Elizabeth L. Munter
History of present illness
A 30-year-old gravida 5, para 4 woman at 10 weeks’gestation presented to the emergency department with heavy vaginal bleeding and lightheadedness. She had been seen in the gyne- cology urgent care clinic earlier that day with light bleeding and lower abdominal cramping. An ultrasound was per- formed, which revealed an approximately eight-week-size intrauterine pregnancy without cardiac activity. She was informed of the diagnosis of a missed abortion, and was counseled on options and offered support. Management options were discussed with her, including expectant manage- ment, medical management with misoprostol, or surgical management with dilation and curettage (D&C). She elected to proceed with medical management and was given misoprostol 800μg per vagina. A follow-up visit was scheduled two days later. Approximately 8 hours after placing the mis- oprostol, she noted her bleeding became significantly heavier and she soakedfive sanitary pads over the hour prior to her arrival in the emergency department. Her past medical history was unremarkable. She had four prior spontaneous vaginal deliveries. A hemoglobin reading obtained at her initial pre- natal visit 3 weeks prior was 12.1 g/dL.
Physical examination
General appearance:No acute distress, alert and oriented woman, though slow in answering questions
Vital signs:
Temperature: 36.6°C Pulse: 122 beats/min
Blood pressure: 78/44 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 98% on room air
Cardiovascular:Tachycardic, no murmurs appreciated Respiratory:Clear to auscultation bilaterally
Abdomen:Soft, nontender
Pelvic:Normal external genitalia. Speculum examination with multiple large clots and on estimated 200 mL of bright red bleeding during the brief exam. Cervix was 1 cm dilated.
No obvious tissue was present at the os. Uterus was eight- week-size, mild tenderness on palpation. Adnexa nontender and without masses
Laboratory studies:
Hb: 6.4 g/dL (normal 12.0–15.0 g/dL) Blood type: A positive
How would you manage this patient?
The patient has significant hemorrhage following misoprostol administration for a missed abortion. She has evidence of volume depletion with tachycardia, hypotension, and acute blood loss anemia. She needs stabilization with intravenous fluids and blood transfusion, and requires immediate D&C to control the bleeding.
Heavy bleeding after medical management of a missed abortion
Significant bleeding is a potential risk with anyfirst-trimester pregnancy loss. Prompt recognition and management is crit- ical. This patient already had tachycardia, hypotension, and a decrease in hemoglobin by the time she was evaluated, which was shortly after her heavy bleeding started, indicative of substantial blood loss. However, patients who present shortly after the onset of even life-threatening bleeding may show only some of these signs, or none at all. Young healthy women are frequently able to compensate systemic blood pressure and cerebral perfusion despite losing large amounts of blood. At some point, a critical volume is lost, and they then rapidly decompensate. Tachycardia is often thefirst sign of volume depletion and will typically be seen before the onset of hypotension or decrease in hemoglobin. Change in hemo- globin values frequently takes the longest to occur, and patients may have lost large amounts of blood volume prior to decreases in hemoglobin measurement. Acute-onset heavy bleeding in the setting of a normal hemoglobin level should not be ignored.
When heavy bleeding following medical management for a missed abortion is encountered, steps must first be taken to stabilize the patient, including establishing intra- venous access and starting fluid resuscitation. Blood should be sent to the laboratory for complete blood count and type and screen. If blood loss is large enough that disseminated intravascular coagulation (DIC) is possible, coagulation studies including prothrombin time, partial thromboplastin time, andfibrinogen should be ordered. For presumed large blood loss, packed red blood cells should be ordered for possible transfusion. In the case of heavy bleeding with hemodynamic instability, the patient should have a uterine curettage performed emergently, with additional trained personnel present to assist in management of the hypovolemia.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Isotonic crystalloid should be used forfluid resuscitation.
Blood transfusion should be considered when symptoms such as lightheadedness or abnormal vital signs do not resolve with the initialfluid management. Decision for transfusion should be based on the estimated volume of blood lost, and should not be withheld based strictly on laboratory values. An unstable patient with a large clinical blood loss may still reflect a near normal hemoglobin value, as a sample drawn early in the hemorrhage will not reflect the ongoing amount of bleeding.
Administration of fresh frozen plasma should be considered with significant transfusion, especially in the setting of abnor- mal coagulation studies. Massive transfusion protocols may be initiated if necessary.
Once the acute bleeding has resolved following curettage, the patient should be observed to ensure the bleeding does not resume. In most instances, the bleeding is caused by retained products of conception, and curettage corrects the bleeding.
The patient should be discharged with an iron supplement to improve anemia. Otherwise, follow-up care is similar to other women undergoing curettage for an early pregnancy failure.
Patients who do not desire pregnancy should be recommended contraception, as ovulation may resume as soon as two weeks following resolution of the pregnancy. Patients losing desired pregnancies should be offered support and grief counseling.
Anti-D immune globulin should be administered to Rh- negative women. In instances of suction curettage for massive blood loss, consideration of pathologic analysis of the specimen may be appropriate to ensure molar pregnancy was not present.
While the amount of bleeding described in this case is unusual, it is a recognized complication with any management option. When a stable patient is initially diagnosed with a missed abortion, the management options include D&C, mis- oprostol, or expectant management. Misoprostol is a prosta- glandin E1 analog that stimulates uterine contractions to promote expulsion of the uterine contents. Several regimens have been studied for missed abortion including 800μg vagin- ally and 600μg sublingually, with or without repeat doses.
Efficacy rates for complete expulsion of uterine contents are approximately 80% [1]. Side effects may include vaginal bleed- ing, nausea, vomiting, and fevers.
Randomized trials comparing management of missed abortion have not individually been adequately powered to detect differences in catastrophic bleeding. However, data is available from a Cochrane review [2] and two additional randomized trials [3,4] not included in the systematic review.
The Cochrane review [2] was updated in 2012 regarding medical management of spontaneous abortion. There was a single review concerning bleeding outcomes with misoprostol compared to D&C. The review identified a single study with 50 patients with no significant difference in post-treatment hematocrit identified. The Miscarriage Treatment (MIST) trial [3] was a randomized controlled trial conducted in Great Britain of missed or incomplete abortions prior to 13 weeks’
gestation. It compared expectant management, medical man- agement with misoprostol (800μg per vagina), and surgical
management with suction curettage. The primary outcome was confirmed gynecologic infection within 14 days; this was found not to be significantly different between any of the management options. One of the secondary outcomes was rate of blood transfusion. Four out of the 398 subjects who received misoprostol required transfusion, while none of the 402 subjects who underwent curettage did, though this difference was not statistically significant.
The Management of Early Pregnancy Failure Study was completed at multiple centers in the United States and published in 2007 [4]. The primary outcome was efficacy. The study was not powered to detect differences in bleeding; how- ever, detailed information regarding bleeding was collected, including hemoglobin at baseline and 14 days following the intervention as well as daily bleeding diaries. There was a significant decrease in hemoglobin from baseline with mis- oprostol compared with curettage (–0.7 g/dL vs.–0.1 g/dL) and a significant increase in the percentage of subjects whose hemo- globin decreased by at least 2 g/dL (10.5% vs. 3.7%) and at least 3 g/dL (5.8% vs. 0.7%). Additionally, subjects who received misoprostol reported more days of bleeding following the inter- vention and were less likely tofind the bleeding to be acceptable.
Transfusions were given to 4 out of 488 women in the mis- oprostol group; none were required in the surgical group.
The above case certainly does not represent a typical out- come following misoprostol for missed abortion. Misoprostol is an appropriate management choice for many women with missed abortion, along with D&C or expectant management.
The advantages of misoprostol can include faster time to resolution compared to expectant management while still avoiding a procedure, which some women prefer. Women should be counseled regarding the efficacy and possible side effects of misoprostol including longer duration of bleeding, and should be given instructions to present for evaluation in the case of brisk bleeding or light-headedness. Additionally, providers should be familiar with the appropriate course of action for heavy bleeding, as described above.
Key teaching points
Acute-onset heavy bleeding in the setting of a normal hemoglobin level should not be ignored.
In the case of heavy bleeding with hemodynamic instability, the patient should have a uterine curettage performed emergently, with additional trained personnel present to assist in management of the hypovolemia.
In most instances, the bleeding is caused by retained products of conception, and curettage corrects the bleeding.
Women should be counseled regarding the efficacy and possible side effects of misoprostol, including longer duration of bleeding, and should be given instructions to present for evaluation in the case of brisk bleeding or light-headedness.
References
1. American College of Obstetricians and Gynecologists. Misoprostol for postabortion care. Committee Opinion No. 427.Obstet Gynecol2009;
113(2 Pt 1):465–8.
2. Neilson JP, Hickey M, Vazquez JC.
Medical treatment for early fetal death
(less than 24 weeks).Cochrane Database Syst Rev2006, Issue 3. Art. No.:
CD002253.
3. Trinder J, Brocklehurst P, Porter R, et al. Management of miscarriage:
expectant, medical, or surgical?
Results of randomised controlled trial (miscarriage treatment [MIST]
trial).BMJ2006;332(7552):
1235–40.
4. Davis AR, Hendlish SK, WesthoffC, et al. Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial.Am J Obstet Gynecol 2007;196(31):e1–31.
Case 28: Heavy bleeding after medical management of a missed abortion