Acute Heavy Uterine Bleeding

Acute heavy uterine bleeding is an episode of heavy menstrual bleeding in a woman of reproductive age, severe enough to need urgent intervention to prevent further blood loss. It may or may not occur on a background of chronic abnormal bleeding.

Causes are anovulation, fibroids, adenomyosis, polyps, bleeding disorders, anticoagulants, retained pregnancy tissue, caesarean scar niche, arteriovenous malformation and cancer. It matters because it may cause shock and need transfusion, and it has several treatments that stop bleeding quickly.

• Risk factors: anovulation (adolescents and perimenopause), bleeding disorders, fibroids, anticoagulants, previous pregnancy, caesarean scar, coagulopathy, thrombocytopenia.
• Pregnancy complications must be excluded first.
• Hormonal treatment stops the bleeding in most women.

Women have profuse vaginal bleeding with clots, soaking a pad every 1 to 2 hours, dizziness, palpitations, pallor, breathlessness and sometimes collapse. Pulse is fast and blood pressure may be low.

• Pulse above 100 per minute, systolic pressure below 100 mmHg in significant loss.
• Pale conjunctivae, cool peripheries, bleeding on speculum examination.
• Differential diagnosis: anovulatory bleeding, fibroids, adenomyosis, endometrial polyp, retained products or miscarriage, ectopic pregnancy, caesarean scar niche or defect, arteriovenous malformation, endometrial or cervical cancer, coagulopathy, anticoagulant effect, thrombocytopenia, trauma.
• Complications: haemorrhagic shock, severe anaemia, need for transfusion, hysterectomy, kidney injury, death.

The approach is concurrent resuscitation and assessment of the cause.

• Pulse, blood pressure, respiratory rate, oxygen saturation, urine output; speculum and bimanual examination to assess bleeding from the cervix, vagina or uterus and to remove clots.
• Urine hCG (a positive test needs ultrasound for miscarriage or ectopic pregnancy); full blood count, platelets, ferritin, prothrombin time, activated partial thromboplastin time, fibrinogen, urea, creatinine, group and cross-match 2 to 4 units; thyroid stimulating hormone.
• Transvaginal ultrasound with colour Doppler for retained tissue, fibroids, adenomyosis, malformation and endometrial thickness.
• Endometrial sampling or hysteroscopy once stable, if age is 45 years or above or risk factors are present.

The principle is to resuscitate, stop the bleeding with tranexamic acid and a high dose hormone, use a balloon or surgery if this fails, and plan treatment of the cause.

Supportive.

• Call for senior help.
• Place two large-bore cannulae.
• Give Ringer's lactate 1 to 2 litres rapidly for shock, and oxygen 10 to 15 L/minute.
• Insert a bladder catheter with hourly urine output.
• Lie the patient flat with legs raised, remove clots from the vagina and admit.
• Transfuse packed red cells for haemoglobin below 7 g/dL, ongoing bleeding or shock.

Pharmacological.

• Tranexamic acid 1 g IV over 10 minutes, then 1 g oral 8-hourly for up to 5 days (maximum 4 g daily; avoid in previous clot).
• Norethisterone 5 mg oral 8-hourly for 10 days.
• Alternatively, combined oral contraceptive pill with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms, one tablet oral 8-hourly for 7 days then one tablet once daily for 21 days (not in previous clot, migraine with aura or hypertension).
• Conjugated oestrogens 25 mg IV every 4 to 6 hours for up to 4 doses where available (not in previous clot or oestrogen sensitive cancer).
• Desmopressin 0.3 micrograms/kg IV over 30 minutes for von Willebrand disease or platelet function defects.
• Ceftriaxone 1 g IV once plus metronidazole 500 mg IV 8-hourly if infection is suspected.
• Ferrous sulphate 200 mg oral 12-hourly for 3 to 6 months after recovery.
• Iron sucrose 200 mg IV in 100 mL sodium chloride 0.9 percent over 30 minutes on alternate days for 3 to 5 doses for severe anaemia.

Procedures.

• Intrauterine balloon tamponade with a Foley catheter (size 16 to 18) inflated with 30 mL sodium chloride 0.9 percent for 12 to 24 hours with antibiotic cover.
• Hysteroscopic removal of polyps or submucous fibroids.
• Suction evacuation of retained products.
• Uterine artery embolisation.
• Dilatation and curettage if bleeding persists in the unstable woman.
• Hysterectomy for uncontrolled bleeding, malignancy or failed treatment.

Special groups.

• Women with positive pregnancy tests have treatment for miscarriage (misoprostol 800 micrograms sublingual once or surgical evacuation) or laparoscopy for ectopic pregnancy.
• Women with bleeding disorders have desmopressin, factor replacement and haematology care.
• Women on anticoagulants have the drug held and reversal considered by the specialist (for warfarin vitamin K 5 to 10 mg IV, and for heparin protamine sulphate 1 mg per 100 IU), with restart planned once bleeding settles.
• Adolescents have full resuscitation and a bleeding disorder screen before hormone treatment.

• Red flags: systolic blood pressure below 90 mmHg, pulse above 120 per minute, haemoglobin below 7 g/dL, bleeding that continues after 24 hours of treatment, syncope, positive pregnancy test with pain, fever, fibrinogen below 2 g/L.
• Follow-up: observation of bleeding, pulse and blood pressure every 15 minutes for 1 hour then hourly; haemoglobin at 6 and 24 hours; review in 2 weeks and 6 weeks; long term plan (levonorgestrel intrauterine system, ablation or hysterectomy) for the underlying cause.