Obgyn · Year 3 · from Obgyn

Case 3: Acute Hemorrhagic Uterine Bleeding

Patient Demographics

  • Age: 16 years
  • Sex: Female
  • Occupation: High school student

Chief Complaint

"I've been bleeding heavily for 3 weeks and I feel really weak and dizzy."

History of Present Illness

The patient is brought to the emergency department by her mother due to heavy vaginal bleeding for the past 3 weeks. She reports soaking through a super tampon and pad every 1-2 hours around the clock, passing large clots "the size of golf balls," and having to wake up multiple times at night to change protection. She feels weak, lightheaded, especially when standing, and has had to miss 2 weeks of school. She denies abdominal pain. Her mother reports the patient has appeared increasingly pale over the past week. The patient had menarche at age 12. Her periods have always been irregular, occurring every 2-6 weeks, and have been heavy since menarche. This is the worst bleeding episode she has experienced. She denies sexual activity. She denies easy bruising, bleeding gums, or nosebleeds.

Past Medical History

  • Heavy menstrual bleeding since menarche
  • Never evaluated or treated for menstrual problems
  • No history of bleeding disorders
  • No prior surgeries
  • Denies sexual activity

Family History

  • Mother: Heavy periods, had hysterectomy at age 38
  • Maternal aunt: History of "bleeding problems"
  • No known diagnosed bleeding disorders in family

Physical Examination Findings

  • Vital Signs: BP 92/58 mmHg (supine), HR 118 bpm (supine), standing BP 78/50 mmHg with HR 142 bpm (positive orthostatic changes), RR 20, Temperature 37.0 degrees Celsius
  • General: Pale, fatigued-appearing adolescent, alert but anxious
  • Skin: Pallor of conjunctivae and nail beds, no petechiae, no purpura, no ecchymoses
  • Cardiovascular: Tachycardic, regular rhythm, grade II/VI systolic flow murmur (likely anemia-related)
  • Abdomen: Soft, non-tender, non-distended
  • External Genitalia: Normal female, blood present at introitus, active moderate bleeding visualized
  • Speculum/Bimanual Examination: Deferred given patient denies sexual activity and is hemodynamically unstable

Diagnostic Workup

  • Urine Pregnancy Test: Negative (confirmed not pregnant)
  • Complete Blood Count:
  • Hemoglobin: 5.8 g/dL (severe anemia)
  • Hematocrit: 17.4%
  • MCV: 68 fL (microcytic)
  • WBC: 7,200/microL (normal)
  • Platelets: 412,000/microL (reactive thrombocytosis)
  • Reticulocyte count: 4.2% (appropriate response)
  • Iron Studies:
  • Ferritin: 4 ng/mL (severely depleted)
  • Iron: 18 mcg/dL (low)
  • TIBC: 485 mcg/dL (elevated)
  • Coagulation Studies:
  • PT/INR: 12.8 seconds / 1.0 (normal)
  • PTT: 42 seconds (mildly prolonged; normal <35)
  • Additional Workup for Bleeding Disorder:
  • Von Willebrand Panel:
  • VWF antigen: 28% (low; normal >50%)
  • VWF activity (Ristocetin cofactor): 22% (low)
  • Factor VIII: 35% (low)
  • Blood type: A positive
  • TSH: 2.8 mIU/L (normal)

Diagnosis

  1. Severe Acute Blood Loss Anemia (Hemoglobin 5.8 g/dL) secondary to:
  2. Acute Abnormal Uterine Bleeding - Heavy Menstrual Bleeding secondary to:
  3. Von Willebrand Disease Type 1 (newly diagnosed)

Management

Immediate Resuscitation:

  1. Two large-bore IV lines established
  2. IV fluid bolus: 1 liter normal saline
  3. Blood bank: Type and crossmatch for 3 units PRBCs
  4. Blood transfusion initiated:
  • 2 units packed red blood cells transfused
  • Goal hemoglobin >8 g/dL initially

Medical Hemostasis - Multi-Agent Approach:

Given severe bleeding and newly diagnosed VWD, aggressive multimodal therapy initiated:

  1. Tranexamic Acid (TXA):
  • Loading dose: 1 gram IV over 10 minutes
  • Maintenance: 1 gram IV every 8 hours
  • Antifibrinolytic - stabilizes clots at endometrial surface
  1. High-Dose IV Conjugated Estrogens:
  • 25 mg IV every 4-6 hours for first 24 hours
  • Rapidly stabilizes the endometrium
  • Maximum 6 doses
  1. High-Dose Combined Oral Contraceptive (once tolerating oral):
  • Monophasic OCP containing 30-35 mcg ethinyl estradiol
  • One tablet every 8 hours until bleeding controlled (usually 24-48 hours)
  • Then taper to one tablet every 12 hours x 2 days
  • Then one tablet daily (continuous, no placebo week initially)
  1. Von Willebrand Disease-Specific Treatment:
  • Hematology consultation emergently
  • Desmopressin (DDAVP): 0.3 mcg/kg IV (releases VWF from endothelial stores)
  • Check VWF levels 1 hour after DDAVP to confirm response
  • May need VWF concentrate (Humate-P) if DDAVP response inadequate

Monitoring:

  • Serial hemoglobin every 6 hours initially
  • Pad/tampon counts to quantify bleeding
  • Strict intake/output
  • Monitor for fluid overload with IV estrogen

Clinical Course:

Day 1:

  • Received 2 units PRBCs, hemoglobin rose to 7.4 g/dL
  • IV estrogen and TXA initiated
  • DDAVP given with good response (VWF rose to 85%)
  • Bleeding significantly reduced within 12 hours

Day 2:

  • Hemoglobin stable at 7.8 g/dL
  • Bleeding controlled, using 2-3 pads per day
  • Transitioned to oral OCP (1 tablet every 8 hours)
  • IV estrogen discontinued
  • Oral TXA started (1.3 grams TID)

Day 3:

  • Hemoglobin 8.2 g/dL
  • Bleeding minimal
  • Transitioned to OCP every 12 hours
  • Oral iron started (ferrous sulfate 325 mg TID)
  • Discharged home

Discharge Plan:

  1. Continued OCP taper:
  • Every 12 hours x 2 days, then daily
  • Continue continuous (no placebo week) for 3 months to allow endometrial healing and iron repletion
  1. Oral Tranexamic Acid: 1.3 grams PO TID during heavy bleeding
  1. Iron Supplementation: Ferrous sulfate 325 mg three times daily with vitamin C to enhance absorption; continue for 3-6 months
  1. Hematology Follow-up:
  • Confirm VWD Type 1 diagnosis
  • Develop bleeding precautions and treatment plan
  • Medical alert bracelet
  • Counsel about surgical/procedural bleeding risk
  1. Gynecology Follow-up:
  • 2-week appointment to assess response
  • Long-term management with continuous hormonal therapy
  • May consider LNG-IUD when older for long-term management

Von Willebrand Disease Education:

  • Most common inherited bleeding disorder
  • Type 1 is most common (75% of cases) - quantitative deficiency
  • Menorrhagia is the most common symptom in affected females
  • All adolescents with heavy menstrual bleeding since menarche should be screened
  • Treatment options: DDAVP, TXA, VWF concentrates, hormonal management

Clinical Image

Image Description: Illustration demonstrating intrauterine balloon tamponade technique for emergency control of uterine hemorrhage. A Foley catheter with a 30-mL balloon is inserted through the cervix and inflated within the uterine cavity, providing mechanical compression of the endometrial surface. This technique can be life-saving as a bridge to definitive treatment in cases of severe acute uterine bleeding.

Attribution: Educational illustration of intrauterine balloon tamponade as described in emergency gynecology literature and ACOG management guidelines for acute abnormal uterine bleeding.

Summary of Key Learning Points

  1. Ruptured ectopic pregnancy is a surgical emergency requiring simultaneous resuscitation and emergent operative intervention; salpingectomy is the procedure of choice for ruptured ectopic in an unstable patient
  1. Ovarian torsion presents with sudden severe unilateral pain and vomiting; normal Doppler flow does NOT exclude torsion - clinical suspicion alone warrants surgery; preserve the ovary whenever possible even if it appears dusky
  1. Acute hemorrhagic uterine bleeding requires multimodal medical management with IV estrogen, tranexamic acid, and high-dose hormonal therapy; all adolescents with heavy menstrual bleeding since menarche should be screened for bleeding disorders (especially von Willebrand disease)
  1. Hemorrhagic shock classification:
  • Class I: <15% blood loss - minimal changes
  • Class II: 15-30% - tachycardia, narrowed pulse pressure
  • Class III: 30-40% - hypotension, tachycardia >120, confusion
  • Class IV: >40% - severe hypotension, lethargy
  1. Massive transfusion protocol should be activated early with balanced 1:1:1 ratio (PRBCs:FFP:platelets); tranexamic acid should be given within 3 hours of hemorrhage onset
  1. Fertility preservation is paramount in young patients - avoid oophorectomy unless ovary is clearly necrotic; salpingectomy is preferred over salpingostomy in ruptured ectopic to reduce persistent ectopic rates
  1. Risk factors for ectopic pregnancy: prior ectopic, prior tubal surgery, PID history, IUD use, assisted reproduction, smoking, advanced maternal age

All cases for this lecture as Markdown