Cannot miss / life threats
Cannot miss / life threats
Diagnostic flow — check first
Diagnostic flow — check first
- β-hCG FIRST in any reproductive-age female — pregnancy changes the entire workup.
- Unstable + positive β-hCG → assume ruptured ectopic until proven otherwise (FAST/TVUS, OB STAT, OR).
- Late-pregnancy bleeding → US to rule out previa BEFORE any digital/speculum exam.
- Postpartum + heavy bleeding → 4 T's (Tone, Trauma, Tissue, Thrombin); uterine massage + oxytocin + TXA.
- Postmenopausal bleeding → endometrial cancer workup (TVUS endometrial stripe + biopsy).
- Heavy bleeding + anticoagulant or known coagulopathy → reverse, replace, hematology consult.
Differential diagnosis — checklist
0/23
Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.
Pregnancy-related (always β-hCG first)0/7
Non-pregnant — structural (PALM)0/4
Non-pregnant — non-structural (COEIN)0/5
Infectious / inflammatory0/3
Pediatric0/4
Initial ED workup
Bedside0/4
- Vitals + orthostatics; assess for shock
- β-hCG (urine then quantitative serum) in any reproductive-age female
- Pelvic / speculum exam (defer digital exam in late-pregnancy bleeding until previa excluded)
- Bedside pelvic / TVUS if available
Labs0/6
- CBC, type & screen (type & cross if heavy / unstable)
- Quantitative β-hCG
- Rh type
- PT/INR/PTT, fibrinogen
- TSH, prolactin if chronic AUB
- GC/Chlamydia NAAT if infection suspected
Imaging0/3
- Transvaginal US — first-line for early pregnancy bleeding and AUB
- Transabdominal US for late-pregnancy bleeding (rule out previa BEFORE digital exam)
- CT if trauma or hemodynamic instability
Initial management0/5
- 2 large-bore IVs, IV crystalloid, blood products if unstable; activate MTP if hemorrhagic shock
- TXA 1 g IV for heavy bleeding (especially PPH)
- Rh-negative + bleeding in pregnancy → RhoGAM 300 µg IM (50 µg if <12 wk)
- Emergent OB consult: ruptured ectopic, PPH, abruption, previa, unstable patient
- Heavy non-pregnant AUB: high-dose estrogen (Premarin 25 mg IV q4h × 24 h) or combined OCP taper; tranexamic acid 1.3 g PO TID
ED next steps
ED next steps
- ABCs, 2 large-bore IVs, vitals + orthostatics; activate MTP if hemorrhagic shock.
- Urine β-hCG immediately; if positive → quantitative serum β-hCG, type & screen, TVUS.
- Pelvic / speculum exam (defer digital exam in late-pregnancy bleeding until previa excluded by US).
- Labs: CBC, type & screen/cross, PT/INR/PTT, fibrinogen, Rh type.
- Rh-negative + any pregnancy-related bleeding → RhoGAM.
- TXA 1 g IV for heavy bleeding; uterotonics for PPH (oxytocin → methylergonovine → carboprost → misoprostol).
- OB consult for any pregnancy-related bleeding, PPH, or hemodynamic instability.
- Postmenopausal bleeding → outpatient TVUS + endometrial biopsy referral.
- Disposition: admit if unstable, transfusion needed, or pregnancy complication; discharge stable AUB with gyn follow-up.
Pearls / pitfalls
Pearls
- Any reproductive-age female with vaginal bleeding gets a β-hCG — no exceptions.
- Postmenopausal bleeding is endometrial cancer until proven otherwise.
- In late-pregnancy bleeding: US BEFORE digital exam (placenta previa).
- Painful bleeding + rigid uterus = abruption; painless bright-red = previa.
- Don't forget Rh status — give RhoGAM to all Rh-negative patients with pregnancy-related bleeding.