Hemorrhage

a. Excessive bleeding may indicate uterine atony, a low-lying implantation, a pregnancy of more advanced gestational age than the first trimester, or perforation. Management requires rapid reassessment of gestational age by examination of the fetal parts already extracted and gentle exploration of the uterine cavity with a curette and forceps. Intravenous oxytocin should be administered, and the abortion should be completed. The uterus then should be massaged to ensure contraction.

b. When these measures fail, the patient should be hospitalized and should receive intravenous fluids and have her blood cross-matched. Persistent postabortal bleeding strongly suggests retained tissue or clot (hematometra) or trauma, and laparoscopy and repeat vacuum curettage is indicated.

5. Hematometra. Lower abdominal pain of increasing intensity in the first 30 minutes suggests hematometra. If there is no fever or bleeding is brisk, and on examination the uterus is large, globular, and tense, hematometra is likely. The treatment is immediate reevacuation.

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