A 29-year-old woman, gravida 2 para 1, at 10 weeks gestation comes to the emergency department due to vaginal bleeding with passage of large clots and intense lower abdominal cramping. The bleeding began 3 hours ago, and she reports worsening dizziness on standing. The patient initiated prenatal care a week ago, and ultrasound at that time revealed a 9-week gestation with a normal fetal heart rate. Today, temperature is 37 C (98.6 F), blood pressure is 90/65 mm Hg, pulse is 110/min, and respirations are 17/min. Large clots of blood are evacuated from the vagina during pelvic examination, after which active bleeding from an open cervical os is noted. Blood type is AB, Rh negative. Hemoglobin is 8.0 g/dL. Bedside transvaginal ultrasound reveals a 9-week-sized fetus in the lower uterine segment with no cardiac activity. Intravenous fluids are begun. Which of the following is the most appropriate next step in management of this patient?
Spontaneous abortion | |
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This patient at 10 weeks gestation has heavy vaginal bleeding, cramping, a dilated cervix, and an ultrasound revealing an intrauterine gestation in the lower uterine segment (ie, no passage of products of conception through the cervical os), a presentation consistent with inevitable abortion.
Management of inevitable abortion is dependent on patient preference and hemodynamic stability. Surgical management via suction curettage is indicated for symptomatic (eg, dizziness on standing) and hemodynamically unstable (eg, hypotensive, tachycardic) patients with anemia from acute blood loss. Suction curettage removes the retained products of conception, allowing the uterus to fully contract around open arterial vessels, which stops the bleeding. In addition, this patient requires Rho(D) immunoglobulin to prevent isoimmunization from Rh incompatibility.
(Choices A and C) Medical (eg, misoprostol) or expectant management is appropriate in hemodynamically stable patients with minimal bleeding. Both types of management avoid the risk for surgical complications (eg, uterine perforation, intrauterine adhesions) but typically require a longer time until treatment is completed and are therefore inappropriate for a symptomatic, bleeding patient whose condition is hemodynamically unstable.
(Choice B) Oxytocin is not effective in stimulating uterine contractions or expelling retained products of conception during the first or second trimesters because few oxytocin receptors are in the uterus during early pregnancy.
(Choice D) This patient's uterine bleeding will likely stop after the uterus has been evacuated. A hysterectomy would be indicated for persistent bleeding after suction curettage only if all other treatments (eg, uterine tamponade, uterine artery embolization) have failed.
Educational objective:
Inevitable abortion presents with heavy vaginal bleeding, cramping, and a dilated cervix without passage of gestational tissue. Surgical management (eg, suction curettage) is indicated for patients whose condition is hemodynamically unstable.