Acute hemorrhagic shock from vaginal laceration during intercourse requiring operative management

Vaginal laceration during consensual intercourse is a rare cause of acute vaginal bleeding. Most coital injuries are minor, although may result in acute hemorrhage and hemodynamic instability. A 30-year-old G3P2012 otherwise healthy woman presented to the emergency department (ED) with acute vaginal bleeding immediately during consensual intercourse. She was initially well-appearing then developed hemorrhagic shock in the ED from ongoing vaginal exsanguination. The bleeding source could not be visualized on speculum examination. She was resuscitated with tranexamic acid, crystalloid, and two units of unmatched whole blood and taken emergently to the operating room. Examination under anesthesia after evacuation identified a horizontal posterior vaginal wall laceration. The laceration was repaired transvaginally with hemostasis, and the patient recovered uneventfully. A vaginal laceration during intercourse may cause acute life-threatening hemorrhage. Bleeding is often occult on speculum examinations although may progress rapidly to shock. Emergency clinicians should exclude pregnancy, initiate early resuscitation, and urgently consult gynecology for examination under anesthesia and repair when indicated.