A 29-year-old woman, gravida 2 para 1, at 10 weeks gestation comes to the emergency department for 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 an ultrasound at that time revealed a 9-week gestation with a normal fetal heart rate. Today, temperature is 37 C (98.7 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 negative. Hemoglobin is 8.0 g/dL. A bedside transvaginal ultrasound reveals a 9-week-size 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?

Question

A 29-year-old woman, gravida 2 para 1, at 10 weeks gestation comes to the emergency department for 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 an ultrasound at that time revealed a 9-week gestation with a normal fetal heart rate.  Today, temperature is 37 C (98.7 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 negative.  Hemoglobin is 8.0 g/dL.  A bedside transvaginal ultrasound reveals a 9-week-size 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?

Quizplus · Accepted Answer

11ec25c8_da0b_4097_bc81_5f645c90d126_MD0003_00 This patient at 10 weeks gestation has heavy vaginal bleeding, cramping, a dilated cervix, and an ultrasound that reveals a nonviable (no fetal heartbeat) intrauterine gestation in the lower uterine segment-a presentation consistent with an inevitable abortion. The management of an inevitable abortion is dependent on patient preference and hemodynamic stability. Surgical management via suction curettage is indicated for hemodynamically unstable (eg, hypotensive, tachycardic) patients with anemia from acute blood loss. Suction curettage removes the retained products of conception, which stops the bleeding. In addition, this patient requires Rho(D) immune globulin to prevent isoimmunization from Rh incompatibility. Suction curettage (Choices A and C) Expectant or medical (eg, misoprostol) management is appropriate in hemodynamically stable patients with minimal bleeding. Both types of management avoid the risk of surgical complications (eg, uterine perforation, intrauterine adhesions) but typically require a longer time until treatment is completed and are, therefore, inappropriate for a hemodynamically unstable, bleeding patient. (Choice B) Oxytocin is not effective in stimulating uterine contractions or expelling retained products of conception during the first or second trimesters as there are few oxytocin receptors 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. (Choice E) Laparoscopy is indicated in the evaluation of an ectopic pregnancy, which typically presents with unilateral pain, light vaginal bleeding, and an ultrasound revealing an empty uterus and an adnexal mass. Educational objective: An 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 hemodynamically unstable patients. References: Expectant, medical, or surgical management of first-trimester miscarriage: a meta analysis. (http://www.ncbi.nlm.nih.gov/pubmed/15863551) First trimester bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/19514696)

A 29-Year-Old Woman, Gravida 2 Para 1, at 10 Weeks