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PV bleeding

First question: is she pregnant — and how far along? Pregnancy status and gestation decide almost everything. Resuscitate the bleeding patient, do a pregnancy test, and think by stage: early pregnancy, later pregnancy (antepartum), after birth (postpartum), or not pregnant. Built for revision, not live patient decisions.

NBNeed for BleepClinical revision for junior doctorsUpdated 6 min read
1

Settle them, and check the basics

resuscitate · pregnant?

Red flags — what each should make you think

Shock + positive pregnancy testruptured ectopic / miscarriage Bradycardia + hypotension + bleedingcervical shock Painful bleeding, hard tender uterusplacental abruption Painless bleeding in later pregnancyplacenta praevia — no digital exam Heavy bleeding after birthpostpartum haemorrhage Postmenopausal bleedingendometrial cancer
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Pearl

Never do a digital vaginal examination in later pregnancy with bleeding until placenta praevia has been excluded on ultrasound: it can provoke catastrophic haemorrhage. And in early pregnancy, a speculum examination can be life-saving: removing products from the cervical os reverses cervical shock.

First actions

  • 🧪Pregnancy test
  • IVTwo large-bore cannulas
  • 🩸Major haemorrhage protocol
  • 🔍Speculum (early pregnancy)
  • DAnti-D
  • ☎Gynae / obstetrics
2

Understand the patient — by stage

the four groups

Early pregnancy (under 24 weeks)

  • Miscarriage — threatened, inevitable, incomplete, complete, missed; TVUSS to confirm
  • Ectopic — see the ectopic page
  • Molar pregnancy — very high hCG, hyperemesis, large-for-dates uterus
  • Management of miscarriage: expectant, medical (misoprostol ± mifepristone) or surgical, per NICE NG126

Antepartum haemorrhage (24 weeks onwards)

  • Placental abruption — painful, tender firm uterus, may be concealed (bleeding underestimates loss), fetal distress
  • Placenta praevia — painless, often recurrent bleeding; no digital exam
  • Vasa praevia — bleeding at membrane rupture with fetal compromise
  • Left lateral tilt, CTG, obstetric team, Kleihauer and anti-D if Rhesus negative
Source: RCOG Green-top 63 — antepartum haemorrhage

Postpartum haemorrhage — the 4 Ts

  • Tone (most common) — uterine atony: uterine massage, oxytocin, ergometrine, carboprost, misoprostol, tranexamic acid
  • Trauma — tears, uterine rupture, inversion
  • Tissue — retained placenta/products
  • Thrombin — coagulopathy (DIC, abruption, pre-eclampsia, amniotic fluid embolism)
  • Call for help, MHP, catheterise, theatre if not controlled
Source: RCOG Green-top 52 — postpartum haemorrhage

Not pregnant

  • Heavy menstrual bleeding (fibroids, coagulopathy, anticoagulants)
  • Postmenopausal bleeding → urgent suspected cancer pathway
  • Cervical/vaginal lesions, trauma, sexual assault (safeguarding)
  • Severe acute bleeding: resuscitate; tranexamic acid, hormonal treatment per gynaecology

Work A–E — assess and act as you go

AAirway. ——
BBreathing. —oxygen if shocked
CCirculation. HR, BP — young women compensate; pregnant women compensate even more.cannulas, blood, left lateral tilt in pregnancy
DDisability. Syncope.—
EExposure. Abdomen, fundal height, uterine tenderness, pad count; speculum if appropriate.—
3

The diagnoses you must not miss

tap to open each

What points toward it, what would rule it in, and how to manage it.

4

Investigate — what to order, when, and what it tells you

test with a question in mind

Pregnancy test

Always
First.

Bloods

Routine
FBC, G&S/crossmatch, clotting, fibrinogen, Rhesus status.
Kleihauer
Rhesus-negative women after 20 weeks (fetomaternal haemorrhage).

Imaging

TVUSS
Early pregnancy.
USS
Placental site in later pregnancy.

Fetal

CTG
From viability onwards.
5

How the plan comes together

disposition · handover

home / EPAU

Stable threatened or complete miscarriage confirmed on scan, small loss: EPAU follow-up, support, safety-net.

admit / theatre

Shock, heavy ongoing bleeding, APH, PPH, ectopic, cervical shock.

Hand over: gestation, estimated loss, haemodynamics, Rhesus status, actions taken.

🩺
Pearl

Pregnant or not, and how many weeks? That one question sorts the differential. Resuscitate first, no digital exam in later pregnancy bleeding, and a speculum can fix cervical shock. Nicely done getting here.

✎

Clerking template

copy or download

PV bleeding — documentation structure

A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.

PV BLEEDING — CLERKING TEMPLATE PRESENTING COMPLAINT: HISTORY OF PRESENTING COMPLAINT Pregnant? LMP / gestation / scans so far: Bleeding — amount / clots / tissue / pads: Pain — site / character: Placental site known (later pregnancy): Fetal movements: Anticoagulants / bleeding disorder: RED FLAGS ASKED (record present or absent) [ ] Shock + positive pregnancy test -> ruptured ectopic / miscarriage [ ] Bradycardia + hypotension + bleeding -> cervical shock [ ] Painful bleeding, hard tender uterus -> placental abruption [ ] Painless bleeding in later pregnancy -> placenta praevia — no digital exam [ ] Heavy bleeding after birth -> postpartum haemorrhage [ ] Postmenopausal bleeding -> endometrial cancer SCORES / KEY CHECKS Pregnancy test: Estimated blood loss: Speculum findings: Rhesus status / anti-D given: USS findings: PAST MEDICAL HISTORY: DRUG HISTORY: ALLERGIES: SOCIAL HISTORY (smoking / alcohol / function / who's at home): FAMILY HISTORY: OBSERVATIONS: RR SpO2 ( % O2) HR BP Temp GCS NEWS2 EXAMINATION A - B - C - D - (GCS pupils glucose ) E - INVESTIGATIONS ORDERED: IMPRESSION: DIFFERENTIALS CONSIDERED: [ ] Ruptured ectopic [ ] Cervical shock [ ] Placental abruption [ ] Major PPH [ ] Threatened miscarriage [ ] Molar pregnancy [ ] Cervical ectropion / polyp [ ] Heavy menstrual bleeding [ ] Postmenopausal bleeding (malignancy) PLAN: 1. 2. 3. ESCALATION / SENIOR DISCUSSION: Discussed with: Time: Advice: SAFETY NET / IF DETERIORATES: Documented by: Grade: Date/Time:
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Test yourself

active recall

Cover the answer, say it out loud, then reveal. Retrieval beats re-reading.

0 / 10 known
Red flag
Shock + positive pregnancy test — what should it make you think?
ruptured ectopic / miscarriage
Red flag
Bradycardia + hypotension + bleeding — what should it make you think?
cervical shock
Red flag
Painful bleeding, hard tender uterus — what should it make you think?
placental abruption
Red flag
Painless bleeding in later pregnancy — what should it make you think?
placenta praevia — no digital exam
Red flag
Heavy bleeding after birth — what should it make you think?
postpartum haemorrhage
Red flag
Postmenopausal bleeding — what should it make you think?
endometrial cancer
Must not miss
How do you rule in ruptured ectopic?
Clinical, USS.
Must not miss
How do you rule in cervical shock?
Speculum.
Must not miss
How do you rule in placental abruption?
Clinical, CTG.
Must not miss
How do you rule in major PPH?
Clinical, 4 Ts.
Q

Frequently asked questions

quick answers
What are the red flags for vaginal (PV) bleeding?
  • Shock + positive pregnancy test — think ruptured ectopic / miscarriage
  • Bradycardia + hypotension + bleeding — think cervical shock
  • Painful bleeding, hard tender uterus — think placental abruption
  • Painless bleeding in later pregnancy — think placenta praevia — no digital exam
  • Heavy bleeding after birth — think postpartum haemorrhage
  • Postmenopausal bleeding — think endometrial cancer
What is the initial management of vaginal (PV) bleeding?
  • Pregnancy test — immediately (and gestation if known)
  • Two large-bore cannulas — FBC, G&S/crossmatch, clotting, Rhesus status
  • Major haemorrhage protocol — if shocked
  • Speculum (early pregnancy) — cervical os, products, source
  • Anti-D — for Rhesus-negative women where indicated
  • Gynae / obstetrics — by gestation

Always alongside senior support and your local guideline.

What diagnoses must you not miss in vaginal (PV) bleeding?
  • Ruptured ectopic — early pregnancy + shock
  • Cervical shock — bradycardia + bleeding
  • Placental abruption — painful · concealed
  • Major PPH — after birth

Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.

What investigations should a junior doctor order for vaginal (PV) bleeding?
  • Pregnancy test — First.
  • Bloods — FBC, G&S/crossmatch, clotting, fibrinogen, Rhesus status.
  • Imaging — Early pregnancy.
  • Fetal — From viability onwards.
Admit or discharge: how is the plan decided for vaginal (PV) bleeding?
  • Home / epau — Stable threatened or complete miscarriage confirmed on scan, small loss: EPAU follow-up, support, safety-net.
  • Admit / theatre — Shock, heavy ongoing bleeding, APH, PPH, ectopic, cervical shock.
Is there a clerking template for vaginal (PV) bleeding?

Yes — there is a free clerking template for vaginal (PV) bleeding on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.

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