Spontaneous Abortion (Miscarriage)

Full stomach - She is still a parturient. Keep her NPO and give aspiration prophylaxis (metoclopramide plus sodium citrate) as you would for any pregnant patient, and plan the airway accordingly.

Quantify the bleeding before induction - Pad count and quantified blood loss, serial vital signs for tachycardia and narrowing pulse pressure, hemoglobin, and a type and cross. Bleeding heavier than a typical menses points to significant loss, and hypovolemic signs can appear before any sign of sepsis.

Access and resuscitation - Large-bore IV, crystalloid for volume depletion, and anticipate transfusion. Monitor the rate of bleeding and the vitals continuously — improvement or deterioration drives whether this stays a short case.

Uterine atony and hemorrhage - Uterine atony with subsequent hemorrhage is the major complication. Have oxytocin ready and give it in step with the obstetrician. If the uterus stays boggy despite oxytocin, methylergonovine 0.2 mg IM and/or carboprost 150-250 mcg IM are the next agents.

Watch for DIC - If bleeding persists after evacuation and uterotonics, think disseminated intravascular coagulation (DIC), send coagulation studies, and plan for ICU-level support rather than a PACU discharge.

Septic abortion - Fever, purulent cervical or vaginal discharge, tachycardia, and hypotension in the setting of retained products. Broad-spectrum IV antibiotics start immediately, and the surgeon proceeds with uterine evacuation rather than waiting out the infection. Treat it as a sepsis case with a short surgical fix.

Uterine perforation - The most common immediate complication of dilation and curettage (D&C), usually at the fundus, and more likely with increasing gestational age, nulliparity, and a retroverted uterus. If bowel injury or significant hemorrhage is suspected, the case converts to laparoscopy — be ready for a laparoscopic setup, not a 10-minute MAC.

Suspected molar pregnancy - Do this one in the OR, not a procedure room. Anesthesia complications and severe hemorrhage are both real possibilities.

Anesthetic technique - IV sedation or a general anesthetic, depending on the patient and setting; the surgeon may also inject 1% lidocaine into the cervix and lower uterine segment. Cervical priming with misoprostol or an osmotic dilator may already be on board, which shortens the most stimulating part of the case.

Coagulation factor deficiency - Replace the deficient factor before the procedure rather than chasing bleeding intraoperatively.

Positioning - Dorsal lithotomy for the whole case. Pad and position the legs deliberately even though the case is short.

Read the room - This is a pregnancy loss, not an elective procedure. Keep the pre-induction conversation quiet and avoid procedural language at the bedside.

Spontaneous abortion is loss of pregnancy before 20 weeks, and it ends 10-20% of clinically recognized pregnancies. About half are driven by fetal chromosomal abnormalities. The subtypes matter because they predict what you'll be anesthetizing for: threatened (bleeding, closed cervical os, viable fetus), inevitable (open os), incomplete (partial passage of products), complete, missed (embryonic demise with no expulsion), and septic (retained products that become infected). Advanced maternal age and prior loss are the biggest risk factors.

The perioperative problem is what retained products do. They keep the uterus from clamping down, so the patient bleeds — occasionally to hypovolemic shock — and they seed infection, producing fever, purulent discharge, tachycardia, and hypotension. Both complications are rare but they are the reason these cases land in the OR.