emDOCs Podcast – Episode 57: Post Abortion Complications Part I

Background

• Abortion techniques and contraception methods have been described throughout history. As of 2021, 24 countries ban abortion in any and all situations.
• Several different means of classifying abortion: medical vs. surgical, gestational age, safe vs. unsafe. Safe vs. Unsafe is the key differentiator. Complication rates differ significantly between these two classes.
• 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 if the country has a formal law, abortion is still widely 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.
• Before 2022, over 26 million “safe” abortions were performed every year, with 20-25 million “unsafe” abortions. 97% of these unsafe abortions occur in developing regions.
  • Resource limited areas are more likely to restrict access to legal abortion, and the restriction affects poorer patients disproportionately, leading to higher proportion of unsafe abortions.
  • Highest rates in Latin America and Africa, lower in Asia.
  • Higher rates of unsafe abortions in patients who are younger, poorer, and lack support of partner.
• In the U.S., approximately 1 million abortions are performed annually, and 25% of females will have an abortion during their lifetime.
  • However, there are limits in the U.S. Many states limit patient access through 24-72 hour waiting periods between counseling and the procedure. Distance from centers and financial costs are other issues.

Complication Rates

• “Safe” abortions are associated with a low risk of complications overall, with 0.11-0.16% of patients experiencing a major complication, 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.

Abortion Methods

• Of 25 million “Unsafe” abortions annually, around 7 million have a complication.
• Methods of safe abortions
  • Safe Medical abortion: Early termination of pregnancy through medication and can be used until 70 days of gestation.
    • In the U.S., a 2-drug regimen of a 200-mg dose of mifepristone and 800-mg dose of misoprostol is used.
    • Efficacy around 96%.
    • Normal adverse effects of medical abortion can include cramping and vaginal bleeding, a brief low-grade fever, headache, dizziness, nausea, vomiting, and diarrhea.
    • Bleeding begins 1-4 hours after misoprostol. Heaviest bleeding is 3-8 hours after administration.
  • Safe Surgical abortion (1^st trimester): vacuum aspiration – the cervix is dilated, a cannula is inserted through the cervix into the uterine cavity, and the uterine contents are aspirated. Ripening agents may be used for cervical preparation with misoprostol.
  • Safe Surgical abortion (2^nd trimester): Dilation and evacuation procedure. Cervical dilation is often used to improve safety and efficiency, with misoprostol and/or osmotic dilators.
• 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

ED evaluation

• Focus is to rule out dangerous complications in patients, whether safe or unsafe abortion.
• History: gestational history, medical vs. surgical abortion, what occurred during the procedure, any known complications during the procedure, constitutional/systemic symptoms, bleeding, vaginal discharge, PMH (diabetes, coagulopathy).
  • Women with self-induced or “unsafe” abortion may not want to disclose attempt due to fear of legal or social repercussion. We have to remain vigilant; early recognition is essential.
  • Exam findings inconsistent with history, severe sepsis or anemia without a source are red flags.
  • Risks are living in resource limited regions, areas with limited access to reproductive health/abortion resources
  • We have to be nonjudgmental and ask directed questions about where and how the abortion was performed.
• Exam: Vital signs, abdomen (peritonitis), pelvic exam (speculum and bimanual).
• Labs and imaging dependent on specific complication. US is one of the main imaging modalities in many complications.

Complications

Bleeding

• Most common complication
  • Unsafe: Severe bleeding occurs in 3%, non-severe in 44%
  • Safe: < 2%
• More common in medical vs. surgical abortion.
• May result in hemorrhagic shock, coagulopathy, death.
• 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).
• Laboratory assessment: CBC, Coagulation panel, 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 1stline, 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

• Second most common complication
  • Unsafe: Severe infection in 5.1%, nonsevere in 24%
  • Safe: < 0.23%
• Infection risk associated with RPOC, non-sterile 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 associated with toxic shock syndrome.
• 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.
• Infection 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, CBC, electrolytes, renal and liver function, lactate, US (evaluate for RPOC), blood/cervical cultures.
• Treatment: Consult OBGYN, obtain source control (vacuum aspiration D&C), administer broad spectrum antibiotics and resuscitate.
  • Gentamicin, clindamycin, ampicillin
  • Piperacillin/tazobactam and clindamycin