Fertility treatments that involve handling of eggs or embryos are referred to as assisted reproductive technology (ART) procedures. These procedures address etiologies related to oocyte, sperm, uterus, a combination of factors, or unknown factors. While ART is commonly utilized for primary and secondary infertility, other indications include fertility preservation prior to cytotoxic therapy, delayed childbearing, genetic disorders or sex screening (preimplantation genetic diagnosis), and childbearing for same-sex couples or individuals without partners.

Oocyte Retrieval

Oocyte retrievals are typically performed transvaginally with ultrasonographic guidance ( Fig. 17.1 ). Laparoscopic oocyte retrieval may be required if transvaginal access to the ovaries is not possible. The 34- to 36-hour timing of oocyte retrieval after hCG administration is necessary to prevent oocyte loss through ovulation. A vaginal ultrasound probe is used to guide the needle into a follicle so the fluid and oocyte can be aspirated for subsequent in vitro care, fertilization, and embryo management. Some may choose to cryopreserve oocytes for later fertilization and pregnancy, especially in the absence of a partner.

Transvaginal Ultrasound-Guided Oocyte Retrieval. The ultrasonographic probe is placed in the vagina and advanced into the posterior fornix. The needle, previously inserted through the needle guide, is advanced through the vaginal wall and ovarian capsule.

Redrawn from Steinbrook R. Egg donation and human embryonic stem-cell research. N Engl J Med . 2006;354:324–326. Copyright © 2006 Massachusetts Medical Society. All rights reserved.

The Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine collaborate with the US Centers for Disease Control and Prevention (CDC) to maintain a data registry and analyze the results of all ART cycles initiated during each calendar year in the United States.

Diminished ovarian reserve due to age or other factors has the largest impact on IVF success. Recently published data indicate that the percentage of intended egg retrievals that resulted in live births was 51.1% for recipients less than 35 years of age and 7.6% for recipients greater than 40 years of age. For those with diminished ovarian reserve, live births occurred in 30.4% for recipients less than 35 years of age and 6.2% for recipients greater than 40 years of age. For the latter individuals, live birth rates increase with use of donor eggs or embryos.

Rarely, ovarian stimulation with gonadotropins can lead to ovarian hyperstimulation syndrome (OHSS) in which multiple follicles cause ovarian enlargement and third space sequestration of fluids occurs. Patient characteristics and response to ovarian stimulation can help predict those at highest risk. Mild OHSS can cause self-limited symptoms including nausea and vomiting, diarrhea, abdominal pain, and dyspnea. In 1% to 5% of cycles, moderate to severe OHSS develops with ascites, hemoconcentration, and leukocytosis. With severe or critical OHSS, patients have more severe intravascular volume depletion and may have renal impairment, electrolyte abnormalities, hydrothorax, pleural or pericardial effusions, and thrombosis among other potentially life-threatening complications. Treatment for OHSS involves supportive care and fluid replacement along with prophylactic anticoagulation.

Anesthetic implications of OHSS include increased free drug concentrations. Rarely, an emergency laparoscopy or laparotomy is required for ovarian torsion. Abdominal paracentesis and thoracentesis may be necessary before the induction of general anesthesia in patients with respiratory compromise caused by massive ascites or pleural effusions.

Multiple-gestation pregnancies have decreased with use of cryopreservation and increased use of single embryo transfers. Triplet and other higher-order multiple births occur in less than 0.1% of embryo transfer cycles. Singleton births occurred after 34.5%, and twin births after 2.3%, of embryo transfer cycles in 2020.

Ectopic pregnancy occurs more frequently after ART or ovulation induction. Rates of ectopic pregnancy after ART have decreased, possibly because of the practice of transferring fewer embryos. Rates of heterotopic pregnancy , a simultaneous intrauterine and ectopic pregnancy, are elevated after ART, especially if more than one embryo is transferred.

Preterm and low-birth-weight infants are more common with ART singleton pregnancies than with naturally conceived pregnancies after controlling for maternal age and parity. Rather than being the cause of this morbidity, ART may well be a marker for underlying conditions that cause the morbidity. In addition, ART pregnancies are at higher risk for placenta previa (relative risk [RR], 6.02; 95% confidence interval [CI], 2.79 to 13.01).

Although most patients undergoing ART procedures are young and otherwise healthy, the use of ART procedures in patients with a growing spectrum of pathologic processes, such as morbid obesity, cancer (with oocyte retrieval performed before chemotherapy or radiation therapy), and severe cardiac, pulmonary, or renal morbidities (with oocyte retrieval performed for embryo transfer in surrogate gestational carriers), requires careful assessment of individual patients.

All patients should follow the American Society of Anesthesiologists fasting guidelines. In the event that a patient does not adhere to fasting guidelines, the decision to delay or cancel the procedure should be made after careful analysis of the potential risks and benefits. If the window for maximal oocyte retrieval (34 to 36 hours after hCG administration) is missed, ovulation with loss of oocytes can occur, invalidating the considerable effort and expense incurred to that point. Moreover, if oocyte retrieval is not performed, the patient is at increased risk for OHSS, with its potential for significant morbidity. In contrast, the risk for pulmonary aspiration of gastric contents may be low, particularly when spinal anesthesia is administered.

The ideal anesthetic technique provides effective pain relief with minimal postoperative nausea, sedation, pain, and psychomotor impairment.

The clinical presentation of the patient with an ectopic pregnancy depends on the gestational age, site of implantation, and extent of hemorrhage. Abdominal pain or vaginal bleeding in a reproductive age female requires evaluation for pregnancy. Before rupture, the signs and symptoms of ectopic pregnancy may be absent or subtle. Patients with hemorrhage (with or without tubal rupture) may experience dizziness or syncope, may have the urge to defecate because of the effect of blood in the cul-de-sac, and may have shoulder pain from diaphragmatic irritation by intraabdominal blood. As with many young, healthy patients, compensation for blood loss can occur with minimal symptoms initially, followed by rapid decompensation.

Ectopic pregnancy should be excluded in any patient who has pelvic pain or vaginal bleeding and a positive pregnancy test. In a woman of reproductive age, the symptoms of ectopic pregnancy must be differentiated from early pregnancy loss (EPL), normal intrauterine pregnancy, abortion complications, and nonpregnancy-related causes of pelvic pain or vaginal bleeding.

Pregnancy of unknown location (PUL) is present when a hCG test is positive and presumed due to pregnancy but the site of implantation is undetermined. Transvaginal ultrasonography can reliably confirm the presence of an intrauterine pregnancy. An intrauterine gestational sac with a yolk sac, embryo, or both is the earliest confirmation of an intrauterine pregnancy and should be visualized by 6 weeks’ gestation. A gestational sac in the adnexa with a yolk sac, fetus, or both confirms the diagnosis of ectopic pregnancy; however, an ectopic pregnancy is often difficult to visualize. Findings suggesting ectopic pregnancy include ultrasonographic visualization of an adnexal mass and free fluid in the cul-de-sac in the absence of an intrauterine pregnancy.

While early diagnosis of ectopic pregnancy is challenging, prompt identification and treatment decreases morbidity and mortality. If concern exists for ectopic pregnancy with a PUL, serial hCG measurements spaced 48 hours apart combined with periodic ultrasonographic evaluation can help clarify the viability of the pregnancy regardless of location. The serum hCG criteria for a viable pregnancy have evolved and become more conservative in several ways. The rate of rise in hCG has been found to vary with the initial hCG value. Additionally, the discriminatory level, the level of hCG at which an intrauterine pregnancy should be visible with ultrasonography, has been raised. The level of hCG does not predict the risk for ectopic pregnancy rupture. Decreasing or plateauing hCG levels typically indicate a nonviable pregnancy.

Uterine aspiration or curettage can be performed when a PUL has been found nonviable or is undesired. Identification of chorionic villi confirms an intrauterine pregnancy. Absence of villi signals either an early intrauterine pregnancy loss or an ectopic pregnancy. Follow-up hCG monitoring is required in this instance until the hCG level is negative, as ectopic pregnancies can still rupture with falling hCG levels.

Management options for ectopic pregnancy include expectant, medical, and surgical. Management choice depends on the characteristics of the ectopic pregnancy, access to follow-up care, and patient preferences and fertility desires. Patients with ectopic pregnancies who are Rh-negative should receive Rho(D) immune globulin.

Expectant management has been studied in patients with hCG levels plateauing at less than 1500 mIU/mL who are hemodynamically stable with an identified ectopic pregnancy or PUL. While outcomes compared favorably to single-dose methotrexate therapy, some do not feel that the risk-benefit balance favors expectant management. For patients with an initial hCG of less than 200 mIU/mL, the success rate is 88%. Evidence of failed expectant management includes pain, inadequate decrease in hCG levels, or hemoperitoneum due to tubal rupture.

Medical management with methotrexate has become a common management strategy for ectopic pregnancies. Candidates for this therapy cannot have a ruptured ectopic pregnancy or any medical contraindications to methotrexate therapy (e.g., lactation, immunodeficiency, or moderate to severe hematologic, hepatic, renal, pulmonary, or peptic ulcer disease) and must be willing and able to participate in posttreatment monitoring. Relative contraindications are summarized in Box 17.1 . Methotrexate regimens to manage ectopic pregnancy utilize one or more intramuscular injections in addition to symptom and hCG monitoring to identify those who require additional methotrexate or surgical management. Success rates vary from 70% to 95% and vary with initial hCG level and regimen used. Side effects of methotrexate are summarized in Box 17.1 . An optimal management regimen has not been identified with an ideal balance of efficacy and few side effects, but one- and two-dose regimens are most common. Compared with surgical management, medical management of ectopic pregnancy results in no difference in overall tubal preservation, tubal patency, risk for repeat ectopic pregnancy, or success of future pregnancies.

Surgical management is indicated for hemodynamic instability or evidence of intraperitoneal bleeding or pain from rupture. Other indications for surgical management include absolute or relative contraindications to methotrexate therapy, failure of medical therapy, and patient preference. Except when large-volume intraperitoneal bleeding is anticipated, laparoscopic surgery is typically performed. Partial or complete salpingectomy removes the ectopic pregnancy and fallopian tube, whereas a salpingostomy opens the tube to remove only the ectopic pregnancy. Choice of technique depends on the patient’s reproductive plans, degree of tubal damage, and condition of the contralateral tube. Salpingostomy has a higher subsequent intrauterine pregnancy rate but also an increased risk for recurrent ectopic pregnancy. Poor visualization at laparoscopy due to hemorrhage may require conversion to laparotomy. To aid hemostasis during laparoscopic removal of the ectopic pregnancy, some surgeons inject dilute vasopressin into the surface of the fallopian tube. This agent causes marked blanching of the tube and results in a relatively bloodless surgical field. If the vasopressin is mixed incorrectly or accidentally injected intravenously, a marked increase in maternal blood pressure may occur.

Interstitial pregnancy occurs in 2% of ectopic pregnancies. Interstitial pregnancy results from implantation in the interstitial portion of the tube, where it traverses the myometrium. This may go unrecognized and may manifest as uterine wall rupture, massive hemorrhage, and shock, resulting in a 2% to 5% mortality rate. IVF, ipsilateral salpingectomy, uterine anomalies, and prior ectopic pregnancy are risk factors. Salpingectomy has become a more common method of tubal sterilization in recent years. If diagnosed prior to rupture, interstitial ectopic pregnancy may be managed with systemic or local methotrexate therapy or selective arterial embolization. At a low initial hCG level with subsequent decline, expectant management may be considered. Surgical resection of an interstitial ectopic pregnancy via cornuotomy may be chosen initially or after failure of medical management, whereas a cornual wedge resection or hysterectomy may be required because of hemorrhage. Cornual wedge resection has a risk for uterine rupture with a future pregnancy.

Cervical pregnancy occurs in 0.4% of ectopic pregnancies. Cervical pregnancy can result in massive, relatively painless hemorrhage because of the inability of the cervix to contract. Differentiating a cervical ectopic pregnancy from an evolving EPL can be challenging. Risk factors include prior dilation and curettage (D & C), prior cesarean delivery, or IVF for the current pregnancy. Owing to its rarity, standardized treatments have not been identified but may include uterine artery embolization (UAE), vaginal or laparoscopic ligation of the cervical branch of the uterine artery, hysteroscopic excision, local or systemic methotrexate, balloon tamponade, partial or complete cervical excision, hysterectomy, or combinations of the above.

Ovarian ectopic pregnancy occurs in 1% to 3% of ectopic pregnancies. It is more common after ART and results when the gestation implants within the ovary. Diagnosis of ovarian ectopic pregnancy is difficult using ultrasonography, and patients often present with intraperitoneal bleeding. Localization of the ectopic pregnancy may occur intraoperatively or on histologic examination. Treatment options include oophorectomy, ovarian wedge resection, or limited removal of the pregnancy only.

Cesarean scar ectopic pregnancy (CSEP) occurs in 4% to 6% of ectopic pregnancies. CSEP occursin 1 in 500 to 560 pregnant patients with a prior low transverse cesarean delivery. In these cases a gestational sac implants in a uterine scar defect (niche or isthmocele) from a prior cesarean delivery. Pain, bleeding, or no symptoms may precede ultrasonographic diagnosis, though the presenting symptom may be hemorrhagic shock. Two types of CSEP occur. Type I CSEP develops with viable pregnancy growth into the uterine cavity, and type II CSEP develops with nonviable pregnancy growth toward the myometrium and bladder. The risk for uterine rupture and hemorrhage, possibly requiring hysterectomy, necessitates prompt identification and management of type II CSEP. Type I CSEP can lead to placenta accreta spectrum disorder with risk for severe hemorrhage later in pregnancy or at delivery. For those with EPL and manageable bleeding, expectant management is an option but can be associated with development of a uterine arteriovenous malformation. Expectant management of a viable pregnancy is not recommended by the Society for Maternal-Fetal Medicine (SMFM) because of the high risk for potentially life-threatening morbidity. In the absence of definitive management options, various interventions may be used depending on presentation and the patient’s desire for fertility. Surgical resection transvaginally or laparoscopically or ultrasound-guided uterine aspiration are operative interventions recommended by the SMFM, and hysterectomy may be considered. Local injection of methotrexate into the gestation may be used with or without another intervention. Potassium chloride injection may be considered for a heterotopic gestation. UAE and balloon catheters have also been utilized.

Abdominal pregnancy , which occurs in 1% of ectopic pregnancies, results from implantation in the peritoneal cavity, not including the fallopian tubes, ovaries, broad ligament, or cervix. Risk factors are thought to be similar to those for other ectopic pregnancies. Maternal mortality is about nine times higher than with other ectopic pregnancies, and fetal mortality may be 45% to 90%. Possibly because of minimal or vague symptoms, abdominal ectopic pregnancies are often diagnosed later in gestation than other ectopic pregnancies. Given the challenges in clinical and ultrasonographic identification of abdominal ectopic pregnancies, most cases are not diagnosed preoperatively. Magnetic resonance imaging may aid in diagnosis and identification of the placental implantation site. While laparoscopic surgery may be sufficient for first-trimester cases, laparotomy is typically undertaken for later gestations. The risk for hemorrhage depends on the site of placental implantation and is lower with attachment to the uterine serosa and higher with attachment to the spleen, liver, iliac vessels, or omentum. Multiple factors impact the decision to remove the placenta or leave it in situ , as both options can result in mortality. The risk for immediate torrential hemorrhage with placental removal is balanced against future complications, which may include secondary hemorrhage, sepsis, preeclampsia, and coagulopathy. In specific circumstances, after careful evaluation and maternal counseling, expectant management has occurred with tertiary center monitoring and availability of a multidisciplinary team.

Heterotopic pregnancy is rare in spontaneous pregnancies, but occurs in up to 1% of IVF pregnancies. Diagnosis can be challenging and relies on symptoms and ultrasonography, with a high index of suspicion required after IVF. Management is typically surgical as systemic methotrexate is contraindicated in the presence of a desired, viable intrauterine pregnancy.

Patients with an unruptured tubal pregnancy typically have normal intravascular volume, minimal bleeding before and during surgery, and low anesthetic and surgical risk. Anesthetic considerations for laparoscopy or laparotomy are summarized in Box 17.2 . Although most patients may prefer general anesthesia, neuraxial anesthesia with an upper sensory level of at least T4 may be an alternative in selected patients. Shoulder pain from diaphragmatic irritation may occur and can be treated with intravenous analgesics (e.g., fentanyl 1 to 2 µg/kg).

A ruptured ectopic pregnancy may be associated with significant preoperative blood loss, but estimation of the extent of blood loss is difficult because healthy patients may maintain a normal blood pressure despite a markedly reduced circulating blood volume. General anesthesia, with preparation for hemorrhage, is preferred if significant bleeding has occurred (e.g., ruptured tubal pregnancy) or is likely to occur (e.g., cervical, interstitial, cornual, cesarean scar, or abdominal ectopic pregnancy, or early placenta accreta). Intraoperative autologous blood transfusion can be used, and it may be useful especially in developing countries, where blood bank supplies may be limited and women typically present late with significant hemoperitoneum and/or hypovolemic shock. The desire to preserve fertility often results in greater blood loss as tissue and organ preservation are attempted. Studies that evaluated obstetric-related intensive care unit admissions found that approximately 9% to 10% of admissions were related to complications from ectopic pregnancies or abortion.

The clinical presentation and management of spontaneous EPL vary. Bleeding may be accompanied by cramping or backache. While historically recommended, alteration of daily activities (e.g., reduced activity or bedrest) does not impact outcome. Approximately 25% of pregnancies are complicated by first trimester bleeding; approximately half of affected women progress to a spontaneous pregnancy loss, with the percentage increasing to about 80% if both cramping and bleeding are present.

Ultrasonographic and hCG criteria for diagnosing EPL have become more conservative based on observational data and a desire to avoid intervention in pregnancies that are viable and desired. Follow-up ultrasonography is indicated when the ultrasonographic diagnostic criteria are not definitively confirmed initially. Once an intrauterine site of pregnancy is confirmed by ultrasonography, hCG testing is no longer helpful in determining viability.

Fetal death in the second trimester, up to 20 to 24 weeks’ gestation, is a mid-trimester pregnancy loss and is more likely to require medical intervention. Presenting signs and symptoms may include decreased fetal movement, vaginal bleeding, pain, and/or rupture of membranes, or no symptoms may occur. Very rarely, coagulation defects, such as disseminated intravascular coagulation, may complicate mid-trimester loss in patients who have longer retention of fetal tissue and/or those who suffer the pregnancy loss at a more advanced gestational age.

First-trimester pregnancy losses can be managed expectantly, medically, or surgically. Factors such as gestational age, patient preference, treatment availability, and cost can all impact management, but the long-term outcome is similar. A woman who is asymptomatic or minimally symptomatic may utilize any management option. Active vaginal bleeding (especially if heavy) typically requires surgical intervention to prevent excessive blood loss and potential shock. Medical disorders that would increase the patient’s risk for bleeding or decrease maternal tolerance of blood loss or current infection are also indications for surgical management.

Conservative management incurs the least initial medical intervention and cost, but the highest chance of serious complications, including need for unplanned or emergency surgery. While most pregnancy losses occur in the early first trimester, spontaneous expulsion of tissue may not occur until the late first trimester. With expectant management, 64% of women will have complete passage of products of conception but some will require surgical intervention for bleeding. Conservative management has higher likelihood of success in early gestations.

Medical management provides more control over timing of tissue expulsion without a procedure. Combination treatment of EPL with misoprostol and mifepristone results in a higher expulsion completion rate of 90.9% and a lower risk for surgical intervention than misoprostol alone, which has a 78% to 83% expulsion completion rate. The potential for an ongoing viable pregnancy after medical abortion with misoprostol alone is about 6% but decreases with increasing number of doses. When a combination of mifepristone and misoprostol is available, it is more effective in managing both EPL and medical abortions than misoprostol alone. Combination regimens involve oral administration of mifepristone and then misoprostol (buccal [FDA-approved], vaginal or sublingual) 24 to 48 hours later. Misoprostol-only regimens use 800-µg doses via buccal, vaginal, or sublingual routes, with the number of doses depending on clinical circumstances. The likelihood of medical management success for EPL and abortion is greater with earlier gestations.

For second-trimester (13 to 24 weeks’ gestation) pregnancy loss or termination, management techniques are similar, although lower doses of medication and shorter time to completion are seen with pregnancy loss. Medical management options include mifepristone with misoprostol, misoprostol alone, high-dose intravenous oxytocin, or vaginal prostaglandin E ₂ . Combining mifepristone and misoprostol optimizes efficacy and efficiency, with 95% completion within 24 hours compared with 80% to 85% completion with misoprostol alone. While two or more prior cesarean deliveries increase the risk for uterine rupture, possibly to 2.5%, this is not considered a contraindication, especially when the alternative is hysterotomy. Other methods are less commonly used. Use of a transcervical balloon catheter in combination with misoprostol alone has shortened time to completion but osmotic dilators have not. Evidence regarding use of cervical preparation prior to mifepristone in combination with misoprostol is lacking. Misoprostol, 15-methyl-prostaglandin F2 _α (carboprost), or a procedural uterine evacuation may be required for retained placental tissue, though the ideal timing of intervention in the absence of hemorrhage is unclear. Compared with dilation and evacuation (D & E), medical induction at 13 to 24 weeks’ gestation was less successful and had higher morbidity with an adjusted RR of 8.5 (95% CI, 3.7 to 19.8).

The cervix can be prepared for a procedure to empty the uterus with vaginal misoprostol or intracervical laminaria, but this is not often required in first-trimester procedures. Procedures to empty the uterus include suction aspiration with a manual or electric vacuum, D & C, and D & E. Procedures currently described as “D & C” in practice may or may not include mechanical cervical dilation prior to suction aspiration with or without subsequent sharp curettage. D & E is the procedural method used to empty the uterus from 13 to 24 weeks’ gestation due to ossified fetal bones that are present beginning at 13 to 15 weeks’ gestation; this involves greater cervical dilation followed by evacuation of the uterus with suction and the aid of surgical forceps. Oxytocin and/or an ergot alkaloid (e.g., methylergonovine) increases uterine tone and may be administered intraoperatively and/or postoperatively to decrease the amount of uterine bleeding. To prevent massive maternal blood loss during a medically induced vaginal delivery, D & E is the procedure of choice for mid-trimester pregnancy loss up to 24 weeks with placenta previa or active bleeding. In the presence of infection, D & E may be delayed until after antibiotics have been administered. Rho(D) immune globulin prophylaxis is widely recommended in the United States for pregnancies ending after 10 weeks’ gestation. With conservative, medical or aspiration management of pregnancies at less than or equal to 12 0/7 weeks’ gestation, Rho(D) immune globulin prophylaxis is no longer routinely recommended but may occur with shared decision making.

An IUD may be placed immediately after a procedure for a first- or second-trimester pregnancy loss or abortion in the absence of sepsis. In cases of medical management, confirmation of completion including placental delivery must occur prior to IUD placement.

Complications of conservative management of EPL, medical management of EPL and abortion, and medical SMA are similar. Care may be sought because of pain, bleeding, and other symptoms that may or may not require intervention. Providers should only request information necessary to provide care.

Complications of procedural management of EPL, abortion, mid-trimester pregnancy loss, and self-managed procedural abortion include cervical laceration, uterine perforation, hemorrhage, retained products of conception, infection, and sepsis. The risk for these complications is increased in pregnancies that have progressed beyond the first trimester, but the risk is still less than delivery later in pregnancy. Complications are higher if procedures occurred in unsafe environments. Infection after EPL or abortion occurs in 0.9% to 2% of patients, with no clear variation based on indication or method of management except for unsafe procedures. The American College of Obstetricians and Gynecologists recommends administration of antimicrobial prophylaxis (e.g., a single dose of doxycycline 200 mg 1 hour before the procedure) for women undergoing uterine evacuation for induced abortion; this regimen has been shown to reduce infection risk by 41%. Because the risk of infection after suction curettage for missed EPL should be similar to that after induced abortion, despite a lack of data, antibiotic prophylaxis should also be considered for these patients. The benefit of antibiotic prophylaxis for the medical management of EPL and medical abortion is unknown, and the routine use of prophylactic antibiotics is not recommended in these circumstances.

Infection may present as increasing abdominal pain, tachycardia, fever, uterine tenderness, or feeling unwell 24 hours or more after the onset of vaginal bleeding or a procedure. Use of multiple doses of misoprostol can cause temperature elevation in 5% to 10% of patients, potentially complicating identification of infection, although temperature should normalize within 2 hours after the medication is discontinued. For those presenting with symptoms of infection, evaluation for retained products of conception is warranted. Uterine perforation should be considered after procedural management, especially if the procedure was unsafe. Prompt administration of broad-spectrum intravenous antibiotics is indicated. If infection leads to organ dysfunction and sepsis, fluid resuscitation and other support may be required. Toxic shock from Clostridium species can occur and presents with flulike symptoms that can progress rapidly to refractory hypotension and death. Hemoconcentration and marked leukocytosis are often present with Clostridium toxic shock.

The risk for uterine perforation during D & C in a recently delivered patient may be as high as 5%. Predisposing factors may include retroverted uterus, infection, later gestational age, and nulliparity. Midline perforation of the fundus with a blunt instrument may be managed with close observation. Use of a sharp instrument poses a greater risk for injury requiring further evaluation and management. Bleeding from vascular damage may be intraabdominal, retroperitoneal, or in the broad ligament. Bowel injury can also be difficult to identify. Laparoscopy, cystoscopy, or other evaluation may be required to evaluate and repair injury. Lower genital tract or bowel injury should be excluded, and the uterus should be promptly evaluated for the presence of retained tissue.

Preexisting anemia, infection, retained products of conception, cervical laceration, uterine perforation, and choice of medical or surgical management may affect decisions regarding transfusion after a first- or mid-trimester pregnancy loss or abortion. Medical management is associated with higher transfusion rate (0.1%) compared with procedural management (0.01%) of first-trimester abortion. Mid-trimester procedural and medical management have similar transfusion rates. Medical management of a mid-trimester abortion may be associated with hemorrhage in 2% to 20% of cases,with rare need for transfusion. The presence of placenta accreta spectrum markedly increases this risk.

Rho(D) immune globulin should be administered to prevent Rh alloimmunization when indicated. Rho(D) immune globulin administration for first trimester bleeding less than 12 weeks’ gestation without pregnancy loss is optional based on immune globulin availability and patient and provider preference. In Rh-negative women who have a pregnancy loss, the risk for alloimmunization is 1.5% to 2% with a spontaneous loss and 4% to 5% after a D & C procedure. While Rho(D)immune globulin is considered in Rh-negative patients after a spontaneous loss, it is indicated at any gestation after a D & C for an early pregnancy loss, a medication managed or surgical termination of pregnancy greater than 12 0/7 weeks’ gestation, or treatment of ectopic pregnancy with medication or surgery.