In a reproductive‑age woman with a missed intrauterine pregnancy at 7 weeks + 2 days who underwent dilation and curettage, what immediate post‑procedure management (including Rh immunoglobulin, prophylactic antibiotics, analgesia, monitoring, and β‑hCG follow‑up) is indicated?

Immediate Post-Dilation and Curettage Management for Missed Abortion at 7 Weeks

Rh Immunoglobulin Administration

All Rh-negative women who undergo dilation and curettage for missed abortion must receive anti-D immunoglobulin within 72 hours of the procedure. 1

• Administer 120 µg (minimum dose) for procedures before 12 weeks' gestation, though 300 µg may also be given 1
• If the 72-hour window is missed, anti-D should still be administered as soon as recognized, up to 28 days post-procedure 1
• Fetomaternal hemorrhage occurs in approximately 32% of spontaneous abortions, making prophylaxis critical even in early first-trimester losses 2
• Women with "weak D" (Du-positive) blood type should not receive anti-D 1

Prophylactic Antibiotics

Routine prophylactic antibiotics are not indicated following uncomplicated dilation and curettage for missed abortion. Current guidelines do not support universal antibiotic prophylaxis for this procedure when performed under standard sterile technique. 3

• Antibiotics should be reserved for patients with specific risk factors (immunocompromised status, prolonged procedure, suspected infection) or if signs of infection develop post-procedure

Analgesia Management

Provide adequate analgesia with NSAIDs or acetaminophen for post-procedure cramping. 3

• NSAIDs (ibuprofen 600-800 mg every 6-8 hours as needed) are first-line for uterine cramping
• Acetaminophen 650-1000 mg every 6 hours can be used as an alternative or adjunct
• Opioid analgesics should be reserved for severe pain not controlled by first-line agents
• Counsel patients that cramping typically resolves within 24-48 hours but may persist for several days

Immediate Post-Procedure Monitoring

Monitor for signs of complications including heavy bleeding, severe pain, fever, or hemodynamic instability before discharge. 3

• Ensure hemodynamic stability (normal vital signs, no orthostatic changes)
• Verify that vaginal bleeding is no heavier than a normal menstrual period
• Assess pain control is adequate with oral analgesics
• Provide clear discharge instructions regarding warning signs: soaking more than 2 pads per hour for 2 consecutive hours, fever >38°C (100.4°F), severe abdominal pain unrelieved by prescribed analgesics, or foul-smelling vaginal discharge 3

β-hCG Follow-Up Protocol

Serial β-hCG monitoring is essential until levels reach zero to exclude gestational trophoblastic disease and ensure complete evacuation. 3

• Obtain baseline β-hCG level within 48 hours post-procedure 3
• Measure β-hCG every 1-2 weeks until three consecutive normal (undetectable) values are documented 3
• β-hCG should decline by approximately 50% every 48-72 hours after successful evacuation 3
• A plateau (less than 15% change over 3 consecutive measurements) or rising β-hCG indicates either retained products of conception or gestational trophoblastic neoplasia and requires immediate gynecologic consultation 3, 2
• If β-hCG remains elevated beyond 6 weeks post-procedure, evaluate for gestational trophoblastic disease with pelvic ultrasound and consider uterine re-evacuation or methotrexate therapy 3

Critical Pitfalls to Avoid

Do not discharge Rh-negative patients without confirming anti-D administration. Studies show that rhesus status is documented in only 13.3% of emergency department notes, and 86.6% of patients are discharged without rhesus status being checked 4

Do not assume complete evacuation based on procedure alone—β-hCG monitoring is mandatory to detect retained products or gestational trophoblastic disease, which occurs in less than 1% of cases but requires specific management 3

Do not delay anti-D administration for blood typing confirmation if Rh status is unknown—administer prophylaxis empirically and document accordingly, as the risk of sensitization outweighs the minimal risk of unnecessary anti-D administration 1

Contraception Counseling

Provide immediate contraception counseling and initiation if desired, as ovulation can resume within 2-3 weeks post-procedure. 3

• Combined hormonal contraceptives, progestin-only pills, depot medroxyprogesterone acetate, etonogestrel implant, and IUDs can all be initiated immediately post-procedure 3
• No backup method is required when contraception is started within 7 days of first-trimester pregnancy loss 3