What is the treatment for incomplete abortion with profuse vaginal bleeding presenting at the Emergency Room (ER) according to Philippine guidelines?

Treatment of Incomplete Abortion with Profuse Vaginal Bleeding in the Emergency Room

Immediate Resuscitation and Stabilization

For incomplete abortion presenting with profuse vaginal bleeding in the ER, immediate hemodynamic stabilization followed by urgent surgical evacuation via vacuum aspiration is the treatment of choice, as medical management is contraindicated in the presence of profuse bleeding. 1

Initial Assessment and Resuscitation

• Establish two large-bore IV lines immediately for rapid fluid and blood product administration if the patient is hemodynamically unstable 2
• Check vital signs immediately, including heart rate and blood pressure, to assess for hypovolemia or shock 3, 2
• Begin crystalloid infusion targeting mean arterial pressure >65 mmHg while avoiding fluid overload 2
• Obtain urgent laboratory studies: complete blood count, coagulation parameters (PT/PTT), blood typing and cross-matching given the profuse bleeding 3, 2
• Transfuse packed red blood cells if hemoglobin drops below 7 g/dL or if there are signs of ongoing hemorrhage 3

Critical Diagnostic Considerations

• Perform speculum examination to identify products of conception in the cervical os, as this can cause cervical vasovagal shock with bradycardia and hypotension—if present, remove immediately with sponge-holding forceps 4
• Ultrasound evaluation should be performed when feasible to confirm incomplete abortion and rule out ectopic pregnancy, though this should not delay definitive treatment in unstable patients 1

Definitive Management: Surgical Evacuation

Why Surgery is Mandatory in Profuse Bleeding

• Medical management with misoprostol is absolutely contraindicated when profuse bleeding is present, as hemorrhage precludes expectant or medical approaches 1
• Vacuum aspiration is the procedure of choice for incomplete abortion, as it is associated with significantly less blood loss (-17 mls), less pain (RR 0.74), and shorter procedure duration (-1.2 minutes) compared to sharp curettage 5
• Surgical evacuation should be performed urgently without delay, as profuse bleeding represents a life-threatening emergency requiring immediate intervention 1, 6

Surgical Technique

• Vacuum aspiration (suction curettage) is preferred over sharp curettage for safety and efficacy 5, 6
• Provide adequate analgesia and sedation as necessary for the procedure 5
• The procedure can be safely performed in the emergency department by trained physicians, with complication rates of approximately 4.5% 6

Management of Specific Complications

If Cervical Vasovagal Shock Occurs

• Recognize the triad: bradycardia, hypotension, and products of conception visible in the cervical os 4
• Remove products immediately using sponge-holding forceps to relieve cervical stimulation 4
• Proceed with complete evacuation once vitals stabilize 4

Post-Evacuation Care

• Monitor vital signs until stable and bleeding is controlled 6
• Ensure complete evacuation to prevent retained products requiring re-evacuation 5
• Administer anti-D immunoglobulin (50 μg) to all Rh-negative women to prevent alloimmunization 1

Common Pitfalls to Avoid

• Do not delay surgical evacuation waiting for ultrasound confirmation if the patient is hemodynamically unstable with profuse bleeding 1
• Do not attempt medical management with misoprostol in the setting of profuse bleeding—this is a contraindication 1
• Do not miss products of conception in the cervical os during initial examination, as this can cause vasovagal shock 4
• Do not use sharp curettage when vacuum aspiration is available, as it causes more blood loss and pain 5

Antibiotic Considerations

• Initiate broad-spectrum antibiotics immediately if there is any suspicion of infection (maternal tachycardia, purulent discharge, uterine tenderness), and proceed with urgent evacuation without waiting for fever to develop 1