Continuing Education Activity
Abortion, the termination of a pregnancy, is a common medical procedure that can be performed through medication or surgery. Worldwide, approximately 73 million elective abortions occur annually. The World Health Organization recognizes comprehensive abortion care as an essential component of health care. Like any medical intervention, abortion carries potential risks and complications. These complications can be physical, emotional, or psychological, and they vary depending on factors such as the method used, the stage of pregnancy, the individual's health status, and the quality of care received.
Understanding abortion-related complications is essential for both patients and healthcare professionals to ensure informed decision-making and appropriate care. However, as of 2019, 1 in every 10 medical schools in the United States offered no abortion training, and among those that did, only half included didactic instruction. Patients with abortion complications are often evaluated in emergency departments, primary care settings, or urgent care clinics, highlighting the importance of clinicians having a clear understanding of these complications.
This activity reviews the epidemiology, pathophysiology, clinical presentation, and management of abortion complications. The activity also highlights the role of an interprofessional healthcare team in coordinating care strategies. Participants are better equipped to provide safe, evidence-based care, counsel patients accurately, and respond to complications promptly, thereby improving patient outcomes and reducing risks.
Objectives:
Screen patients effectively for risk factors that increase the likelihood of abortion-related complications.
Select appropriate diagnostic tools and laboratory tests to evaluate abortion-related adverse events.
Implement evidence-based protocols for the timely management of abortion complications.
Collaborate with interprofessional team members to ensure comprehensive care for patients experiencing abortion-related complications.
Access free multiple choice questions on this topic.
Introduction
Elective abortion is a common medical procedure in the United States and worldwide. Around 1 million legal abortions are performed in the United States every year, with over 90% occurring in the first trimester.[1] When performed according to current guidelines,[2][3][4] abortion is approximately 14 times safer than childbirth.[5][6][7] However, complications can and do occur. To understand abortion complications and their management, it is important to outline how elective abortions are performed.
Elective abortions can be performed in 2 ways—surgically and medically. Surgical abortions involve the evacuation of the products of conception through a dilated cervix. In contrast, medical abortions use a combination of mifepristone and misoprostol. In the United States, medical abortions are typically offered up to 70 days (10 weeks) of gestation due to reduced efficacy and higher complication rates beyond that point.[2] In contrast, procedural abortions are effective at any gestational age.[4]
Patients undergoing procedural abortions typically receive several medications to optimize safety and comfort, including analgesia, conscious sedation, and, depending on the gestational age, medications and osmotic dilators to soften the cervix.[3][4] Following the procedure, which is typically vacuum aspiration with or without dilation and evacuation, the clinician inspects the retrieved material to confirm completion.[3][4] In the case that fetal tissue is not visible on manual inspection (a common occurrence for abortions performed at very early gestations), quantitative serum beta-human chorionic gonadotropin (β-hCG) levels are measured at baseline and again several days later to rule out ongoing pregnancy, including ectopic pregnancy. Patients rarely require a scheduled follow-up visit after a procedural abortion,[3][4] and typically experience cramping and bleeding similar to a normal menses that tapers down over 1 to 3 weeks.
For first-trimester medical abortion, the most common regimen is oral mifepristone followed 24 hours later by misoprostol, which may be administered vaginally, sublingually, or buccally.[2] Mifepristone is a progesterone receptor blocker that enhances the efficacy of misoprostol, a synthetic prostaglandin that induces uterine contractions, softens the cervix, and facilitates the expulsion of the pregnancy within 8 hours of administration.[2][4] Analgesics and antiemetics, such as ibuprofen and ondansetron, are often administered prophylactically in anticipation of the predictably strong cramping, moderate to heavy bleeding, and nausea that occur during 1 to 2 hours in which the pregnancy is expelled.[2][4]
Similar to procedural abortions, medical abortions do not require routine follow-up unless serial β-hCG values are needed to confirm completion.[2][4] Once the pregnancy is expelled, patients can expect cramping and bleeding similar in volume to normal menses, which tapers over 1 to 4 weeks.
Over the past 2 decades, medical abortions have seen a general trend toward fewer diagnostic tests and fewer (or no) required clinic visits. Telehealth abortions are safe, effective, provide better access to care, and are supported by current guidelines.[2][4][8] Nevertheless, clinicians need to recognize that telehealth abortions are initiated without a baseline ultrasound. As a result, patients presenting with complications may require closer evaluation for conditions such as ectopic pregnancy or gestational age significantly exceeding estimates based on the reported last menstrual period.
Etiology
Possible complications of elective abortion in approximate order of decreasing prevalence include the following:
Ongoing intrauterine pregnancy complicates approximately 0.5% of medical abortions but can also occur following procedural abortions when performed at very early gestations.[9]
Uterine hemorrhage is often caused by retained products of conception (incomplete abortion) but can also result from uterine atony, placental abnormalities, coagulopathy, uterine perforation, or cervical laceration.[11] Injury to the uterus or cervix can occur during procedural abortions, and the risk increases with higher gestational age. Severe cases may involve injury to adjacent organs, such as the bladder or rectum.[11][12]
Although not a direct result of induced abortion, ectopic pregnancies account for approximately 1.5% of all pregnancies and can be life-threatening.[1] Ectopic pregnancy should always be included in the differential diagnosis unless an intrauterine pregnancy was confirmed before the abortion.
Post-abortion infections are most commonly caused by retained products of conception, which become a nidus for infection.[13] Infections are especially common following unsafe abortions involving nonsterile instruments.[13][14][15]
Disseminated intravascular coagulation is a widespread derangement of the clotting cascade, leading to the consumption of coagulation factors and platelets. Obstetrical causes of disseminated intravascular coagulation are believed to result from the large amount of tissue factor that is released when the placental bed is disrupted.[16] Disseminated intravascular coagulation can also arise from severe hemorrhage, sepsis, or amniotic fluid embolism.[11][16]
Hematometra is the painful accumulation of blood within the endometrial cavity. This rare complication can occur post-abortion if the cervical canal becomes obstructed, typically by retained fetal tissue.
Uterine rupture is an exceedingly rare complication of medical abortion. Risk factors include medical abortion in the second trimester and uterine scarring from prior cesarean section.[11]
Epidemiology
Complications occur in approximately 2% of elective abortions performed in the United States, and a minority of these (around 1 in 4) require procedural intervention or hospitalization.[8][9][10][12] In 2022, the mortality rate from legally induced abortion in the United States was 0.8 deaths per 100,000 abortions, representing approximately 1 out of every 28 maternal deaths.[1] In contrast, in countries with limited access to safe abortions, abortion-related deaths are far more frequent and represent around 1 in 10 maternal deaths.[15]
Risk factors for abortion-related complications are as follows:
Increased gestational age
Prior cesarean delivery
Increased maternal age
Fetal demise before the abortion
Surgical inexperience
Unsafe (illegal) abortion
History and Physical
Obtaining a detailed history and performing a thorough physical examination are critical for evaluating patients presenting with possible abortion complications. These steps guide clinical decision-making and help differentiate between expected post-procedural symptoms and true medical emergencies.
Key information to collect: Was it medical or procedural? What was the gestational age, and how was it confirmed? Was the abortion supervised/performed by a licensed provider? Obtain records from the abortion provider when feasible, and never assume that ectopic pregnancy has already been ruled out. Inquire about current or recent medication use. Ask about underlying medical conditions, especially bleeding disorders or conditions that could predispose to infection.
Bleeding assessment: Patients should be asked to quantify their bleeding. Saturating more than 2 maxi pads per hour for 2 consecutive hours, or saturating more than 6 pads in 24 hours, should prompt suspicion for uterine hemorrhage regardless of the patient's apparent hemodynamic status. In many cases, patients with incomplete abortions present with heavy bleeding that is subacute, occurring over hours or days. Early recognition and treatment of these slow hemorrhages are critical to preventing excessive blood loss.
Pain evaluation: Severe pelvic pain is unusual following an uncomplicated procedural abortion, and there should be minimal cramping after the first week. For medical abortions, intense pelvic pain is expected only during 1 to 2 hours in which the pregnancy is expelled from the uterus. Deviations from these patterns should prompt suspicion for incomplete abortion, infection, ectopic pregnancy, hematometra, or trauma to the uterus. Assessing costovertebral angle tenderness and peritoneal signs can point toward pyelonephritis or appendicitis, both of which are common and can mimic septic abortion.
Associated symptoms: Patients should be asked about associated symptoms, including dizziness or syncope. These symptoms should prompt suspicion for hemorrhage or sepsis. Occasionally, septic abortion can present with chills and flu-like symptoms without fever or significant pelvic tenderness.[14]
Vital signs: The patient's vital signs should be assessed, and orthostatic vital signs should be considered to detect early hemodynamic compromise. Fever is always abnormal following an abortion. Occasionally, patients may experience transient adverse effects of misoprostol, including chills, mild elevation of body temperature (<100 °F), body aches, diarrhea, and nausea with or without vomiting; however, these adverse effects typically last less than 6 hours.[2]
Physical examination findings: The conjunctivae should be assessed for pallor, and the skin and intravenous (IV) sites should be assessed for signs of bleeding diathesis. Disseminated intravascular coagulation can present with petechiae, purpura, or bleeding at IV sites; however, disseminated intravascular coagulation can also manifest as uterine hemorrhage without other findings.[16] An abdominal examination should assess for tenderness and guarding. Bruising around the umbilicus can suggest intraperitoneal bleeding.
Pelvic examination: A pelvic exam should be performed toevaluate the rate of bleeding, the degree of cervical dilation, and trauma to the cervix or vagina. Rarely, products of conception can be observed within the cervical os and should be promptly removed. Foul-smelling discharge can suggest infection. On bimanual exam, a boggy uterus suggests uterine atony as a cause of hemorrhage. Uterine or adnexal tenderness can be a sign of infection, ectopic pregnancy, trauma, or hematometra.
Evaluation
A urine hCG test is an essential diagnostic tool. A negative urine hCG rules out an ongoing pregnancy, including ectopic pregnancy, and significantly reduces the likelihood that the patient's presenting symptoms are due to an abortion complication. A positive test, however, is less informative, as this is an expected result for up to 6 weeks following an elective abortion.[2]
Pelvic imaging with transvaginal ultrasonography can identify an ongoing intrauterine pregnancy or a retained gestational sac. However, imaging alone is often insufficient to confirm or exclude ectopic pregnancy, uterine perforation, infection, or incomplete abortion.[13][17][18] Endometrial thickness on ultrasound does not correlate with the need for intervention following a medical abortion.[18] Instead, most abortion complications are diagnosed based on history, physical examination, and blood tests, with imaging serving a supportive and sometimes secondary role.
A complete blood count provides important clues. Leukocytosis suggests an infection, whereas anemia may indicate significant blood loss. Thrombocytopenia is a common feature of disseminated intravascular coagulation.[16] Additional studies to evaluate for disseminated intravascular coagulation include prothrombin time, partial thromboplastin time, fibrin degradation products, and fibrinogen.[11][16] In the case of hemorrhage that could require transfusion, the patient's blood should be typed, screened, and cross-matched.
If infection is suspected, cultures of the cervix, urine, and endometrium should be obtained.[13] If screening for sexually transmitted infections was not performed at the time of the abortion, a nucleic acid amplification test should be performed for Neisseria gonorrhoeae and Chlamydia trachomatis.[13]
Quantitative serum β-hCG levels should be trended unless the abortion provider previously ruled out an ectopic pregnancy. β-hCG values that decrease by at least 50% in 48 hours (or 80% by 1 week) are consistent with complete abortion.[2]
Testing for the Rh(D) antigen and administration of anti-D immunoglobulin for Rh-negative patients is typically managed by the provider at the time of abortion. The necessity of anti-D prophylaxis for abortions performed before 12 weeks of gestation is still a topic of debate.[2][4]
Treatment / Management
Patients diagnosed with an ongoing, viable pregnancy after abortion should be counseled on their available options in a nonjudgmental way [2][4] or should be referred to a healthcare provider who can provide such counseling. Patients who received misoprostol should understand that it poses teratogenic risks to the developing fetus.[2]
Heavy or prolonged uterine bleeding after first-trimester medical abortion is typically the result of incomplete abortion and can be managed in several ways. Expectant management with close follow-up may be appropriate for clinically stable patients who wish to avoid further intervention.[2][4] Alternatively, a repeat dose of misoprostol (600 or 800 mcg through the buccal or sublingual route) may be appropriate,[2][4] keeping in mind that this leads to a transient increase in bleeding and cramps. Uterine aspiration by a trained clinician is the definitive treatment for incomplete abortion and is the best choice for patients with significant blood loss.[2][4]
Primary treatment of brisk uterine hemorrhage includes a combination of uterine massage and uterotonic medications.[11] Additionally, uterine aspiration is indicated when retained products of conception are present.[11] First-line uterotonic agents typically include methylergonovine maleate (0.2 mg intramuscularly) and misoprostol (800–1000 mcg sublingually or rectally).[11] Additional options include intramuscular oxytocin and intracervical vasopressin.[11] For patients with uterine atony and continued bleeding despite these measures, a Foley or Bakri balloon can be inserted into the endometrial cavity and filled with saline to temporarily tamponade the uterus.[11] Intravenous fluid resuscitation is essential for patients with significant blood loss or hemodynamic instability. In some cases, red blood cell transfusion may be necessary and can be administered in conjunction with fresh frozen plasma and/or cryoprecipitate if disseminated intravascular coagulation is suspected.[11] Controlling the source of bleeding is critical, and in some cases, it may require uterine artery embolization or hysterectomy.[11]
Patients who experience bleeding from cervical lacerations require immediate hemostasis, which can be achieved by applying ferric subsulfate or, for larger lacerations, through surgical repair.[11] Uterine perforation, typically associated with procedural abortion, is managed either expectantly or surgically, depending on the extent of the trauma.[3][11]
In cases of septic abortion, management involves the timely administration of broad-spectrum antibiotics and prompt uterine aspiration to remove retained fetal tissue.[13] Sepsis can progress rapidly in obstetric infections, and delays in antibiotic treatment significantly increase the risk of death.[13][14]
Diagnosed tubal ectopic pregnancy should be managed surgically if there is any sign of rupture or imminent rupture.[17] Select patients can be treated expectantly or with intramuscular methotrexate in consultation with an obstetrician or gynecologist.[17] Of note, ectopic pregnancies are considered nonviable,[17] and their management is unaffected by recent changes in abortion laws.
Rh testing and anti-D immunoglobulin administration may also be considered, depending on the patient's clinical context.[2][4]
Differential Diagnosis
When evaluating a patient with symptoms following an elective abortion, it is essential to consider a broad differential diagnosis to distinguish expected postprocedural effects from true complications. Accurate identification of the underlying cause is critical to ensure timely and appropriate management.
Conditions that may mimic abortion complications include the following:
Prognosis
The prognosis after an abortion complication depends on the type of complication, the healthcare setting, and the promptness of assessment and treatment. Septic abortion carries the highest risk of death.[13] For patients with post-abortion hemorrhage, mortality risk increases with gestational age.[11] Globally, abortion-related mortality remains high, mainly because over half of procedures are performed under unsafe conditions.[15]
Complications
Abortion complications can occasionally lead to further medical issues if not promptly recognized and managed. Understanding the potential sequelae of abortion-related complications is essential for preventing escalation and ensuring optimal patient outcomes.
Possible sequelae from abortion complications include:
Deterrence and Patient Education
Patients should be counseled to seek immediate medical evaluation for escalating vaginal bleeding, severe or worsening pelvic pain, or clinical signs suggestive of infection, such as fever, purulent discharge, or malaise. The use of sanitary pads rather than intravaginal products is recommended after the procedure to facilitate an accurate assessment of bleeding patterns. Non-opioid analgesics are the preferred first-line agents for post-abortion pain management.[2][3] Patients should be informed of the potential for emotional responses, including grief or guilt, and offered referral to mental health services or counseling if indicated. As ovulation may resume within 2 weeks post-abortion, contraceptive counseling should be provided before discharge.[4] Most contraceptive methods can be initiated immediately, except intrauterine devices, which are contraindicated in the presence of active pelvic infection.[2][4] Follow-up with the abortion provider or primary care clinician is strongly advised to ensure resolution of symptoms and address any ongoing health needs.
Pearls and Other Issues
Effective management of abortion complications requires not only clinical knowledge but also practical insight drawn from experience and evidence-based practice. The following clinical pearls highlight key considerations to support safe, timely, and informed care in patients presenting with post-abortion concerns.
Always distinguish between expected post-abortion symptoms, such as mild cramping and light to moderate bleeding, and signs of complications, such as heavy bleeding, severe pain, and fever.
Retained products of conception are a common cause of post-abortion bleeding and can occur after both medical and surgical abortions.
Septic abortion is a medical emergency; early signs may include fever, uterine tenderness, tachycardia, and malodorous discharge.
Ultrasound and serial β-hCG measurements are valuable tools in evaluating incomplete abortion or ectopic pregnancy.
Hemorrhage may present subtly; assess for orthostatic changes, ongoing bleeding, and signs of hypovolemia.
Bowel injury should be ruled out because, if missed, it carries a high mortality rate.
Intrauterine devices should not be placed in patients with suspected or confirmed pelvic infection.
Ovulation can occur as early as 2 weeks post-abortion—address contraceptive needs before discharge.
Non-opioid analgesics are typically sufficient for managing post-abortion pain.
Emotional distress is common post-abortion; screen for psychological symptoms and refer for counseling when appropriate.
Encourage follow-up with a primary care provider or abortion provider to monitor recovery and address complications early.
Enhancing Healthcare Team Outcomes
Although most abortions are uncomplicated, some may involve serious complications with increased risk of morbidity and mortality. Managing abortion complications effectively demands a collaborative, interprofessional approach grounded in a shared commitment to patient-centered care, safety, and ethical practice. The interprofessional team includes a triage nurse, an emergency medicine clinician, an obstetrician, and a radiologist. In some instances, consultation with a general surgeon or infectious disease specialist may be necessary.
Treatment for abortion-related complications ranges from low-risk expectant management to complex medical or surgical interventions. When procedural intervention is likely, involvement of an obstetrician or general surgeon is recommended. A notable exception is uterine aspiration in low-risk patients following medical abortion, which a trained emergency medicine clinician may perform.
Strategic communication across disciplines is essential to ensure timely information exchange, coordinated interventions, and continuity of care. Ethical responsibilities include providing nonjudgmental support and advocating for patients' rights and well-being. Care coordination efforts, such as streamlined referrals and follow-up planning, help optimize clinical outcomes and reduce preventable harm. By fostering mutual respect and clear communication within the team, healthcare providers can enhance patient safety, improve treatment adherence, and promote holistic recovery, ultimately elevating overall team performance in addressing abortion-related complications.
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Disclosure: Erica Parks declares no relevant financial relationships with ineligible companies.
Disclosure: Christopher Martinez declares no relevant financial relationships with ineligible companies.
