Abortion Complications

Etiology

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. Incomplete evacuation of the products of conception leads to the collection of blood in the uterus, causing overdistention and atony which results in hemorrhage. It can also lead to infection and possible sepsis. Injury from the surgical procedure itself depends upon the method used and includes vaginal or cervical lacerations, as well as uterine, bowel, or bladder injury.

Epidemiology

The frequency and severity of abortion complications depend on gestational age at the time of the abortion and the method of abortion.[8][9] 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.[10] 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.

History and Physical

A good history is essential to make a timely and correct diagnosis. The emergency clinician should ask about 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, post-abortion complaints, 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 without 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 the ED are essential as patients that were 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 an 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. Bowel or bladder perforation should be considered in patients with low abdominal pain.

Evaluation

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

• Complete blood count (CBC) 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-human chorionic gonadotropin (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

• Abdominal X-rays should be obtained to rule out bowel perforation.
• Pelvic ultrasound (US) should be done to rule out an ectopic pregnancy.
• Computed tomography (CT) scan should be done to assess for fluid collection in the pelvis, retained byproducts, and 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 transfer to the operating room/intensive care unit.[11][12](B3)

In addition to volume resuscitation, patients with a triad of pain, bleeding, low-grade fever should be treated for pain 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 should be sought.

If uterine perforation, or 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 should be obtained to look for retained products of conception, failed abortion, continued pregnancy, or ectopic pregnancy.

Differential Diagnosis

• Appendicitis
• Urinary tract infection
• Renal stone
• Pyelonephritis
• Ruptured ovarian cyst
• Pelvic inflammatory disease
• 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

It is worth mentioning that according to multiple studies, legally induced abortions are markedly safer than childbirth.[13]