From the Guidelines
Heavy vaginal bleeding post medical therapeutic abortion requires immediate administration of tranexamic acid, at an initial dose of 1 g, to reduce total blood loss, as recommended by the most recent guidelines 1.
Management of Heavy Vaginal Bleeding
Heavy vaginal bleeding after a medical abortion is a serious condition that requires prompt medical attention. The patient should contact their healthcare provider or go to the emergency room if they experience excessive bleeding, such as soaking through more than two maxi pads per hour for two consecutive hours, passing clots larger than a lemon, feeling dizzy, lightheaded, or experiencing severe pain.
Causes and Treatment
While some bleeding is expected after a medical abortion and can last 1-2 weeks, excessive bleeding may indicate an incomplete abortion or other complications. The most common cause of early postpartum hemorrhage is related to uterine atony, which can be treated with uterine massage and uterotonic drugs such as oxytocin 1.
Monitoring and Intervention
Monitoring of haemostatic function is crucial in obstetric haemorrhage, and point-of-care (POC) testing is preferred over laboratory testing due to its faster results 1. Tests should include plasma fibrinogen concentration or POC equivalent, and any abnormalities should be treated promptly.
Key Interventions
- Administer tranexamic acid (1 g) to reduce total blood loss 1
- Monitor haemostatic function using POC testing 1
- Treat any abnormalities in haemostatic function promptly 1
- Consider uterine massage and uterotonic drugs such as oxytocin to treat uterine atony 1
- Stay hydrated, rest, and monitor temperature for signs of infection
- Keep track of bleeding patterns to report to the healthcare provider
From the FDA Drug Label
Misoprostol may produce uterine contractions, uterine bleeding, and expulsion of the products of conception. Abortions caused by Misoprostol may be incomplete A major adverse effect of the obstetrical use of misoprostol is uterine tachysystole which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism and lead to adverse fetal heart changes Vaginal administration of misoprostol, outside of its approved indication, has been used as a cervical ripening agent, for the induction of labor and for treatment of serious postpartum hemorrhage in the presence of uterine atony Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia, and fetal and maternal death have been reported.
Heavy vaginal bleeding post medical therapeutic abortion can be a result of the use of misoprostol, as it may produce uterine contractions, uterine bleeding, and expulsion of the products of conception. The risk of severe genital bleeding is increased with the use of misoprostol for medical therapeutic abortion.
- Key points:
- Misoprostol may cause uterine contractions and bleeding
- Uterine tachysystole and uterine rupture are potential risks
- Severe genital bleeding and other adverse effects have been reported
- Clinical decision: Monitor patients closely for signs of heavy vaginal bleeding and other adverse effects after medical therapeutic abortion with misoprostol 2 3.
From the Research
Heavy Vaginal Bleeding Post Medical Therapeutic Abortion
- Heavy vaginal bleeding is a potential complication of medical therapeutic abortion, although it is rare, occurring in fewer than 1% of abortions 4.
- The causes of hemorrhage after abortion can be attributed to atony, coagulopathy, and abnormal placentation, as well as procedure complications such as perforation, cervical laceration, and retained tissue 4.
- The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage and development of an organized approach to treatment, including assessment and examination, uterine massage and medical therapy, resuscitative measures, and interventions such as embolization and surgery 4.
- Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation, while methylergonovine prophylaxis is associated with more bleeding at the time of dilation and evacuation 4.
- The use of tranexamic acid as prophylaxis and treatment for postabortion hemorrhage requires further research 4.
- In the context of medical abortion, the immediate use of oral contraceptive pills does not affect the duration or amount of vaginal bleeding or the complete abortion rate 5.
- Initial evaluation of heavy vaginal bleeding should focus on hemodynamic stability, with a thorough history and work-up including laboratory and imaging studies 6.
- Treatment approaches for heavy vaginal bleeding include acute stabilization and long-term treatment with medical and surgical modalities 6.
- Oxytocin and tranexamic acid, oxytocin and misoprostol, oxytocin and methylergometrine, or carbetocin are recommended for the prevention of postpartum hemorrhage after vaginal delivery, which may also be applicable to medical therapeutic abortion 7.