INITIAL MANAGEMENT
When a woman describes
bleeding in early pregnancy
the treating doctor must first
determine whether she has
heavy bleeding and/or severe
pain. Saturation of pads
and/or passing clots larger
than a 20 cent piece implies
heavy bleeding. If either is
present this scenario must betreated as a clinical emergency.
The possibility of cervical
shock should always be considered.
A speculum examination
should be performed,
and any products of conception
(POC) should be removed
from the cervix . This is the
only way to reverse shock associated
with this condition.
Basic life support principles
apply. It is important to:
• Ensure that the woman has
a clear airway and adequate
breathing before the speculum
examination is performed.
• Gain IV access with a cannula
of at least 16G diameter
and start IV crystalline
fluids at a rate that maintains
adequate blood pressure
(>100/60) and pulse
rate (<100 beats per minute).
• As the IV is inserted, take
blood for blood group typing
and FBC, and arrange
cross-match of four units of
packed cells.
If analgesia is required, small
bolus doses of IV morphine
2mg titrated to pain at 5-
minute intervals gives quick
relief but should be accompanied
by metoclopramide 10mg
IV as an anti-emetic.
If shock cannot be controlled
despite adequate IV fluids
and removal of POC, the
woman must be prepared for
emergency D&C. Surgery
should not be delayed due to
haemodynamic instability; it
should be performed before
blood and fluid losses have
been replaced. Sometimes surgical
evacuation of the uterus
is needed to resolve shock.
