What is the next step in management for a patient who underwent Medical Termination of Pregnancy (MTP) with ongoing bleeding and discharge for a month?

Management of Prolonged Bleeding After Medical Termination of Pregnancy

This patient requires urgent pelvic ultrasound with Doppler evaluation to rule out retained products of conception (RPOC) and uterine arteriovenous malformation (AVM), as prolonged bleeding one month post-MTP is abnormal and warrants immediate investigation. 1, 2

Immediate Assessment Required

Clinical Evaluation

• Assess hemodynamic stability immediately: Check vital signs for hemorrhagic shock (systolic BP <100 mmHg, heart rate >100 bpm, signs of hypoperfusion including cool/clammy skin, altered consciousness) 3
• Quantify bleeding severity: Determine if this is minor spotting versus active hemorrhage requiring urgent intervention 4
• Obtain hemoglobin level: The patient has been bleeding for a month and may be significantly anemic, potentially requiring transfusion 2

Diagnostic Workup

• Pelvic ultrasound with Doppler is mandatory: This is the single most important next step to identify RPOC versus AVM 2
  • Transvaginal approach is preferred for optimal visualization 3
  • Doppler evaluation is critical—a hypervascular region or pulsating lesion suggests AVM, which can be life-threatening 2
• Quantitative β-hCG level: Should be undetectable by 4 weeks post-MTP; persistent elevation suggests RPOC or gestational trophoblastic disease 5

Critical Differential Diagnoses

Retained Products of Conception (Most Common)

• Complete abortion rates for medical TOP are approximately 95%, meaning 5% have incomplete abortion 1
• RPOC typically presents with persistent bleeding and may show echogenic material in the endometrial cavity on ultrasound 1
• Management: Vacuum aspiration is indicated if RPOC confirmed 1

Uterine Arteriovenous Malformation (Life-Threatening)

• This is a critical diagnosis that must not be missed: AVMs can develop after surgical or medical TOP and cause catastrophic hemorrhage 2
• Ultrasound findings include hypervascular region with turbulent flow on Doppler, or a pulsating lesion 2
• Key pitfall: AVMs can be mistaken for RPOC, and attempting curettage on an AVM causes life-threatening hemorrhage 2
• Management: Uterine artery embolization is the definitive treatment 2

Gestational Trophoblastic Neoplasia (Rare but Important)

• Persistent β-hCG elevation 6+ weeks post-evacuation suggests GTN 5
• Requires staging workup including chest X-ray and CT if metastatic disease suspected 5

Management Algorithm

If Hemodynamically Unstable

1. Immediate resuscitation: Large-bore IV access, fluid resuscitation, type and cross-match 3
2. Direct compression/packing of any visible bleeding source 4
3. Target systolic BP 80-100 mmHg until bleeding controlled 3
4. Emergency ultrasound at bedside if available 3
5. Urgent gynecology consultation for potential surgical intervention 4

If Hemodynamically Stable (Most Likely Scenario)

1. Obtain pelvic ultrasound with Doppler within 24-48 hours 3, 2
2. Check hemoglobin and β-hCG levels 5, 2
3. Based on ultrasound findings:
   • RPOC without AVM: Proceed with vacuum aspiration 1
   • AVM present: Refer for uterine artery embolization—do NOT perform curettage 2
   • Normal ultrasound with elevated β-hCG: Workup for GTN 5
   • Normal ultrasound with normal β-hCG: Consider hormonal causes or endometritis

Common Pitfalls to Avoid

• Never perform blind curettage without ultrasound evaluation: This can cause catastrophic hemorrhage if an AVM is present 2
• Do not dismiss prolonged bleeding as "normal post-MTP": Bleeding should resolve within 2-3 weeks; one month is abnormal 1
• Do not rely on clinical examination alone: The patient in the case report had normal hysteroscopy initially but had a life-threatening AVM 2
• Ensure concrete follow-up plans: This patient has already been bleeding for a month, suggesting inadequate initial follow-up 3

Additional Considerations

• Screen for infection: Mild whitish discharge may indicate endometritis, which can prolong bleeding 1
• Prophylactic antibiotics may be indicated if infection suspected 1
• Blood transfusion may be necessary given prolonged bleeding duration 2
• Psychological support: The case report patient became depressed and lost her job due to prolonged bleeding complications 2