Post Abortion Complications

Post-Abortion Complications
Anand Swaminathan and Brit Long

• Safe vs Unsafe Abortions 
  • Abortions are classified as “safe” vs. “unsafe”, and then by the mechanism (medical vs. surgical).
  • The type of abortion matters; it affects complications and patient outcomes.
  • The World Health Organization (WHO) defines “safe” abortion as abortion in countries where abortion law is not restrictive (abortion is legally permitted for social or economic reasons, or without specification as to reason) or countries in which, despite formal law, safe abortion is broadly available.
  • The WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy either by individuals without the necessary skills or in an environment that does not conform to minimum medical standards, or both. 
    • Unsafe abortion mainly endangers women in developing countries where abortion is highly restricted by law and countries where even if legally permitted, safe abortion is not easily accessible. In this type of setting, women with an unintended pregnancy often self-induce abortions or obtain clandestine abortions from medical practitioners, para medical workers, or traditional healers.
    • Unsafe abortion is a persistent, preventable pandemic.
  • “Safe” abortions are overall very safe; 0.11-0.16% major complication rates, mortality rates 0.62 per 100,000.
  • Of 25 million “Unsafe” abortions annually, around 7 million have a complication. 
    • There are 68,000 deaths per year due to unsafe abortions; accounts for 4.7-13.2% of all maternal deaths annually.
    • In countries with significant resources, 30 women per 100,000 unsafe abortions die annually, but this rises to 220 deaths per 100,000 unsafe abortions in settings with limited resources.
    • Morbidity and mortality associated with poor provider skill, poor technique, unsanitary conditions, lack of appropriate equipment, toxic substances, poor maternal health, increased gestational age, lack of access to care after abortion.
• Methods of unsafe abortions 
  • Oral and injectable treatments/toxins: metal salts, phosphorus, turpentine, lead, kerosene, detergents, uterine stimulants (misoprostol or oxytocin), chloroquine, OCPs, hormones, teas and herbal remedies.
  • Preparations placed in the cervix, vagina, or rectum: potassium permanganate tablets, herbal preparations, misoprostol, enemas.
  • Intrauterine instrumentation: catheter insertion and then infusion of substance (alcohol, saline), foreign body insertion (knitting needles, stitch hook, coat hanger, air blown through a syringe).
  • Transcervical introduction of substances: soap, cresol, phenol.
  • Trauma to the abdomen/back: self-inflicted blows, abdominal massage, jumping from a height, lifting heavy weights.
• Bleeding: 
  • Unsafe: Severe bleeding occurs in 3%, non-severe in 44%
  • Safe: < 2%
  • May result in hemorrhagic shock, coagulopathy, death.
  • More common in medical vs. surgical abortion.
  • Several causes: trauma/laceration (vagina, cervix, uterus, adnexal vasculature, atony, infection, retained products, coagulopathy. 
    • Similar to PPH with 4 T’s (tone, tissue, trauma, thrombin).
    • More rare: ectopic pregnancy, uterine artery pseudoaneurysm, abnormal placenta location, AV malformation.
  • In safe medical abortions, heavy bleeding occurs 3-8 hours after meds. Excessive bleeding is 2 pads per hour for 2 hours in a row. Median duration of bleeding is 11-13 days, but 25% have bleeding up to 17 days or longer.
  • Pelvic exam is essential (speculum and bimanual exam).
  • CBC, coags, Type and screen.
  • US for RPOC, hematometra, free fluid in abdomen.
  • Treatment determined by underlying cause; consult OBGYN. 
    • If unstable, transfuse/resuscitate. Administer TXA. May require massive transfusion protocol (especially if 2 units pRBCs administered).
    • Cervical laceration: direct pressure/silver nitrate, but if larger, absorbable sutures.
    • RPOC or hematometra suspected: speak with OBGYN. Treatment is vacuum aspiration. May be performed in ED in resource limited settings.
    • Uterine atony: fundal massage. May use uterotonic agents (Misoprostol 800 to 1,000 mg by rectum is 1st line, followed by methylergonovine 0.2 mg intramuscularly (can be repeated up to 5 times and acts rapidly) and carboprost intramuscularly.). Hold on uterotonic agents if concerned about RPOCs. May need sterile catheter balloon or Bakri balloon.
    • Refractory bleeding; IR for uterine artery embolization or surgical laparotomy and even hysterectomy. Surgery also necessary if heterotopic pregnancy.
    • Consider DIC.
• Infection 
  • Unsafe: Severe infection in 5.1%, nonsevere in 24%
  • Safe: < 0.23%
  • Related to RPOC, nonsterile technique, trauma
  • Most cases are polymicrobial. Bacteria include endogenous vaginal flora and preexisting infections (Chlamydia, Gonorrhea, Trichomonas). Group B strep, E. Coli, Staph, and anaerobes are common.
  • Group A strep and clostridial species are very dangerous: toxic shock with rapid deterioration.
  • Patients present with fever, chills, malaise, abdominal/pelvic pain, vaginal bleeding and discharge.  Exam may reveal significant abdominal tenderness and boggy/tender uterus with dilated cervix.
  • May lead to sepsis, septic shock, organ failure, DIC, and future sterility. TSS: Initial symptoms are nonspecific and can include abdominal pain or cramping, nausea, vomiting, diarrhea, and chills.  Patients develop signs of septic shock.
  • Evaluation includes pelvic exam, US (RPOC), blood/cervical cultures, normal sepsis labs.
  • Consult OBGYN, obtain source control (vacuum aspiration D&C), administer broad spectrum antibiotics. Gentamycin, clindamycin, ampicillin.
• Trauma 
  • Usually due to insertion of foreign body.
  • Unsafe: severe 7.2%, nonsevere 5.5%
  • Can damage vaginal canal, cervix, uterus, GI tract, bladder. Perforation may result.
  • Vaginal/cervical lacerations present with bleeding.
  • Uterine perforation is most common upper genital tract injury. Occurs in 0.1-2.3% of safe abortions. 
    • Larger perforation: bleeding, instability, constitutional signs/symptoms, abdominal/pelvic pain.
    • Smaller perforation may go undetected.
    • US is 1st line test: defects in the uterine wall, abnormal uterine contents, abdominal free fluid, or visualized fetal tissue. If US negative or other complications such as bowel perforation suspected, obtain CT.
    • Surgical/OBGYN consult for surgical repair.
  • Bowel/bladder perforations can occur. Require further specialist management for surgery.
• Chemical burns/drug toxicity 
  • Variety of signs and symptoms dependent on agent. Damage to vaginal area/uterus, may have renal/liver toxicity.
  • Many patients seek out medications on the internet, with no healthcare oversight.  Products bought online claiming to be misoprostol are not regulated and may contain other substances.
  • Misoprostol toxicity may present with high fever, hypoxemia, hypotension, chills and rigors, abdominal cramping, vomiting and diarrhea, agitation, AMS, myalgias and rhabdomyolysis. 
    • Symptoms develop soon after ingestion, as the medication is completely absorbed from the stomach in 90 minutes.  Symptoms can last 12 hours.
    • Treatment includes removing remaining tablets from the vagina or stomach (lavage), supportive care.
• Medical abortion complications 
  • Patients may present after receiving medications. Our job is to determine if abortion was completed and assess the patient for complications. Consider ectopic and heterotopic pregnancy.
  • Obtain CBC, Beta HCG, US.
  • Pregnancy expulsion usually at 3-8 hours after receiving medications. 
    • 3-8 hours and well-appearing, minimal pain, discharge with follow up.
  • If past 8 hours, look for gestational sac or RPOC with US. If present, incomplete abortion may have occurred and OBGYN should be consulted.  Not clear cut, as debris in the uterus is not confirmatory for RPOC in this setting.
  • If the patient has a reassuring US (ie, no gestational sac observed in the uterus), normal laboratory testing results, stable vital signs, and a benign examination result, discharge from the ED can be considered with clinic follow-up.
• Amniotic fluid embolism 
  • Abnormal maternal inflammatory response after exposure to fetal tissue
  • Very rare.
• Presents with hypotension, acute dyspnea, desaturation, pulmonary edema, cardiovascular collapse, and coagulopathy. 
  • Treatment focuses on maintaining CV function, oxygenation, managing coagulopathy and bleeding.