How is excessive bleeding after a Dilation and Curettage (D&C) managed?

Management of Excessive Bleeding After Dilation and Curettage (D&C)

Excessive bleeding after D&C requires immediate assessment and intervention based on bleeding severity, with specific measures to control hemorrhage and stabilize the patient.

Assessment of Bleeding Severity

First, determine if the bleeding meets criteria for major bleeding:

• Hemodynamic instability (systolic BP <90 mmHg, drop in systolic BP >40 mmHg, or heart rate increase)
• Clinically overt bleeding with hemoglobin decrease ≥2 g/dL
• Administration of ≥2 units of red blood cells

Initial Evaluation

• Vital signs: Heart rate, blood pressure (including orthostatic changes)
• Quantify blood loss: Saturated pads, clots passed
• Laboratory assessment: Complete blood count, coagulation studies (PT, aPTT, fibrinogen)
• Assess for signs of shock: Decreased urine output (<0.5 mL/kg/hr), altered mental status

Management Algorithm

For Major Bleeding (Life-threatening)

1. Stop any anticoagulant medications if patient is on them 1
2. Provide volume resuscitation with warmed fluids and blood products if needed 1
3. Administer oxytocin to produce uterine contractions and control postpartum bleeding 2
   • Typical dose: IV infusion of oxytocin
4. Provide local therapy/manual compression 1
   • Direct pressure on bleeding sites
   • Uterine massage if appropriate
5. Consider surgical intervention if bleeding persists 1
   • Repeat curettage to remove retained products of conception
   • Uterine balloon tamponade
   • Uterine artery embolization
   • Surgical exploration if needed

For Non-Major Bleeding

1. Provide local therapy/manual compression 1
2. Consider continuing anticoagulation (if applicable) with appropriate dose adjustments 1
3. Monitor vital signs and bleeding for progression to major bleeding

Special Considerations

Coagulopathy Management

• If dilutional coagulopathy develops (common in massive hemorrhage):
  • Administer fresh frozen plasma early to prevent worsening 1
  • Monitor fibrinogen levels and replace as needed
  • Consider platelet transfusion if count is low or dysfunction is suspected

Reversal of Anticoagulation (If Applicable)

For patients on anticoagulants with major bleeding:

• For VKA (e.g., warfarin): Administer 5-10 mg IV vitamin K 1, 3
• For DOACs: Consider specific reversal agents based on the specific medication 1

Monitoring After Initial Control

• Repeat hemoglobin and coagulation studies every 6-8 hours for 24-48 hours 3
• Monitor urine output as indicator of adequate perfusion
• Observe for signs of rebleeding

When to Restart Anticoagulation (If Applicable)

Once bleeding is controlled, assess if there's a clinical indication for continued anticoagulation. Consider these factors before restarting 1:

• Was the bleeding at a critical site?
• Is the patient at high risk of rebleeding?
• Has the source of bleeding been identified and controlled?
• Are surgical procedures planned?

Common Pitfalls to Avoid

1. Underestimating blood loss: External bleeding may not reflect the total blood loss; monitor vital signs closely
2. Delayed intervention: Hemodynamic "stability" does not reliably exclude significant hemorrhage 4
3. Inadequate resuscitation: Ensure adequate volume replacement before attempting definitive procedures
4. Overlooking coagulopathy: Dilutional and consumptive coagulopathy can develop rapidly in massive hemorrhage 1
5. Failure to warm patient and fluids: Hypothermia worsens coagulopathy 1

By following this structured approach to managing excessive bleeding after D&C, clinicians can effectively control hemorrhage, prevent complications, and improve patient outcomes.