What is the appropriate management of a full‑term pregnant woman with an intrauterine device (IUD) presenting with hematemesis?

Management of Hematemesis in Full-Term Pregnancy with IUD

The immediate priority is to assess and manage the hematemesis as a potential life-threatening maternal collapse using a systematic ABCDE approach, while recognizing that the IUD presence is likely incidental to the acute bleeding presentation.

Initial Assessment and Stabilization

The presentation of blood vomiting (hematemesis) in a full-term pregnant woman requires urgent evaluation for maternal collapse, regardless of IUD presence. 1

• Apply systematic ABCDE assessment to identify reversible causes of collapse, as survival rates are greater when the cause is rapidly identified and treated 1
• Consider the "4 H's and 4 T's" framework, with addition of eclampsia and intracranial hemorrhage specific to pregnancy 1
• Maintain high clinical suspicion even if Modified Early Warning Scores appear normal, as pregnant women can tolerate significant physiological derangement before decompensation 1

Differential Diagnosis for Hematemesis

The hematemesis itself is not a typical complication of IUD presence in pregnancy. The key causes to evaluate include:

Hemorrhagic Causes

• Concealed hemorrhage must not be forgotten, including splenic artery rupture or hepatic rupture, which can present with hematemesis 1
• Major obstetric hemorrhage (incidence 6 in 1000 maternities) from placental abruption, uterine rupture, or other sources 1
• Fit, healthy pregnant women can tolerate significant blood loss before showing signs of decompensation 1

Non-Obstetric Gastrointestinal Causes

• Upper GI bleeding from peptic ulcer disease, esophageal varices, or Mallory-Weiss tears (use general medical knowledge to evaluate)

IUD-Specific Considerations

While the IUD presence complicates the pregnancy, it is unlikely to be the direct cause of hematemesis:

• Pregnancy with IUD in situ is associated with increased risks of late miscarriage, preterm delivery, vaginal bleeding, chorioamnionitis, and placental abruption 2
• Intra-amniotic infection occurs in 45.9% of pregnancies with IUD versus 8.8% without IUD 2
• However, these complications typically present with vaginal bleeding, not hematemesis

IUD Management at Term

Do not attempt IUD removal during acute hematemesis management 3

• The IUD should be addressed after maternal stabilization
• At full-term gestation, the IUD will typically be delivered with the placenta
• If the patient desires IUD removal at any time, remove it and offer counseling on alternative contraceptive methods 3

Management Algorithm

1. Immediate resuscitation: Secure airway, breathing, circulation per maternal collapse protocol 1
2. Identify bleeding source: Distinguish upper GI bleeding from other causes of hematemesis
3. Assess for obstetric complications: Evaluate for placental abruption, uterine rupture, or other pregnancy-related hemorrhage 1
4. Initiate massive transfusion protocol if indicated for hemorrhagic shock 1
5. Prepare for delivery: At full-term, expedited delivery may be necessary depending on maternal and fetal status
6. Address IUD: Will typically be expelled with placenta; document removal post-delivery

Critical Pitfalls to Avoid

• Do not assume the IUD is causing the hematemesis - this diverts attention from life-threatening causes 1
• Do not underestimate blood loss - it is often difficult to estimate accurately, especially with slow, steady bleeding 1
• Do not delay delivery if maternal or fetal compromise is present at full-term gestation
• Do not attempt IUD removal during acute maternal instability 3