Introduction

Roughly one million induced abortions are performed each year in the United States alone. Although deemed safe, therapeutic abortions, as well as spontaneous miscarriages, can lead to a variety of complications. Most complications are considered minor such as pain, bleeding, infection, and post-anesthesia complications, while others are major, namely uterine atony and subsequent hemorrhage, uterine perforation, injuries to adjacent organs (bladder or bowels), cervical laceration, failed abortion, septic abortion, and disseminated intravascular coagulation (DIC).[1][2]

The total abortion-related complication rate including all sources of care including emergency departments and the original abortion facility is estimated to be about 2%.

The incidence of abortion-related emergency department visits within six weeks of initial abortion procedure is about 40%.[3]

Etiology

Post-abortion complications develop as a result of three major mechanisms: (1) infection, (2) incomplete evacuation of the products of conception, leading to hemorrhagic complication, and (3) injury from the surgical procedure itself.

Epidemiology

The frequency and severity of abortion complications depend on gestational age at the time of the abortion and the method of abortion. [4][5]

Complications based on gestational age are as follows:

• Eight weeks and under - Less than 1%
• 8-12 weeks - 1.5-2%
• 12-13 weeks - 3-6%
• 2nd trimester - Up to 50%

The estimated abortion complication rate for all healthcare sources is about 2% for medication abortion, 1.3% for first-trimester aspiration abortion, and 1.5% for second-trimester or later abortions

In the United States, mortality rates per 100,000 abortions are as follows: fewer than 8 weeks - 0.5%; 11-12 weeks - 2%; 16-20 weeks - 14%; and more than 21 weeks - 18%.

In the United States, mortality from septic abortion rapidly declined after the legalization of abortions. Death now occurs in fewer than 1 per 100,000 abortions. The risk of death from septic abortion increases with the progression of gestation.

Curiously, one study reports that women aged 30–39 years were more likely to have a complication after an abortion compared with women ages 20–24 years and Hispanic women were significantly less likely to have a complication compared with white women.

Pathophysiology

As described in the Etiology section, there are three major mechanisms by which abortion complications can be classified. Infection can be the result of a failure to exercise universal precautions prior to the procedure, such as hand washing, surgical glove use, proper sterilization of the field, use of non-sterile instruments, as well as the presence of a pre-existing infectious process in a patient such as cervicitis or endometritis. (2) Incomplete evacuation of the products of conception leads to the collection of blood in the uterine, causing overdistention and atony which results in hemorrhage. It can also lead to infection and possible sepsis. (3) Injury from the surgical procedure itself depends upon the method used and include vaginal or cervical lacerations, as well as uterine, bowel, or bladder injury. 

History and Physical

A good history is essential to make a timely and correct diagnosis. The emergency physician must ask the timing of the abortion, whether it was performed by an appropriate abortion provider at the appropriate facility, and whether any intraoperative or early postoperative complications took place. A thorough past medical and past surgical history are important to obtain, including chronic conditions or past surgeries that may complicate the current condition further. Careful medication history is of paramount importance, such as fertility medications and anticoagulants. 

The presentation depends on the type of complication that a patient develops. Intraoperative and early postoperative complications are usually not seen in Emergency Departments (ED) as they are identified and managed by abortion providers during or immediately following the procedure. 

However, the post-abortion triad (pain, bleeding, low-grade fever) frequently is seen in the ED, and the diagnosis of retained products of conception must be sought promptly as a source of the symptoms. Excessive bleeding (postoperative hemorrhage) may be indicative of uterine atony, uterine perforation, ectopic pregnancy, coagulopathy, or iatrogenic surgical instrumentation injury. The post-abortion syndrome can present as progressively worsening lower abdominal pain and hemodynamic compromise absent vaginal bleeding. This is due to the collection of blood and/or retained products of conception in the uterus, causing overdistention of the uterine cavity, which is unable to contract in order to expel its contents. 

Bowel or bladder injury may initially present as bleeding and pain, but may quickly progress to infection and septic shock. 

Failed abortion is more common with early gestational age, and patients may present to ED with symptoms of continued pregnancy. 

The physical exam must include the following:

1. Vital signs - Frequent vital signs in ED are essential as patients afebrile in triage may develop a fever while in ED. Tachycardia and hypotension are indicative of a hemodynamic compromise.
2. Abdominal exam - Look for peritoneal signs, absent bowel sounds, palpable masses, or severe tenderness.
3. Pelvic exam - Assess for severity of vaginal bleeding, look for obvious vaginal or cervical injury, determine whether the cervical opening to the uterus is open or closed, and note the size and tonus of the uterus as well as uterine tenderness and/or adnexal tenderness.
4. Rectal exam may be necessary if a bowel injury is suspected.

Evaluation

The following lab tests are helpful in the evaluation of post-abortion complications:

• CBC (complete blood count) to assess a drop in hemoglobin/hematocrit which may be indicative of ongoing hemorrhage. 
• Complete metabolic panel to assess any renal, hepatic or electrolyte abnormalities.
• Beta-HCG to establish a baseline to monitor the predicted decline in level or to compare with the pre-existing level.
• Coagulation studies, especially if a patient is expected to go to the operating room.
• Blood type/Rh with antibody screen to establish the need for Rhogam and/or for possible impending blood transfusion.
• Blood cultures if sepsis is suspected.
• If DIC is suspected, fibrinogen, fibrin-split products, and d-dimer should be obtained.

Treatment / Management

As always, ABC is first! 

The patient's hemodynamic status must be assessed immediately, and intravenous access obtained. If the patient exhibits signs of volume depletion, the practitioner must start resuscitation with intravenous crystalloid fluids and assess the volume of blood loss. The potential for blood transfusion must be anticipated. The patient's vital signs, the rate of bleeding, and the overall condition must be monitored constantly for improvement or deterioration. Consider oxytocin administration in consultation with Ob/Gyn colleagues, if uterine atony is highly suspected. If the bleeding persists, DIC should be considered, and the patient should be prepared for the transfer to operating room/intensive care unit.[6][7][8]

Patients with a triad of pain, bleeding, low-grade fever should be volume resuscitated with intravenous crystalloids, pain treated with either non-steroidal anti-inflammatory drugs or opioids, and broad-spectrum antibiotics must be started immediately, preferably intravenously. In most cases, the patient will require evacuation of blood clots and/or retained products of conception. Thus an early Ob/Gyn consultation must be sought.

If uterine perforation, bladder or bowel injury are suspected, patients need hemodynamic resuscitation and expedited transfer to the operating room.

If a septic abortion is suspected, sepsis treatment must be instituted according to institutional guidelines, broad-spectrum antibiotics must be initiated as early as the diagnosis is considered, and arrangements need to be made to transfer the patient to the operating room. 

In a hemodynamically stable patient, pelvic ultrasonography must be obtained to look for retained products of conception, failed abortion, continued pregnancy, or ectopic pregnancy. 

Complications

• Hemorrhage
• Sepsis
• Peritonitis
• Deep vein thrombosis
• Death

Pearls and Other Issues

Curiously, after reviewing multiple articles on the complications of abortion, it is worth mentioning that some studies that legally induced abortions are markedly safer than childbirth. 

Enhancing Healthcare Team Outcomes

While most abortions are straightforward, there are some which are associated with complications, which can be life-threatening. Because of the high morbidity of abortion complications, a multidisciplinary team that includes an obstetrician, radiologist, general surgeon, urologist, and an infectious disease expert is recommended. All patients who develop an abortion-related complication need to be closely monitored to ensure that there are no missed injuries. Prior to discharge, the nurse should educate the patient on proper contraceptive measures as a means of birth control, to avoid unwanted pregnancies. The patient should be urged to remain compliant with antibiotic therapy if the abortion was septic.

Over the past 3 decades, the mortality rates associated with abortions have significantly dropped in the US. However, outside North America and Europe, septic abortions continue to be associated with high rates of maternal mortality, chiefly because of illegal abortions performed in unsanitary environments. According to the WHO, each year nearly 70,000 women die globally from septic abortions. The risk of septic abortions is markedly increased with advanced gestational age.[9][10][3] (Level V)

Questions

To access free multiple choice questions on this topic, click here.

References

1.

Bhandekar SS, Chauhan AR, Ambadkar A. Prospective Comparative Study of Oral Versus Vaginal Misoprostol for Second-Trimester Termination of Pregnancy. J Obstet Gynaecol India. 2018 Dec;68(6):456-461. [PMC free article: PMC6207541] [PubMed: 30416272]

2.

Stifani BM, Vilar D, Vicente L. "Referendum on Sunday, working group on Monday": A success story of implementing abortion services after legalization in Portugal. Int J Gynaecol Obstet. 2018 Oct;143 Suppl 4:31-37. [PubMed: 30374988]

3.

Manyeh AK, Nathan R, Nelson G. Maternal mortality in Ifakara Health and Demographic Surveillance System: Spatial patterns, trends and risk factors, 2006 - 2010. PLoS ONE. 2018;13(10):e0205370. [PMC free article: PMC6197633] [PubMed: 30346950]

4.

Kotb NA, Ibrahim SF. Violent deaths of pregnant women in Egyptian governorates of Cairo and Giza. J Forensic Leg Med. 2018 Nov;60:25-29. [PubMed: 30223232]

5.

Calvert C, Owolabi OO, Yeung F, Pittrof R, Ganatra B, Tunçalp Ö, Adler AJ, Filippi V. The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services: a systematic review and meta-regression. BMJ Glob Health. 2018;3(3):e000692. [PMC free article: PMC6035513] [PubMed: 29989078]

6.

Costescu D, Guilbert É. No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods. J Obstet Gynaecol Can. 2018 Jun;40(6):750-783. [PubMed: 29861084]

7.

Bain LE, Kongnyuy EJ. Eliminating the high abortion related complications and deaths in Cameroon: the restrictive legal atmosphere on abortions is no acceptable excuse. BMC Womens Health. 2018 May 24;18(1):71. [PMC free article: PMC5968528] [PubMed: 29793462]

8.

Bonet M, Nogueira Pileggi V, Rijken MJ, Coomarasamy A, Lissauer D, Souza JP, Gülmezoglu AM. Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation. Reprod Health. 2017 May 30;14(1):67. [PMC free article: PMC5450299] [PubMed: 28558733]

9.

Silva FAC, Ferreira ALCG, Hazin-Costa MF, Dias MLG, Araújo AS, Souza AI. Adverse clinical and obstetric outcomes among pregnant women with different sickle cell disease genotypes. Int J Gynaecol Obstet. 2018 Oct;143(1):89-93. [PubMed: 30030929]

10.

Moore AM, Dennis M, Anderson R, Bankole A, Abelson A, Greco G, Vwalika B. Comparing women's financial costs of induced abortion at a facility vs. seeking treatment for complications from unsafe abortion in Zambia. Reprod Health Matters. 2018 Dec;26(52):1522195. [PMC free article: PMC6331180] [PubMed: 30388961]