What should I do if I experience sudden heavy menstrual bleeding with clots after a miscarriage?

Immediate Evaluation and Management of Heavy Bleeding After Miscarriage

You need urgent medical evaluation if you are soaking through a large pad or tampon every hour for 4 consecutive hours, or if you experience dizziness, lightheadedness, or severe abdominal pain. 1

Urgent Assessment Required

Seek immediate care if you have:

• Heavy bleeding saturating a large pad or tampon hourly for at least 4 hours 2
• Signs of hemodynamic instability (dizziness, rapid heartbeat, feeling faint) 1
• Severe abdominal pain 1
• Fever or signs of infection 1

First Steps in Evaluation

All reproductive-age women with abnormal uterine bleeding after miscarriage must be tested for pregnancy to rule out retained products of conception or ectopic pregnancy. 2

Your healthcare provider should assess:

• The exact timing since your miscarriage 1
• Volume and duration of current bleeding 1
• Size and frequency of clots (clots ≥1 inch diameter suggest significant blood loss) 3
• Whether you're changing pads/tampons more than hourly ("flooding") 3
• Check for anemia with hemoglobin testing 3

Management Approach

For heavy bleeding after miscarriage, surgical management (dilation and curettage) is generally recommended to avoid excessive bleeding, particularly if retained products are suspected. 2

Medical Management Options

If surgical intervention is not immediately needed or available:

Tranexamic acid (TXA) is highly effective for reducing menstrual blood loss and can reduce bleeding by approximately 50% compared to placebo. 4 TXA works by preventing clot breakdown and is generally safe, with minimal thromboembolic risk in reproductive-age women. 4

Target fibrinogen level ≥1.5 g/L should be maintained for 3 days after the bleeding episode if you require fibrinogen replacement therapy. 2

Hormonal Options

• Levonorgestrel intrauterine device (IUD) is the most effective long-term option for preventing future heavy bleeding, reducing menstrual blood loss by 71-95%. 2
• Oral progestins can reduce bleeding by 87% and may be used for short-term control. 2
• Combined oral contraceptives or estrogen for 10-20 days can help control acute bleeding episodes. 1

Important Caveats

NSAIDs should be used cautiously - while they can reduce bleeding by 5-7 days of treatment 1, they may not be appropriate if you have cardiovascular risk factors or are on anticoagulation. 2

If bleeding persists despite initial treatment, you require evaluation for:

• Retained products of conception 1
• Underlying bleeding disorders (present in up to 20% of women with heavy menstrual bleeding) 3, 5
• Uterine pathology 3
• Coagulation abnormalities 6

Women over 35 with persistent unexplained bleeding should undergo endometrial sampling to rule out endometrial pathology. 1

Follow-Up Care

Monitor for:

• Development of anemia (check ferritin levels, as low ferritin predicts significant blood loss) 3
• Continued heavy bleeding or clots 3
• Any signs of infection 1

Close clinical observation for at least 72 hours is recommended for women with significant bleeding. 2

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