Synopsis
Recognise dangerous uterine bleeding, resuscitate while excluding pregnancy and extrauterine sources, use haemostatic medicines safely in stable patients, and escalate without delay to tamponade, radiology or surgery when bleeding continues.
- Estimate physiological severity before counting pads: observations, consciousness, perfusion, urine output, ongoing visible loss and comorbidity determine urgency.
- Ask last normal period and obtain a consented pregnancy test early, but never delay resuscitation or theatre for an unstable suspected pregnancy haemorrhage.
- Confirm the source with focused abdominal and consented speculum examination when stable enough; avoid digital vaginal examination in later-pregnancy bleeding until placenta praevia is addressed.
- Obtain two large-bore cannulas, full blood count, group-and-save or crossmatch, renal and liver profile, coagulation and fibrinogen under the major-haemorrhage pathway, with venous gas and lactate when unwell.
- Haemoglobin can remain initially normal in acute blood loss; transfusion and haemorrhage activation are driven by physiology, ongoing loss and anticipated control, not a delayed number alone.
- For a haemodynamically stable non-pregnant patient without contraindication, tranexamic acid and an appropriate hormonal regimen can reduce bleeding while cause and definitive follow-up are arranged.
- A licensed oral norethisterone regimen for dysfunctional uterine bleeding is 5 mg three times daily for 10 days, but exclude pregnancy and major thrombotic or hepatic contraindications before use.
- Oral tranexamic acid for heavy menstrual bleeding is 1 g three times daily for up to four days from the onset of heavy loss; renal impairment and thrombotic history modify safety.
- If bleeding persists or the patient is unstable, senior options include uterine tamponade, hysteroscopy with treatment, evacuation for retained tissue, uterine artery embolisation or surgery according to cause and fertility goals.
- After control, treat iron deficiency, establish the PALM-COEIN cause, review anticoagulation collaboratively and provide a written plan for recurrence.
Key red flags
A positive or uncertain pregnancy test changes the emergency differential to ectopic pregnancy, miscarriage, retained tissue, trophoblastic or placental bleeding and requires the appropriate obstetric pathway.
Tachycardia, hypotension, narrow pulse pressure, delayed capillary refill, oliguria, altered mentation or rising lactate signals tissue hypoperfusion even before haemoglobin falls.
Severe unilateral pain, peritonism, shoulder-tip pain or collapse raises intraperitoneal bleeding and should not be managed as isolated heavy menstruation.
Fever, offensive discharge, recent uterine procedure, postpartum state or marked tenderness raises uterine infection or sepsis and requires antimicrobial and source-control planning.
Anticoagulant exposure, thrombocytopenia, liver disease or inherited bleeding disorder may amplify loss and needs urgent haematology-informed reversal or replacement without delaying local control.
Bleeding continuing despite resuscitation and appropriate medication requires immediate procedural escalation rather than repeated outpatient-dose prescriptions.
Tachycardia, pallor, dizziness and delayed refill can precede hypotension and a haemoglobin fall, especially in a young otherwise healthy patient.
Investigation priorities
Determine haemorrhage severity and response to resuscitation in real time.
Management branches
Uterine bleeding accompanies shock, hypoperfusion, ongoing flooding or rapid deterioration.
- Activate ABCDE, major-haemorrhage and senior gynaecology and anaesthetic support, establish large-bore access, warm the patient and send urgent crossmatched bloods.
- Establish pregnancy status and likely anatomical source without delaying transfer to theatre, embolisation or pregnancy-specific surgery when clinically compelling.
- Use blood components, tranexamic acid or reversal under the local protocol and move to mechanical or operative haemostasis if loss continues.
Bleeding is substantial but observations and perfusion remain stable and pregnancy is excluded.
- Obtain full blood count, group-and-save and focused examination, and review thrombosis, liver, kidney, contraceptive and medicine factors.
- Offer oral tranexamic acid and an appropriate hormonal regimen such as licensed norethisterone when indicated and safe, with exact duration and stop advice.
- Arrange timely ultrasound, hysteroscopy or specialist review and escalate immediately if flooding, pain, symptoms or physiology worsens despite treatment.