Prehospital Care
Prehospital care for patients with suspected abortion complications includes the following:
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Monitor vital signs.
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Stabilize with intravenous fluids (eg, normal saline, Ringer's lactate), if the patient is hemodynamically unstable.
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Administer oxygen.
Emergency Department Care
Screen all patients with postabortion complications for Rh factor. Administer Rho(D) immune globulin (RhoGAM) if results indicate that the patient is Rh-negative and unsensitized.
Patients with the postabortion triad (ie, pain, bleeding, low-grade fever) may respond to treatment with oral antibiotics and ergot preparations. Immediately initiate these agents. In most cases, however, blood clots or retained products of conception must be evacuated from the uterus. In these cases, administer medications parenterally, as the patient will undergo anesthesia.
Hemorrhage or hematometra
Monitor vital signs and rate of bleeding. Administer fluids and blood as needed.
Administer intravenous oxytocin for treatment of uterine atony.
Alternative treatments for uterine atony include intracervical vasopressin or carboprost tromethamine and bimanual uterine massage.
If bleeding persists, screen for coagulopathy/DIC and obtain immediate gynecologic consultation with the intention of transferring the patient to the operating room (OR) for repeat curettage and, if necessary, hysterectomy.
Uterine perforation, bowel injury, and bladder injury
If one or any combination of these complications is suspected or diagnosed in the ED, treat as follows:
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Hemodynamically stabilize the patient
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Insert a Foley catheter
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Transfer to the OR for laparoscopy/laparotomy and further treatment
Failed abortion, continued pregnancy, and ectopic pregnancy
If the patient is stable, perform ultrasonography and obtain a beta-human chorionic gonadotropin (hCG) level to establish the diagnosis and further treatment.
If the patient is unstable, transfer to the OR for dilation and curettage (D&C) and/or laparoscopy/laparotomy.
Suspected septic abortion
Administer intravenous fluids through a large-bore angiocatheter.
For patients who are unstable, administer oxygen and insert a Foley catheter.
Early antibiotic treatment may be guided by Gram stain, but broad-spectrum coverage is recommended.
Perform evacuation of retained tissues from the uterine cavity, preferably by D&C. If D&C is not immediately available, high doses of oxytocin can be used.
Laparotomy may be needed if the above measures elicit no response.
A hysterectomy may be necessary in cases of uterine perforation, bowel injury, clostridial myometritis, and pelvic abscess.
Management of septic shock is discussed in Shock, Septic.
Consultations
Consult an obstetrician/gynecologist (OB/GYN) in all cases of postabortion complications.
Consult surgery and urology if bowel or bladder injury is diagnosed.
