Management of Vaginal Bleeding One Week After D&C for Anembryonic Pregnancy
Vaginal bleeding one week after a D&C for anembryonic pregnancy should be evaluated promptly with clinical assessment and ultrasound to rule out retained products of conception, which is the most common cause requiring intervention.
Initial Assessment
- Bleeding characteristics: Assess volume, presence of clots, duration, and associated symptoms
- Vital signs: Check for tachycardia, hypotension, or other signs of hypovolemia
- Physical examination: Evaluate uterine size, tone, and tenderness
- Laboratory tests: Consider hemoglobin/hematocrit, coagulation studies, and quantitative β-hCG
Diagnostic Approach
Transvaginal Ultrasound
- First-line imaging modality to evaluate for:
- Retained products of conception (RPOC)
- Endometrial thickness (>10mm suggests RPOC)
- Intrauterine fluid collections or hematomas
- Vascular flow patterns (increased vascularity suggests RPOC)
Management Algorithm
Mild Bleeding (similar to normal menses)
- Expectant management is appropriate if:
- Stable vital signs
- No significant pain
- Normal ultrasound findings
- Decreasing β-hCG levels
- Follow-up in 1-2 weeks to ensure resolution
Moderate Bleeding with Retained Products
- Medical management:
- Misoprostol 800 mcg vaginally (preferred over 400 mcg due to higher complete evacuation rate within 12 hours) 1
- May repeat dose if no evacuation within 24 hours
Heavy Bleeding or Hemodynamic Instability
- Surgical management:
- Repeat D&C under ultrasound guidance
- Consider intraoperative hysteroscopy to visualize and remove retained tissue
- Administer uterotonics (oxytocin, methylergonovine, or prostaglandins) to maintain uterine contraction 2
Severe Hemorrhage
- Aggressive management:
Special Considerations
Risk Factors for Complications
- Previous cesarean delivery (increased risk of cesarean scar pregnancy complications) 5
- Multiple previous D&Cs (increased risk of Asherman syndrome)
- Coagulopathies or bleeding disorders
Warning Signs Requiring Immediate Attention
- Soaking through >1 pad per hour
- Passing large clots (>golf ball size)
- Severe abdominal pain
- Fever >38°C (suggesting infection)
- Signs of hypovolemia (dizziness, tachycardia, hypotension)
Follow-up Recommendations
- Repeat β-hCG in 1-2 weeks to ensure complete resolution
- Follow-up ultrasound if bleeding persists beyond 2 weeks
- Consider hysteroscopy if persistent irregular bleeding suggests intrauterine adhesions
Prevention of Complications
- Prophylactic antibiotics if clinical signs of infection
- Consider hormonal therapy (combined oral contraceptives) to stabilize the endometrium if bleeding persists beyond 2 weeks
- Avoid intercourse, tampons, and douching for 2 weeks after bleeding resolves
Vaginal bleeding after D&C is common, but persistent or heavy bleeding requires thorough evaluation to prevent serious complications like hemorrhage or infection.