What is the management for post-D&C (dilation and curettage) bleeding?

Management of Post-D&C Bleeding

For post-D&C bleeding, the first-line management should include assessment of bleeding severity, local compression, and uterotonic medications such as oxytocin, followed by surgical interventions if bleeding persists.

Initial Assessment and Management

Assess Bleeding Severity

• Determine if bleeding meets criteria for major bleeding:
  • Bleeding at a critical site
  • Hemodynamic instability
  • Clinically overt bleeding with hemoglobin decrease ≥2 g/dL or requiring ≥2 units of blood 1

First-Line Interventions

1. Local compression

   • Apply direct pressure/compression to control bleeding 1
   • Consider vaginal packing if appropriate

2. Pharmacological management

   • Oxytocin: 10-40 units in 1000 mL of IV fluid, infused at a rate necessary to control uterine atony 2
   • Alternative: 10 units IM after placental delivery 2

3. Volume resuscitation

   • Initiate fluid therapy using 0.9% NaCl or balanced crystalloid solution if significant bleeding 1
   • Target hemoglobin of 70-90 g/L if transfusion becomes necessary 1

Second-Line Interventions

If bleeding persists despite first-line measures:

Surgical Management

1. Repeat curettage

   • Consider repeat D&C if retained products of conception are suspected
   • CAUTION: Repeat curettage may worsen bleeding if a pseudoaneurysm is present 3

2. Uterine packing

   • Early packing can reduce or stop venous bleeding 1
   • Consider leaving packing in place for 24-48 hours to lower risk of rebleeding 1

Advanced Interventions

1. Angiographic embolization

   • Gold standard for treatment of pseudoaneurysms 3
   • Consider if bleeding persists despite other measures
   • Allows for both diagnosis and treatment simultaneously
   • Preserves fertility compared to more invasive surgical options 3

2. Hysteroscopy

   • Allows direct visualization of the endometrial cavity and endocervix 1
   • Can diagnose focal lesions possibly missed by initial D&C 1
   • Operative hysteroscopy (CPT code 58558) can be used for treatment of identified pathology 4

Special Considerations

Delayed Bleeding

• Consider pseudoaneurysm of the uterine artery if bleeding occurs days to weeks after D&C 3
• Diagnostic features: anechoic area with turbulent flow on Doppler ultrasound 3
• AVOID therapeutic curettage in suspected pseudoaneurysm as it may worsen bleeding 3

Imaging

• Transvaginal ultrasonography: First-line imaging to assess for retained products or structural abnormalities 1
• Saline infusion sonohysterography: High sensitivity (96-100%) for assessing uterine and endometrial pathology 1
• Pelvic MRI: Consider if cervical involvement is suspected 1

Monitoring

• Monitor vital signs, bleeding amount, and hemoglobin levels
• Repeat hemoglobin/hematocrit measurements to detect ongoing bleeding 1
• Blood lactate should be used to estimate and monitor extent of bleeding and tissue hypoperfusion 1

Algorithm for Management

1. Mild bleeding (no hemodynamic instability, minimal blood loss):

   • Continue oxytocin
   • Provide local compression
   • Monitor for 24-48 hours

2. Moderate bleeding (increased but not life-threatening):

   • IV oxytocin infusion
   • Consider imaging to identify source
   • Prepare for possible surgical intervention

3. Severe bleeding (hemodynamic instability or significant blood loss):

   • Immediate fluid resuscitation
   • High-dose oxytocin infusion
   • Urgent surgical intervention (repeat D&C or hysteroscopy)
   • Consider angiographic embolization if bleeding persists

Remember that bleeding patterns after D&C are variable, but heavy bleeding typically lasts only a few days 5. Persistent or recurrent bleeding warrants thorough investigation to rule out underlying pathology, especially in postmenopausal women 6.