Management of Early Second Trimester Pregnancy Loss and Bleedingng

Significant hemorrhage in pregnancy loss under 20 weeks is uncommon, as the uterine vascular supply and placental surface area are typically limited at this gestational age. When it does occur, management should follow the principles outlined in the Postpartum Hemorrhage section of the PESP and/or Emergnecy Childbirth section of the ALS PCS, emphasizing hemodynamic support, assessment of placental status, and rapid transport for definitive care.

If the patient is bleeding but the placenta has not delivered, encourage the patient to push with contractions, and attempt delivery of the placenta if possible, and initiate bimanual compression if bleeding persists or becomes severe. Fundal massage should not be performed prior to placental delivery of if there is uncertaintly about the placenta. 

If the placenta has delivered but is not intact, begin bimanual compression immediately once bleeding is considered significant, typically between 500 and 1000 mL. Ongoing bleeding in this setting suggests retained products and requires urgent transport.

If the placenta has delivered and is intact but bleeding continues, encourage the patient to void their bladder, then attempt firm, rotational fundal massage on the upper uterus. If this fails to control bleeding, start bimanual compression.

If labour and contractions have not occurred, oxytocin is less likely to be effective due to limited uterine receptor sensitivity. However, a patch consultation may be reasonable if the bleeding is clinically significant. IV therapy can be initiated at the end of this sequence for paramedics who are IV-certified to maintain perfusion during transport.

Reference

Association of Ontario Midwives. (2023). Postpartum and Early Stage Pregnancy (PESP) (2nd ed.). Toronto, ON: Author.

Cloutier-Holtz, K., Helen, K., Nair, J., Romeiko, N., Sabados, A., Viets, L., Zimmerman, S., et al. (2021). Emergency Skills Workshop Manual (7th ed.). Toronto, ON: Association of Ontario Midwives.

Hutton, E., Leslie, M. A., Porteous, R., Rogers, J., Seddon, F., Tate, M., et al. (1996). Emergency Skills Workshop Manual(1st ed.). Toronto, ON: Association of Ontario Midwives.