Case Presentation
A 26-year-old female G5P1300 with a past medical history of asthma was brought in by ambulance for vaginal bleeding. She was diagnosed at an outside hospital with a miscarriage 3 weeks prior to presentation. Transvaginal ultrasound at that time demonstrated an 8-week intrauterine pregnancy without fetal cardiac activity.
She was last seen by OB 2 days prior to presentation, where she was prescribed misoprostol, which was sent to her pharmacy but never picked up by the patient. Heavy vaginal bleeding started 1 hour prior to arrival, which prompted EMS activation. EMS reported seeing a large amount of blood in her bathroom at home, but they were not able to quantify or take a picture prior to patient transport.
On arrival to the ED, the patient had a blood pressure of 69/40, pulse of 57, respiratory rate of 20-30, and intermittent oxygen desaturations to 70% on room air, improving to 100% with 4L via nasal cannula.
On physical exam she had a thready radial pulse and increased work of breathing but lung sounds were clear to auscultation with good air entry, and abdomen was soft. Her mentation was slowed but she remained oriented without focal neurologic deficits. The sheets and pants the patient arrived in had been soaked through with blood, and blood was running down her legs. Sterile speculum exam showed active passage of bright red blood and clots, with products of conception visualized exiting the cervical os. FAST exam was done at bedside, with no free fluid visualized in the abdomen. The uterus on transabdominal ultrasound was filled with heterogenous blood products.
Upon presentation, she was administered 2 units of emergency release uncrossmatched pRBCs, 10 units IM Pitocin, 2 grams of tranexamic acid (TXA), and 1000 mcg rectal misoprostol. OB/GYN was emergently paged. Her point-of-care hemoglobin was 9.4, confirmed to be 10 on formal labs (normocytic), down from a baseline of 11.6 two months prior. There was a leukocytosis of 13.3, likely reactive. There were no major electrolyte derangements. PT and INR were normal, and aPTT was low at 19.5.
At bedside, the remaining products were gently removed with ring forceps from the cervical os under visualization with speculum, after which bleeding was controlled. Subsequent transabdominal ultrasound demonstrated a grossly empty uterus. She was admitted to the OB/GYN service for observation. At the time of admission, the patient had been weaned to room air saturating 100%, now hemodynamically stabilized (pulse of 72 and BP of 105/71) with improved mentation.
Clinical Takeaways
As EM learners and even as medical students, we are trained to remember the steps to manage post-partum hemorrhage; how should our management change for life-threatening hemorrhage from first-trimester miscarriage?
In any undifferentiated patient with early hemorrhage, the hemoglobin level is not a reliable measure of how much blood the patient has lost.1 Always treat the patient in front of you, by history, physical exam, and vital signs.
Providers should utilize ultrasound in these patients to evaluate differential diagnoses, such as ruptured ectopic pregnancy, by FAST exam to assess for free fluid in the abdomen. They may then use ultrasound to evaluate for products within the uterus and confirm when all products have been evacuated.
Despite this patient’s hemorrhage, her shock index was not elevated. The classic paradigm for hemorrhage is that tachycardia is the first sign of impending shock. It is possible that the patient’s protracted cervical dilation led to a profound vagal response, causing hypotension without tachycardia. This phenomenon has been described in the literature during gynecologic procedures requiring cervical dilation,2 and has also been described in EM:RAP.3 Though blood products are always the best first choice in resuscitating a bleeding patient, in these specific patients there may be a role for crystalloids and atropine should they become hypotensive and bradycardic.
In contrast to post-partum hemorrhage, oxytocin should not be used as a first-line agent for first-trimester hemorrhage because the uterus early in pregnancy (<20 weeks) has not yet developed enough oxytocin receptors to make it effective.4 Other commonly used uterotonics may be considered; in this case, not carboprost due to her history of asthma, which is an important clinical history to obtain even in a high-stress resuscitation. They may require bimanual massage and ultimately procedural intervention such as suction. Definitive management includes removing the products of conception from the cervix to allow for the cervix to close. The emergency provider may use sponge forceps to remove products under speculum examination. Deeper products within the endocervical canal and within the uterus require specialist consultation.
Case Conclusion
This is an example of a rare but life-threatening complication of spontaneous miscarriage. Emergency teams should be aware of the underlying pathophysiology and what methods are appropriate to manage this condition.
While this patient was admitted, she underwent suction dilation and curettage, and she was discharged the next day with a course of prophylactic doxycycline. She followed up in clinic 10 days later and was reported to be doing well, desiring to plan for her next pregnancy.
References
- Figueiredo S,TaconetC, Harrois A, et al. How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study. Ann Intensive Care. Jul 6 2018;8(1):76.
- Ubeda A, Cabrera S,EscalesC, et al. Predictors of vasovagal symptoms or syncope during outpatient diagnostic hysteroscopy: A prospective observational study. Eur J Obstet Gynecol Reprod Biol. May 2025;309:121–125.
- Cardy V, James H, Shepherd B.Right on Prime. The Generalist: First-Trimester Shock and Bleeding. July 2020.
- Zwerling B, Edelman A, Jackson A, Burke A, Prabhu M. Society of Family Planning Clinical Recommendation:Medication abortion between 14 0/7 and 27 6/7 weeksof gestation: Jointly developed with the Society for Maternal-Fetal Medicine. Am J Obstet Gynecol. Oct 2025;233(4):229–249.