What is the best course of action for a patient diagnosed with an inevitable abortion who develops severe bleeding and loses consciousness?

Immediate Surgical Evacuation via Dilation and Curettage

A patient with inevitable abortion who develops severe bleeding and loses consciousness requires immediate dilation and curettage (D&C) to control life-threatening hemorrhage—this is a medical emergency demanding urgent surgical intervention, not observation or medical management. 1, 2

Why D&C is the Only Appropriate Choice

Severe bleeding with hemodynamic instability (loss of consciousness) represents uncontrolled hemorrhage requiring immediate surgical evacuation. 1, 2 The patient has progressed beyond a stable inevitable abortion to a life-threatening hemorrhagic emergency where:

• Loss of consciousness indicates profound hypovolemic shock requiring immediate hemorrhage control 2
• Surgical evacuation (D&C) is the definitive treatment for controlling bleeding from incomplete uterine evacuation 1, 3
• Vacuum aspiration or D&C has significantly lower hemorrhage rates (9.1%) compared to medical management (28.3%) 1, 3

Why Other Options Are Contraindicated

Observation (Option A) - Absolutely Contraindicated

• Expectant management carries 60.2% maternal morbidity versus 33.0% with active intervention 1
• Postpartum hemorrhage occurs in 23.1% with expectant management versus 11.0% with surgical care 1
• Active bleeding with hemodynamic compromise is an absolute contraindication to observation 1, 3

Misoprostol (Option B) - Inappropriate for Emergency

• Medical management takes hours to days to achieve evacuation, unacceptable in hemorrhagic shock 1
• Misoprostol has 28.3% hemorrhage rate and 17.4% retained tissue rate requiring subsequent surgical intervention 1, 3
• This patient needs immediate hemorrhage control, not delayed medical evacuation 2

Methotrexate (Option C) - Wrong Indication

• Methotrexate is used for ectopic pregnancy, not inevitable abortion 1
• Has no role in managing hemorrhage from inevitable abortion 1

Immediate Management Algorithm

Step 1: Resuscitation While Preparing for Surgery

• Apply high-flow oxygen and establish large-bore IV access (two 14-16 gauge lines or central access) 2
• Begin massive transfusion protocol with warmed blood products in 1:1:1 ratio (RBCs:FFP:platelets) 2
• Obtain urgent labs: CBC, coagulation panel, type and cross-match 2
• Administer tranexamic acid 1g IV over 10 minutes if within 3 hours of bleeding onset 2

Step 2: Urgent Surgical Evacuation

• Proceed immediately to D&C without delay for definitive hemorrhage control 1, 2, 3
• Vacuum aspiration is preferred over sharp curettage when feasible, with lower complication rates 4, 5
• Ultrasound guidance reduces complications (0.87% retained products versus 2.6-4.9% without guidance) 4

Step 3: Intraoperative Hemorrhage Control

• Oxytocin infusion after evacuation: 10-40 units in 1000mL at rate to control atony 6
• If bleeding persists despite evacuation and oxytocin, consider uterine artery embolization or surgical hemostasis 2

Step 4: Post-Procedure Critical Care

• Admit to intensive care for hemodynamic monitoring and continued resuscitation 2
• Monitor for ongoing bleeding, coagulopathy, and infection 2
• All Rh-negative women receive 50 μg anti-D immunoglobulin after procedure 1, 3

Critical Pitfalls to Avoid

• Do not delay surgery waiting for laboratory results in hemodynamically unstable patients 2
• Do not attempt medical management in hemorrhagic shock—this requires immediate surgical intervention 1, 3
• Do not use methylergonovine before complete evacuation—it causes sustained contraction trapping retained tissue 3
• Do not underestimate blood loss—loss of consciousness indicates >30-40% blood volume loss requiring aggressive transfusion 2

The answer is D: Dilation and curettage. This patient requires immediate surgical evacuation to control life-threatening hemorrhage. 1, 2, 3