AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Complications of spontaneous and therapeutic abortions include (1) complications of anesthesia, (2) postabortion triad (ie, pain, bleeding, low-grade fever), (3) hematometra, (4) retained products of conception, (5) uterine perforation, (6) bowel and bladder injury, (7) failed abortion, (8) septic abortion, (9) cervical shock, (10) cervical laceration, and (11) disseminated intravascular coagulation (DIC).

Pathophysiology

Postabortion complications develop as a result of 3 major mechanisms, as follows: (1) incomplete evacuation of the uterus and uterine atony, which leads to hemorrhagic complications, (2) infection, and (3) instrumental injury.

Frequency

United States

Frequency depends on gestational age (GA) at time of abortion and method of abortion. Complication rates according to GA at time of abortion are as follows: (1) fewer than 6 weeks, less than 1%; (2) 12-13 weeks, 3-6%; and (3) second trimester, up to 50%, possibly higher.

Mortality/Morbidity

Mortality and morbidity depend on GA at time of abortion. In the US, mortality rates per 100,000 abortions are as follows: (1) fewer than 8 weeks, 0.5; (2) 11-12 weeks, 2.2; (3) 16-20 weeks, 14; and (4) more than 21 weeks, 18.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Presentation depends on the type of complication the patient develops.

• Intraoperative and early postoperative complications rarely are seen in the ED, but some patients develop these types of complications and present to the ED for treatment. Complications include the following:
• • Local anesthesia: Paracervical block is the most common method of anesthesia for therapeutic abortion. Accidental intravascular injection of anesthetic is a potentially life-threatening complication of this method that could lead to convulsion, cardiopulmonary arrest, and death.
  • General anesthesia: Complications with general anesthesia may lead to uterine atony with severe hemorrhage.
  • Cervical shock: Vasovagal syncope produced by stimulation of the cervical canal during dilatation may occur. Rapid recovery usually follows.
  • Postabortion triad: Pain, bleeding, and low-grade fevers are the most common presenting complaints. Postabortion triad usually is caused by retained products of conception.
  • Hemorrhage: Excessive hemorrhage during or after abortion may signify uterine atony, cervical laceration, uterine perforation, cervical pregnancy, a more advanced GA than anticipated, or coagulopathy.
  • Hematometra: Patients usually present with persistent postabortion bleeding and increased lower midline abdominal pain.
  • Perforation: Patients with uterine perforation missed during the procedure usually present to the ED with increased abdominal pain, bleeding (possibly ranging from very mild to absent), and fever. If perforation results in injury to major blood vessels, patients may present in hemorrhagic shock.
  • Bowel injury: This may accompany uterine perforation. If initially unrecognized, patients present with abdominal pain, fever, blood in the stool, nausea, and vomiting.
  • Bladder injury: This occurs as a result of uterine or cervical perforation. Patients present with suprapubic pain and hematuria.
  • Septic abortion: Patients present with fever, chills, abdominal pain, and vaginal bleeding.
  • Failed abortion (continued intrauterine or ectopic pregnancy): Failure to terminate pregnancy is relatively common with very early abortions ( <6 wk GA). Such patients may present to the ED with symptoms of continuing pregnancy such as hyperemesis, increased abdominal girth, and breast engorgement. In addition, an unrecognized ectopic pregnancy in the postabortion period presents in the usual manner.
  • DIC: Suspect DIC in all patients who present with severe postabortion bleeding, especially after midtrimester abortions. Incidence is approximately 200 cases per 100,000 abortions; this rate is even higher for saline instillation techniques (660 per 100,000 abortions).

Physical

• Vital signs
• • Monitoring of vital signs is essential for patients with postabortion complications.
  • Increasing fever could be a sign of progressing infection.
  • Tachycardia and hypotension may be signs of severe hemorrhage or septic shock.
• Abdominal examination
• • Suprapubic tenderness is common in the postabortion period. Severe tenderness is unusual, however, and may be a sign of hematometra, bladder perforation, or bowel injury.
  • Tenderness in other areas of the abdomen (eg, rebound tenderness, guarding) strongly indicates instrumental injury complications (eg, perforation, bowel injury, bladder injury).
  • A tender mass in suprapubic area suggests hematometra.
  • Diminished or absent bowel sounds are a sign of developing peritonitis.
• Vaginal examination
• • Assess the quantity and rate of hemorrhage.
    • Look for possible vaginal or cervical injury.
    • Identify the source of bleeding (eg, intrauterine, cervical os, lesions of vulva, vagina, or vaginal portion of cervix).
  • Cervical motion tenderness on bimanual examination may be suggestive of pelvic infection or ectopic pregnancy.
  • A large tender uterus may be a sign of hematometra.
  • Adnexal tenderness or masses may suggest ectopic pregnancy, pelvic inflammatory disease (PID), cyst, or hematoma.
• Rectal examination
• • Rectal examination must be performed if bowel injury is suspected.
  • Presence of rectal tenderness and blood (or guaiac-positive stool) makes the diagnosis of bowel injury almost certain.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Perforated viscus
Acute peritonitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Complete blood count, platelets
• Sequential Multiple Analysis-7
• Beta-human chorionic gonadotropin; requesting a quantitative level may provide useful information and a basis for future comparison.
• Prothrombin time/activated partial thromboplastin time
• Urinalysis
• Type and screen or type and cross with antibody screen (with severe hemorrhage)
• Fibrinogen and fibrin split products if DIC is suspected
• D-dimer

Imaging Studies

• To exclude free air as a result of bowel perforation, perform either upright chest x-ray or obtain kidney, ureter, bladder (KUB) and upright abdominal x-rays.
• Order or perform ultrasound with a vaginal probe to rule out ectopic pregnancy, retained products of conception, and hematometra.
• Order arteriography if injury to large blood vessels is suspected.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

Monitor vital signs and provide fluid resuscitation if the patient is hemodynamically unstable.

Emergency Department Care

Screen all patients with postabortion complications for Rh factor. Administer Rho(D) immune globulin (RhoGAM) if results indicate that the patient is Rh-negative and unsensitized.

• Patients with the postabortion triad (ie, pain, bleeding, low-grade fever) may respond to treatment with oral antibiotics and ergot preparations. Immediately initiate these agents. In most cases, however, blood clots or retained products of conception must be evacuated from the uterus. In these cases, administer medications parenterally, as the patient will undergo anesthesia.
• Hemorrhage or hematometra
• • Monitor vital signs and rate of bleeding. Administer fluids and blood as needed.
  • Administer IV oxytocin for treatment of uterine atony.
  • Alternative treatments for uterine atony include intracervical vasopressin or carboprost tromethamine and bimanual uterine massage.
  • If bleeding persists, screen for coagulopathy/DIC and obtain immediate gynecologic consultation with the intention of transferring the patient to the operating room (OR) for repeat curettage and, if necessary, hysterectomy.
• Uterine perforation, bowel injury, and bladder injury: If one or any combination of these complications is suspected or diagnosed in the ED, treat as follows.
  • Hemodynamically stabilize the patient.
  • Insert a Foley catheter.
  • Transfer to the OR for laparoscopy/laparotomy and further treatment.
• Failed abortion, continued pregnancy, and ectopic pregnancy
• • If the patient is stable, perform ultrasound and a beta-human chorionic gonadotropin (hCG) test to establish diagnosis and further treatment.
  • If the patient is unstable, transfer to the OR for dilation and curettage (D&C) and/or laparoscopy/laparotomy.

Consultations

• Consult an obstetrician/gynecologist (OB/GYN) in all cases of postabortion complications.
• Consult surgery and urology if bowel or bladder injury is diagnosed.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.

Drug Category: Antibiotics

Immediately administer broad-spectrum antibiotics to patients with severe postabortion infection.

Drug Category: Ergot alkaloids

Ergot derivatives are used for oxytocic effects on uterine muscle. These agents prevent postabortion uterine atony and hemorrhage.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient treatment includes repeat D&C, laparoscopy, and laparotomy (for treatment of complicated perforation, bowel and bladder injuries, refractory bleeding).

Further Outpatient Care

• If the patient is discharged from the ED, arrange definite follow-up care in 1-2 days with primary gynecologist.

Deterrence/Prevention

• Educate patients about contraceptive measures to deter them from using abortion as a means of birth control.

Patient Education

• For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Procedures Center. Also, see eMedicine's patient education articles Miscarriage, Abortion, and Dilation and Curettage (D&C).

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Do not underestimate the amount and rate of bleeding. In the supine position, more than 500 cc of blood may collect in the vagina without severe external bleeding. Always perform a pelvic examination on a postabortion patient who is bleeding.
• Aggressively treat vaginal bleeding even if it seems minimal. Stabilize the patient with 2 large-bore IVs and with oxygen. Closely monitor vital signs.
• In postabortion patients with abdominal pain beyond the pelvic area, suspect perforation and evaluate with KUB/upright x-rays and pelvic ultrasound. Consult a gynecologist and, if suspicion is high, insist on laparoscopy.
• The chance of a missed ectopic pregnancy always exists. Do not presume intrauterine pregnancy in a patient who has just had an abortion; she may have had a missed ectopic pregnancy.
• Do not delay administration of antibiotics if a patient has signs of severe postabortion infection. Administer broad-spectrum antibiotics before completing diagnostic workup.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Darney PD, ed. Handbook of Office and Ambulatory Gynecologic Surgery. Blackwell Science, Inc;1987:108.
• Grimes DA, Cates W Jr. Deaths from paracervical anesthesia used for first-trimester abortion, 1972-1975. N Engl J Med. Dec 16 1976;295(25):1397-9. [Medline].
• Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol. Jul 1990;76(1):129-35. [Medline].
• Sam C, Hamid MA, Swan N. Pyometra associated with retained products of conception. Obstet Gynecol. May 1999;93(5 Pt 2):840. [Medline].
• Shannon C, Brothers LP, Philip NM, Winikoff B. Infection after medical abortion: a review of the literature. Contraception. Sep 2004;70(3):183-90. [Medline].
• Shulman SG, Bell CL, Hampf FE. Uterine perforation and small bowel incarceration: sonographic and surgical findings. Emerg Radiol. Aug 16 2006;[Medline].
• Stuart GS, Sheffield JS, Hill JB, et al. Morbidity that is associated with curettage for the management of spontaneous and induced abortion in women who are infected with HIV. Am J Obstet Gynecol. Sep 2004;191(3):993-7. [Medline].
• Stubblefield PG. First and second trimester abortion. In: Nichols DH, ed. Gynecologic and Obstetric Surgery. Mosby-Year Book;1993:1016-1030.
• Stubblefield PG, Grimes DA. Septic abortion. N Engl J Med. Aug 4 1994;331(5):310-4. [Medline].
• Stubblefield PG. Pregnancy termination. In: Obstetrics: Normal and Problem Pregnancies. 3rd ed. Churchill Livingstone;1996:1249-1276.

Article Last Updated: Aug 29, 2006