What is the emergency management of miscarriage hemorrhage?

Emergency Management of Miscarriage Hemorrhage

The emergency management of miscarriage hemorrhage should begin with prompt administration of tranexamic acid 1g IV over 10 minutes, followed by a second dose if bleeding continues after 30 minutes or restarts within 24 hours. 1

Initial Assessment and Stabilization

• Assess hemodynamic stability: Monitor vital signs, focusing on heart rate, blood pressure, and signs of hypovolemic shock
• Establish IV access with two large-bore (16-18G) cannulas
• Draw blood for:
  • Complete blood count
  • Coagulation studies (PT, PTT, fibrinogen)
  • Type and cross-match
• Begin fluid resuscitation with isotonic crystalloid solutions
• Position patient in lateral decubitus position to attenuate hemodynamic impact 1

Medical Management

First-line interventions:

1. Tranexamic acid (TXA): 1g IV over 10 minutes, with a second dose if bleeding continues after 30 minutes or restarts within 24 hours 1

   • TXA should be given as soon as possible, as delay reduces benefit (10% reduction in effectiveness for every 15-minute delay)
   • TXA should not be given beyond 3 hours after onset of bleeding as it may be harmful

2. Uterotonics:

   • Oxytocin: 5-10 IU slow IV or IM 1
   • Higher-dose oxytocin (80 IU/500mL) appears more effective than lower doses for preventing further hemorrhage 2, 3

3. If bleeding persists:

   • Ergot derivatives (if not contraindicated by hypertension)
   • Prostaglandins: Carboprost tromethamine (Hemabate) 250 μg IM, may repeat at 15-90 minute intervals (maximum 8 doses) 4
   • Misoprostol: 1000 μg rectally has been shown effective for hemorrhage unresponsive to oxytocin and ergometrine 5

Surgical Management

If medical management fails to control bleeding:

1. Manual evacuation of clots and uterine massage
2. Uterine tamponade with balloon or packing
3. Surgical evacuation of retained products of conception (RPOC)
4. Interventional radiology for uterine artery embolization (if available and patient is stable)
5. Surgical options if bleeding is uncontrolled:
   • Uterine compression sutures
   • Uterine or hypogastric artery ligation
   • Hysterectomy (as last resort)

Blood Component Therapy

• Initiate early hemostatic resuscitation with red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio for severe hemorrhage 6
• Maintain fibrinogen levels >200 mg/dL 6
• Maintain platelet count >50,000/mm³ 6
• Do not delay transfusion while awaiting laboratory results if hemorrhage is severe 6

Supportive Measures

• Maintain normothermia (>36°C) as hypothermia impairs coagulation 6
• Correct acidosis
• Consider thromboprophylaxis after bleeding is controlled, especially in high-risk patients 1
• Monitor for signs of coagulopathy, which can develop rapidly in obstetric hemorrhage

Special Considerations

• Hypofibrinogenemia (fibrinogen <2 g/L) is the most common coagulation factor deficiency in obstetric hemorrhage and is associated with progression to massive bleeding 1
• Early identification and treatment of hypofibrinogenemia can reduce progression from major to massive hemorrhage 1
• Prolongation of PT and APTT above normal non-pregnant range may indicate factor depletion and should be managed with FFP 1

Pitfalls to Avoid

1. Delayed administration of TXA - efficacy decreases by 10% for every 15-minute delay; no benefit after 3 hours 1
2. Underestimating blood loss - visual estimation is often inaccurate; use volumetric and gravimetric techniques 1
3. Focusing only on uterotonic agents - miscarriage hemorrhage may be due to retained tissue or trauma requiring surgical intervention
4. Failure to monitor coagulation status - obstetric hemorrhage can rapidly lead to coagulopathy
5. Delayed escalation of care - have a clear escalation plan with early involvement of senior staff

The management of miscarriage hemorrhage requires rapid assessment and a stepwise approach to interventions, with early use of tranexamic acid being a cornerstone of treatment. Prompt recognition and management of coagulopathy is essential to prevent morbidity and mortality.