Clinical Pathways
Clinical Pathways
Hemodynamically unstable
Hemodynamically unstable

Hemodynamically unstable

View The Full Pathway

Action

  • Initiate resuscitation (IV access, crystalloid fluid [Class II], consider blood transfusion)
  • Check CBC and PT/INR
  • Obtain emergent gynecology consult

Decision

Active bleeding?

Yes

  • Estrogen 25 mg IV q4 hr (Class II)
  • Consider intrauterine balloon tamponade (Class III)
  • Obtain emergency gynecology consult

Background

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References
  1. Munro MG, Critchley HOD, Fraser IS. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018;143(3):393-408. (Practice guidelines) DOI: 10.1002/ijgo.12666
  2. Levy-Zauberman Y, Pourcelot AG, Capmas P, et al. Update on the management of abnormal uterine bleeding. J Gynecol Obstet Hum Reprod. 2017;46(8):613-622. (Practice guidelines) DOI: 10.1016/j.jogoh.2017.07.005
  3. ACOG committee opinion no. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013;121(4):891-896. (Practice guidelines)
  4. Gupta J, Kai J, Middleton L, et al. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013;368(2):128-137. (Randomized controlled trial; 571 patients)
  5. Kaunitz AM, Bissonnette F, Monteiro I, et al. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116(3):625-632. (Randomized controlled trial; 165 patients)
  6. Lukes AS, Moore KA, Muse KN, et al. Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116(4):865-875. (Randomized controlled trial; 115 patients)
  7. Jensen JT, Parke S, Mellinger U, et al. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol.2011;117(4):777-787. (Randomized controlled trial; 165 patients)
  8. Deneris A. PALM-COEIN nomenclature for abnormal uterine bleeding. J Midwifery Womens Health. 2016;61(3):376-379. (Guideline)
  9. Wouk N, Helton M. Abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2019;99(7):435-443. (Practice guideline)
  10. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012;120(1):197-206. (Practice guideline)
  11. Haamid F, Sass AE, Dietrich JE. Heavy menstrual bleeding in adolescents. J Pediatr Adolesc Gynecol. 2017;30(3):335-340. (Clinical recommendations)
  12. Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3-13. (Practice guideline)
  13. Kaunitz AM. Abnormal uterine bleeding in reproductive-age women. JAMA. 2019;321(21):2126-2127. (Practice guideline)
  14. Cheong Y, Cameron IT, Critchley HOD. Abnormal uterine bleeding. Br Med Bull.2017;123(1):103-114. (Review)
  15. Toth M, Patton DL, Esquenazi B, et al. Association between Chlamydia trachomatis and abnormal uterine bleeding. Am J Reprod Immunol. 2007;57(5):361-366. (Cross-sectional study; 92 patients)
  16. Kamer SM, Foley KF, Schmidt RL, et al. Analytical sensitivity of four commonly used hCG point of care devices. Clin Biochem. 2015;48(6):448-452. (Comparative study)
  17. Moghazy D, Al-Hendy O, Al-Hendy A. Krukenberg tumor presenting as back pain and a positive urine pregnancy test: a case report and literature review. J Ovarian Res.2014;7:36. (Case report)
  18. Gottlieb M, Wnek K, Moskoff J, et al. Comparison of result times between urine and whole blood point-of-care pregnancy testing. West J Emerg Med. 2016;17(4):449-453. (Prospective, observational study; 265 patients)
  19. Dyne PL, Miller TA. The patient with non-pregnancy-associated vaginal bleeding. Emerg Med Clin North Am. 2019;37(2):153-164. (Review)
  20. DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding--a double-blind randomized control study. Obstet Gynecol. 1982;59(3):285-291. (Double-blind randomized control study; 36 patients)
  21. Francois KE, Foley MR. Antepartum and postpartum hemorrhage. In: Landon MB, Galan HJ, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Philadelphia, PA: Elsevier; 2012:415-444. (Textbook chapter)
  22. James AH, Kouides PA, Abdul-Kadir R, et al. Evaluation and management of acute menorrhagia in women with and without underlying bleeding disorders: consensus from an international expert panel. Eur J Obstet Gynecol Reprod Biol. 2011;158(2):124-134. (Expert consensus)
  23. Borhart J. Emergency department management of vaginal bleeding in the nonpregnant patient. Emerg Med Pract. 2013;15(8):1-20. (Review)
  24. Bradley LD, Gueye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol. 2016;214(1):31-44. (Review)
  25. Lethaby A, Wise MR, Weterings MA, et al. Combined hormonal contraceptives for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;2(2):CD000154. (Cochrane review; 8 randomized controlled trials, 805 participants)
  26. Shaaban MM, Shabaan MM, Zakherah MS, et al. Levonorgestrel-releasing intrauterine system compared to low dose combined oral contraceptive pills for idiopathic menorrhagia: a randomized clinical trial. Contraception. 2011;83(1):48-54. (Single-center, open, randomized clinical trial; 112 patients)
  27. Endrikat J, Shapiro H, Lukkari-Lax E, et al. A Canadian, multicentre study comparing the efficacy of a levonorgestrel-releasing intrauterine system to an oral contraceptive in women with idiopathic menorrhagia. J Obstet Gynaecol Can. 2009;31(4):340-347. (Prospective randomized open-label study; 39 patients)
  28. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013;121(4):891-896. (Practice guidelines)
  29. Bofill Rodriguez M, Lethaby A, Low C, et al. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;8(8):CD001016. (Cochrane review; 15 randomized controlled trials, 1071 women) DOI: 10.1002/14651858.CD001016.pub3
  30. Munro MG, Mainor N, Basu R, et al. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2006;108(4):924-929. (Randomized controlled trial; 40 patients)
  31. Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316(19):2025-2035. (Practice guideline)
  32. Bofill Rodriguez M, Lethaby A, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;9(9):CD000400. (Cochrane review; 19 randomized controlled trials, 759 women)
  33. Ylikorkala O, Pekonen F. Naproxen reduces idiopathic but not fibromyoma-induced menorrhagia. Obstet Gynecol. 1986;68(1):10-12. (Double-blind placebo-controlled trial; 25 patients)
  34. Reid PC, Virtanen-Kari S. Randomised comparative trial of the levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia: a multiple analysis using total menstrual fluid loss, menstrual blood loss and pictorial blood loss assessment charts. BJOG. 2005;112(8):1121-1125. (Randomized controlled clinical trial; 51 patients)
  35. Bryant-Smith AC, Lethaby A, Farquhar C, et al. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2018;4(4):CD000249. (Cochrane review; 13 randomized controlled trials, 1312 participants)
  36. de Bruijn AM, Ankum WM, Reekers JA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial. Am J Obstet Gynecol. 2016;215(6):745. (Randomized controlled trial; 177 patients)
  37. De Crem N, Peerlinck K, Vanassche T, et al. Abnormal uterine bleeding in VTE patients treated with rivaroxaban compared to vitamin K antagonists. Thromb Res.2015;136(4):749-753. (Review)
  38. Agnelli G, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med. 2013;368(8):699-708. (Randomized double-blind comparative study; 2482 patients)
  39. Weitz JI, Lensing AWA, Prins MH, et al. Rivaroxaban or aspirin for extended treatment of venous thromboembolism. N Engl J Med. 2017;376(13):1211-1222. (Randomized placebo-controlled multicenter comparative study; 3365 patients)
  40. Weaver J, Shoaibi A, Truong HQ, et al. Comparative risk assessment of severe uterine bleeding following exposure to direct oral anticoagulants: a network study across four observational databases in the USA. Drug Saf. 2021;44(4):479-497. (Retrospective comparative study; 363,919 women)
  41. Male C, Lensing AWA, Palumbo JS, et al. Rivaroxaban compared with standard anticoagulants for the treatment of acute venous thromboembolism in children: a randomised, controlled, phase 3 trial. Lancet Haematol. 2020;7(1):e18-e27. (Randomized controlled trial; 500 children)
  42. Maher P, Taub E. Emergency department management of patients taking direct oral anticoagulant agents. Emerg Med Pract. 2019;21(8):1-28. (Review)
  43. McCaskill A, Inabinet CF, Tomlin K, et al. Prepubertal genital bleeding: examination and differential diagnosis in pediatric female patients. J Emerg Med. 2018;55(4):e97-e100. (Case report and practice guidelines)
  44. Howell JO, Flowers D. Prepubertal vaginal bleeding: etiology, diagnostic approach, and management. Obstet Gynecol Surv. 2016;71(4):231-242. (Review)
  45. Lopez HN, Focseneanu MA, Merritt DF. Genital injuries acute evaluation and management. Best Pract Res Clin Obstet Gynaecol. 2018;48:28-39. (Review) DOI: 10.1016/j.bpobgyn.2017.09.009
  46. Spitzer RF, Kives S, Caccia N, et al. Retrospective review of unintentional female genital trauma at a pediatric referral center. Pediatr Emerg Care. 2008;24(12):831-835. (Review)
  47. Lethaby A, Hussain M, Rishworth JR, et al. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev.2015(4):CD002126. (Cochrane review; 21 randomized controlled trials, 2082 women) DOI: 10.1002/14651858.CD002126.pub4
  48. Schlaff WD, Ackerman RT, Al-Hendy A, et al. Elagolix for heavy menstrual bleeding in women with uterine fibroids. N Engl J Med. 2020;382(4):328-340. (Review)

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