What are the management options for vaginal bleeding after an abortion?

Management of Vaginal Bleeding After Abortion

The primary management of vaginal bleeding after abortion should include assessment of bleeding severity, uterine massage, and administration of uterotonic medications such as oxytocin, with escalation to surgical interventions if bleeding persists. 1

Initial Assessment

• Evaluate hemodynamic stability:

  • Vital signs: heart rate, blood pressure
  • Signs of hypovolemia: tachycardia, hypotension
  • Quantify blood loss: saturated pads, clots, duration of bleeding

• Determine bleeding pattern:

  • Normal post-abortion bleeding typically lasts 9-14 days (longer after medical abortion than surgical abortion) 2
  • Abnormal bleeding includes:
    • Soaking more than 2 pads per hour for 2+ consecutive hours
    • Persistent bleeding beyond 2 weeks
    • Recurrent heavy bleeding after initial lightening

Management Algorithm

Step 1: Medical Management

• First-line treatment: Uterine massage and uterotonic medications
  • Oxytocin 10-40 units in 1000 mL IV fluid, infused at a rate to control uterine atony 3
  • Misoprostol 800 mcg orally or sublingually (reduces bleeding duration and amount) 4
  • Methylergonovine 0.2 mg IM (avoid in hypertensive patients)

Step 2: Laboratory Evaluation

• Complete blood count to assess hemoglobin/hematocrit
• Coagulation studies (PT, PTT, fibrinogen)
  • Fibrinogen levels <200 mg/dL indicate severe hemorrhage 5
  • Maintain platelet count >50,000/mm³ 5

Step 3: Procedural Interventions

• Re-aspiration/curettage if retained tissue is suspected
• Balloon tamponade for persistent bleeding
• Tranexamic acid 1g IV for refractory bleeding 6

Step 4: Advanced Interventions

• Uterine artery embolization via interventional radiology
• Surgical management if bleeding remains uncontrolled:
  • Uterine compression sutures
  • Hypogastric artery ligation (though efficacy is not fully proven) 6
  • Hysterectomy as last resort

Special Considerations

Transfusion Therapy

• For severe hemorrhage, initiate early hemostatic resuscitation with 1:1:1 ratio of red blood cells, fresh frozen plasma, and platelets 5
• Don't delay transfusion while waiting for laboratory results

Rh Status Management

• Administer anti-D immunoglobulin (50 μg) to Rh-negative women after abortion 6
• This is a Level C recommendation but widely practiced to prevent alloimmunization

Post-Procedure Monitoring

• Monitor vital signs every 15 minutes until stable
• Observe for at least 1-2 hours after bleeding is controlled
• Provide clear discharge instructions about when to seek emergency care

Prevention Strategies

• Prophylactic oxytocin after surgical evacuation reduces bleeding risk 1
• Oral misoprostol (200 mcg every 6 hours for 48 hours) reduces duration and amount of vaginal bleeding after surgical evacuation 4
• Consider prophylactic antibiotics to prevent infection which can worsen bleeding

Follow-up Care

• Schedule follow-up within 1-2 weeks
• Advise patients that fertility awareness-based contraception methods should be delayed until after first post-abortion menses 6
• Counsel that bleeding patterns may vary but should progressively improve

Remember that while some bleeding after abortion is expected, hemorrhage requiring intervention occurs in fewer than 1% of abortions 1. Prompt recognition and systematic management are essential to prevent morbidity and mortality.