Recognition and Treatment of Postabortion Complications
Just under 1 million pregnancies are terminated each year in the United States (Jones & Jerman, 2017). Less than 1% of women terminating a pregnancy will experience a major complication, and most complications will be recognized in the immediate postabortion period and treated by the provider onsite (Cappiello, Beal, & Simmonds, 2011). Still, some abortion complications will emerge after the woman is discharged home, and clinicians working in an emergency department or obstetric triage unit need to be able to recognize these complications.
This chapter will cover symptomatology, physical assessment, and clinical management of the most common complications of abortion, including infection and bleeding. Other rare complications, including uterine perforation, cervical lacerations, sepsis, and a discussion of postabortion emotional issues, will also be included.
TYPES OF ABORTIONS
Early abortions can be accomplished with either aspiration or medication. Early aspiration abortion, sometimes called surgical abortion, is completed with dilation and suction curettage. The incidence of complications from aspiration abortion is outlined in Exhibit 6.1. In medication abortion, mifepristone and misoprostol are the medications of choice, though sometimes misoprostol alone or methotrexate is used. Exhibit 6.2 lists the incidence of complications from medication abortion. Later abortions involve performing dilation and evacuation of the pregnancy, or labor induction.
Types and Incidences of Complications From Aspiration Abortion
• Incomplete abortion (0.3%–2.0%)
• Infection (0.1%–2.0%)
• Cervical laceration (0.6%–1.2%)
• Uterine perforation (<0.4%)
• Blood clots (<0.2%)
• Excessive bleeding (0.02%–0.3%)
• Death (0.0006%, 1 in 160,000 cases)
Sources: Achilles & Reeves (2011); National Abortion Federation (2006); Paul and Stein (2011).
Types and Incidences of Complications From Medication Abortion
• Incomplete abortion (<3%)
• Continuing pregnancy (<1%)
• Excessive bleeding (<1%)
• Infections (0.09%–0.6%)
• Death from Clostridium sordellii-related toxic shock (<0.001%)
Sources: American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 143 (2014); National Abortion Federation (2006, 2014); Paul and Stein (2011).
Women with complications from abortion will most often present with bleeding, pain, or both. While bleeding and crampy pain are normal after an abortion, symptoms, such as uterine tenderness, heavy bleeding, and fever, suggest a postabortion complication.
Nearly all women experience bleeding postabortion, typically for several days, followed by spotting for up to 4 weeks or longer (Davis, Westhoff, & DeNonno, 2000; Paul & Stein, 2011). Bleeding with a medication abortion is often heavier than a normal period (ACOG Practice Bulletin No. 143, 2014). However, comparative studies of aspiration and medication abortion show total blood loss to be similar in the two methods, with bleeding after a medication abortion having a longer duration (Jensen, Astley, Morgan, & Nichols, 1999; National Abortion Federation, 2014). Most women experience cramping after an abortion. With medication abortion, pain can range from mild to severe, usually resolving shortly after the abortion is complete (National Abortion Federation, 2014; Spitz, Bardin, Benton, & Robins, 1998). With aspiration abortion, most women experience only mild uterine cramping and this usually resolves within a few days.
HISTORY AND DATA COLLECTION
For any woman presenting postabortion, it is crucial to determine when the abortion occurred, what type was performed, and at what gestational age. The later in gestation that a woman has an abortion, the more likely she is to experience a complication. It is critical to obtain a description of any bleeding the woman is experiencing, the rate at which the woman is saturating pads, and whether any clots or tissue have been passed. In assessing pain, it is important to distinguish between cramping, which can be associated with retained products of conception (POCs), and fundal tenderness, which can 59be associated with infection. Additional history includes whether the woman experienced any fevers, chills, lightheadedness, or any persistent pregnancy symptoms like breast tenderness, nausea, and vomiting. It is important to take a careful medication history. After an abortion, it is usual for women to receive antibiotics, commonly doxycycline, and uterotonics such as methergine. In gathering the history, it may be helpful to speak with the abortion provider to obtain details of the procedure and any immediate complications. Complete and compassionate care requires assessing each woman’s emotional status, as the life situation that leads a woman to terminate a pregnancy can be complex and stressful. Careful assessment will identify those women most likely to need postabortion emotional support.
In addition, some women who have attempted a self-induced abortion may present for care. One study reported more than 2% of abortion patients had ingested something in an attempt to end a pregnancy. They most commonly used misoprostol, but also reported using herbs, teas, and vitamin C (Jones, 2011; Texas Policy Evaluation Project, 2015).
Vital signs are obtained to assess for fever, tachycardia, and/or hypotension. If the uterus is enlarged above the pubic symphysis an abdominal examination is performed to assess for tenderness, uterine tone/consistency, and size. A speculum examination is an essential part of the physical assessment. During the speculum examination, inspect for bleeding and determine whether the bleeding is coming from the cervical os and whether there are any cervical or vaginal lacerations. The amount of bleeding in terms of number of scopettes used to wipe away the blood and the color of the blood is described. Any mucopurulent discharge and any POCs in the vagina or protruding from the cervical os should be identified. Gonorrhea and chlamydia cultures are collected, if these have not already been collected near the time of the abortion. After the speculum examination, a bimanual examination to assess the uterus for enlargement, tone, and tenderness is performed.
LABORATORY AND IMAGING STUDIES
Blood type and antibody screen are important to obtain. Typically, a woman who is Rh negative will have received Rh immune globulin from the abortion provider. However, any woman who is Rh negative and has self-induced an abortion will need Rh immune globulin. If bleeding is heavy, a complete blood count (CBC) and coagulation studies must be ordered. If a woman shows signs of sepsis, also obtain lactic acid level, renal function tests, and blood cultures.
While a single quantitative serum beta-hCG does not aid in diagnosing an abortion complication, it may be useful to follow serial quantitative results for appropriate decline over time. Beta-hCG levels fall steadily after a first trimester aspiration abortion, halving at least every 48 hours. Because beta-hCG levels are as high as 150,000 in early pregnancy, levels may still be high enough to cause urine pregnancy tests to remain positive for as long as 60 days postabortion. With medication abortion, beta-hCG levels continue to increase after mifepristone is administered and then generally, but not always, 60decline rapidly after misoprostol is administered. Even women with a successful medication abortion may continue to have elevated beta-hCG levels (Fjerstad & Edelman, 2011).
Ultrasound is useful for determining if a gestational sac or fetal parts remain in the uterus. Determining endometrial thickness with ultrasound is not clinically useful postabortion, as there is no thickness that correlates consistently with the need to intervene (Cowett, Cohen, Lichtenberg, & Stika, 2004; Reeves, Lohr, Harwood, & Creinin, 2008). Ultrasound may be used to assess for intra-abdominal hematoma when uterine perforation is suspected in a woman exhibiting signs of hypovolemic shock.