Patients using mifepristone and misoprostol or misoprostol-alone for management of early pregnancy loss (EPL) or medication abortion (MAB) are expected to have a bleeding phase.¹ While these treatments are very safe and effective, a common concern includes excessive bleeding. It is imperative to counsel your patients about expected bleeding and when they should be concerned. Typically, bleeding is more intense than a regular period and may include clots. The most significant bleeding generally happens within 24 hours. However, some individuals may experience heavy bleeding for up to 48 hours and might pass clots for days or even weeks afterward. Distinguishing normal from concerning bleeding can often be done with careful history taking alone.

Clinicians receiving calls from patients regarding bleeding should start by asking three main questions: 1) time the medication was taken in the case of a MAB or onset of bleeding in the case of an EPL, 2) number of pads soaked per hour, and 3) presence of anemia symptoms. You can view this tool from RHAP to aid the phone triage of bleeding.

When evaluating excessive bleeding, it is important to take into account the duration of bleeding, amount of bleeding, along with symptoms concerning for anemia such as lightheadedness or shortness of breath. Although it is normal to have some bleeding after EPL or MAB, studies show a useful indicator to determine successful management of EPL or MAB is termination of bleeding within 2 weeks. Studies show there is a sixfold increased risk of retained products of conception (RPOC) for patients who have persistent bleeding after 2 weeks,² so patients with bleeding >14 days should have a careful clinical assessment of their risk for RPOC. Patients who report soaking more than 2 pads per hour for 2 consecutive hours is concerning, as this may suggest incomplete abortion or RPOC.² Patients who are bleeding less than this need reassurance that this is normal.³ If the patient reports excessive bleeding, has symptoms concerning for anemia, or you have clinical concern for RPOC based on duration of bleeding then misoprostol 400 to 800 mcg +/- ibuprofen 800mg should be prescribed, which will induce uterine contractions and help expel any remaining tissue.¹ Patients who are asymptomatic should be counseled on supportive care, including ibuprofen, antiemetics, and an increase in fluid intake.

If a patient has persistent heavy bleeding despite the above medications, the patient will need to be seen in person for further evaluation, which should include a physical exam, pelvic exam, orthostatic vital signs, and a hemoglobin level. If abnormal findings are noted, procedural intervention such as uterine aspiration should be considered.¹ If a patient is hemodynamically unstable, the patient should be referred to the Emergency Department for further treatment.

RHAP Resources:

Phone Triage Call: Bleeding with Medication or Expectant Management of Miscarriage

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Sources:

1. Hendriks E, MacNaughton H, MacKenzie MC. First Trimester Bleeding: Evaluation and Management. Am Fam Physician. 2019;99(3):166-174.

2. Enzelsberger SH, Wetzlmair D, Hermann P, et al. Bleeding pattern after medical management of early pregnancy loss with mifepristone-misoprostol and its prognostic value: a prospective observational cohort study. Arch Gynecol Obstet. 2022;306(2):349-355. doi:10.1007/s00404-021-06291-5

3. Macnaughton H, Nothnagle M, Early J. Mifepristone and Misoprostol for Early Pregnancy Loss and Medication Abortion. Am Fam Physician. 2021;103(8):473-480.

4. Kruse B, Poppema S, Creinin MD, Paul M. Management of side effects and complications in medical abortion. Am J Obstet Gynecol. 2000;183(2 Suppl):S65-S75. doi:10.1067/mob.2000.107946

Pharma-free: The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or products. The information in the Insights is unbiased, based on science alone.

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