Introduction

Roughly a million abortions are performed each year in the United States alone (CDC 2015)[1][2]. This number may be underestimated since the reporting of the abortions is not mandatory in the USA. 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)[3][4][5]

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%.[6]

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. [7][8]

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

The mortality rate in the USA related to induced abortion was 0.6 deaths per 100,000 abortions.[9] In the United States, mortality from septic abortion rapidly declined after the legalization of abortions. The risk of death from septic abortion increases with the progression of gestation.

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 complains, such as pain, bleeding, low-grade fever are frequently 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 the 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. A rectal exam may be necessary if a bowel injury is suspected.
5. One should consider bowel or bladder perforation in patients with low abdominal pain

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.

Imaging Studies

• X-rays to rule out bowel perforation
• US to rule out an ectopic pregnancy
• CT scan to assess for fluid collection in the pelvis, retained byproducts, adnexal mass

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 the operating room/intensive care unit.[10][11]

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 the 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. 

Differential Diagnosis

• Appendicitis
• UTI
• Renal stone
• Pyelonephritis
• Ruptured ovarian cyst
• PID
• Vaginitis

Prognosis

The overall prognosis after suffering a complication from an abortion depends on the gestational age. The younger the gestational age, the lower the risk of complications. The highest risk of death is from a septic abortion; the majority of these cases are a result of illegal abortions in developing countries.  Based on WHO data, nearly 70,000 women die each year as a result of complications from illegal or unsafe abortions. In the US, there were only 10 such deaths reported in 2010, but this could be due to under-reporting.

Complications

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

Medical/Legal Issues

Abortion may seem to be a minor procedure but there are many medical and legal issues surrounding this procedure and they include the following:

1. The rate and amount of bleeding can be easily underestimated especially when the patient is in the supine position. Thus, clinicians should always perform a pelvic exam in a post-abortion patient to determine that there is no blood that has collected in the vagina or uterus.All patients should have 2 large-bore IVs and oxygen, even if they initially appear to be stable. Blood must be crossed and typed in cases of bleeding.
2. The vital signs have to be frequently monitored.
3. Uterine perforation if missed can be life-threatening. If the patient has abdominal pain post-abortion, the gynecologist should be consulted ASAP and a CT scan ordered. Some patients may benefit from a diagnostic laparoscopy.
4. In any post-abortion patient, one should never assume that ectopic pregnancy is ruled out
5. If the patient appears septic, broad-spectrum antibiotics need to be started even before the diagnostic workup is complete
6. Always obtain a thorough gynecological and obstetric history
7. Consider the fact that the patient may have retained products of conception which may be the cause of complications.
8. Finally always rule out bowel injury post-abortion, because if missed, it carries a high mortality.

Pearls and Other Issues

 It is worth mentioning that according to mutliple studies, legally induced abortions are markedly safer than childbirth[12]. 

Enhancing Healthcare Team Outcomes

While most abortions are straightforward, there are some which are associated with complications, which can be life-threatening.[13] Because of the high morbidity of abortion complications, an interprofessional team that includes an obstetrician, radiologist, triage nurses, nurse practitioner, general surgeon, urologist, and an infectious disease expert is recommended.

The majority of patients with post-abortion complications present to the emergency room and are first seen by the triage nurse. The triage nurse has to be familiar with potential post-abortion complications and quickly admit the patient and alert the interprofessional team. Besides acute hemorrhage, post-abortion complications can include septic shock, perforated bladder or bowel, and a possible ectopic pregnancy- all lethal conditions which if not promptly diagnosed can lead to high mortality. While the interprofessional team is arranging the imaging studies, the nurses need to ensure that the patient has 2 large-bore IV, oxygen and that routine blood work including a crossmatch has been sent. All hemodynamically unstable patients need to be continuously monitored by a dedicated nurse reporting abnormalities to the clinician.

A thorough physical exam including the pelvis must be done immediately to ensure that there are no missed injuries. If the patient requires urgent surgery, anesthesia and the operating room nurses need to be notified. Stable patients still need close monitoring since obvious internal bleeding may not be visible. During the monitoring period, the nurse should communicate immediately with the interprofessional team if there are any changes in the vital status or worsening of abdominal pain. Once the post-abortion complication has been managed, the interprofessional team including the nurse practitioner 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.

Outcomes

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. The key to reducing mortality is patient education and increased awareness among the healthcare workers about the potentially lethal complications that can follow an abortion.

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