as treatment options for stable and unstable patients.

References / Further Reading

Edited by Adaira Landry, MD

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