Abortion Complications Medication

Author: Slava V Gaufberg, MD; Chief Editor: Pamela L Dyne,

Background
Complications of spontaneous miscarriages and therapeutic abortions include the following:

Complications of anesthesia Postabortion triad (ie, pain, bleeding, low-grade fever) Hematometra Retained products of conception Uterine perforation Bowel and bladder injury Failed abortion Septic abortion Cervical shock Cervical laceration Disseminated intravascular coagulation (DIC)

The term "septic abortion" refers to a spontaneous miscarriage or therapeutic/artificial abortion complicated by a pelvic infection.

Pathophysiology
Postabortion complications develop as a result of 3 major mechanisms as follows: incomplete evacuation of the uterus and uterine atony, which leads to hemorrhagic complications; infection; and injury due to instruments used during the procedure. In septic abortion, infection usually begins as endometritis and involves the endometrium and any retained products of conception. If not treated, the infection may spread further into the myometrium and parametrium. Parametritis may progress into peritonitis. The patient may develop bacteremia and sepsis at any stage of septic abortion. Pelvic inflammatory disease (PID) is the most common complication of septic abortion.

Epidemiology
Frequency
United States

Frequency of complications depends on gestational age (GA) at the time of miscarriage or abortion and method of abortion. Complication rates according to gestational age at the time of abortion are as follows:

8 weeks and under - Less than 1% 8-12 weeks - 1.5-2% 12-13 weeks - 3-6% Second trimester - Up to 50%, possibly higher

Mortality/Morbidity
Mortality and morbidity depend on gestational age at the time of miscarriage or abortion. In the United States, mortality rates per 100,000 abortions are as follows: fewer than 8 weeks, 0.5%; 11-12 weeks, 2.2%; 16-20 weeks, 14%; and more than 21 weeks, 18%. Septic abortion was once the leading cause of maternal death around the world. The condition remains a primary cause of maternal mortality in the developing world, mostly as a result of illegal abortions. According to the World Health Organization, about 68,000 women die each year due to complications from unsafe abortions, with sepsis as the main cause of death.[1] In the United States in 2005, 7 women reportedly died from complications of legal induced abortion.[2] In the United States, mortality from septic abortion rapidly declined after legalization of abortion. Death now occurs in less than 1 per 100,000 abortions. Figures for most European countries are similar to US rates. The risk of death from septic abortion rises with the progression of gestation.

Other Problems to be Considered

Perforated viscus Acute peritonitis

Medical/Legal Pitfalls

Do not underestimate the amount and rate of bleeding. In the supine position, more than 500 mL of blood may collect in the vagina without severe external bleeding. Always perform a pelvic examination on a postabortion patient who is bleeding. Failure to aggressively treat vaginal bleeding, even if it seems minimal: Stabilize the patient with 2 large-bore IVs and with oxygen. Closely monitor vital signs. Failure to diagnose uterine perforation may lead to life-threatening complications: In postabortion patients with abdominal pain beyond the pelvic area, suspect perforation and evaluate with kidney, ureter, and bladder (KUB)/upright radiographs and pelvic ultrasonography. Consult a gynecologist and, if suspicion is high, insist on laparoscopy.

Failure to diagnose ectopic pregnancy: The chance of a missed ectopic pregnancy always exists. Do not presume intrauterine pregnancy in a patient who has just had an abortion; she may have had a missed ectopic pregnancy. Failure to promptly administer broad-spectrum antibiotic therapy may result in complications, including sepsis and septic shock. Do not delay administration of antibiotics if a patient has signs of severe postabortion infection. Administer broadspectrum antibiotics before completing diagnostic workup. Failure to obtain information about recent termination of pregnancy may lead to a wrong diagnosis or delayed/inappropriate treatment. Failure to evacuate retained products of conception from the uterus leads to treatment failure and possible complications. Failure to diagnose bowel injury may lead to life-threatening complications.

History
Presentation depends on the type of complication the patient develops. Intraoperative and early postoperative complications are rarely seen in the ED, but some patients develop these types of complications and present to the ED for treatment. Complications include the following:

Local anesthesia: Paracervical block is a common method of anesthesia for therapeutic abortion. Accidental intravascular injection of anesthetic is a potentially life-threatening complication of this method that could lead to seizure, cardiopulmonary arrest, and death. General anesthesia: Complications with general anesthesia may lead to uterine atony with severe hemorrhage. Cervical shock: Vasovagal syncope produced by stimulation of the cervical canal during dilatation may occur. Rapid recovery usually follows. Postabortion triad: Pain, bleeding, and low-grade fevers are the most common presenting complaints. Postabortion triad usually is caused by retained products of conception. Hemorrhage: Excessive hemorrhage during or after abortion may signify uterine atony, cervical laceration, uterine perforation, cervical pregnancy, a more advanced gestational age than anticipated, or coagulopathy. Hematometra: Also known as post abortion syndrome, this is the result of retained products of conception or uterine atony for other causes. The endometrium is distended with blood, and the uterus is unable to contract to expel the contents. Patients usually present with increasing lower midline abdominal pain, absent or decreased vaginal bleeding, and, at times, hemodynamic compromise. This may develop immediately after miscarriage or abortion, or it may develop insidiously. Perforation: Patients with uterine perforation missed during the procedure usually present to the ED with increased abdominal pain, bleeding (possibly ranging from very mild to absent), and fever. If perforation results in injury to major blood vessels, patients may present in hemorrhagic shock. Bowel injury: This may accompany uterine perforation. If initially unrecognized, patients present with abdominal pain, fever, blood in the stool, nausea, and vomiting. Bladder injury: This occurs as a result of uterine or cervical perforation. Patients present with suprapubic pain and hematuria.

Septic abortion: This is endometritis. Patients present with fever, chills, abdominal pain, vaginal discharge, vaginal bleeding, and history of recent pregnancy. Failed abortion (continued intrauterine or ectopic pregnancy): Failure to terminate the pregnancy is relatively common with very early abortions (< 6 wk gestational age). Such patients may present to the ED with symptoms of continuing pregnancy such as hyperemesis, increased abdominal girth, and breast engorgement. In addition, an unrecognized ectopic pregnancy in the postabortion period presents in the usual manner. Disseminated intravascular coagulation: Suspect DIC in all patients who present with severe postabortion bleeding, especially after midtrimester abortions. Incidence is approximately 200 cases per 100,000 abortions; this rate is even higher for saline instillation techniques (660 per 100,000 abortions).

Physical

Vital signs o Monitoring of vital signs is essential for patients with postabortion complications. o Increasing fever could be a sign of progressing infection. o Tachycardia and hypotension may be signs of severe hemorrhage or septic shock. Abdominal examination o Suprapubic tenderness is common in the postabortion period. Severe tenderness is unusual and may be a sign of hematometra, bladder perforation, or bowel injury. o Tenderness in other areas of the abdomen (eg, rebound tenderness, guarding) strongly indicates instrumental injury complications (eg, perforation, bowel injury, bladder injury). o A tender mass in the suprapubic area suggests hematometra. o Diminished or absent bowel sounds are a sign of developing peritonitis. Vaginal examination o Assess the quantity and rate of hemorrhage. Look for possible vaginal or cervical injury. Identify the source of bleeding (eg, uterine; cervical os; lesions of the vulva, vagina, or vaginal portion of cervix). o Cervical motion tenderness on bimanual examination may be suggestive of pelvic infection or ectopic pregnancy. o A large tender uterus may be a sign of hematometra. o Adnexal tenderness or masses may suggest ectopic pregnancy, pelvic inflammatory disease (PID), cyst, or hematoma. Rectal examination o A rectal examination must be performed if bowel injury is suspected. o The presence of rectal tenderness and blood (or guaiac-positive stool) makes the diagnosis of bowel injury almost certain.

Causes
Two major factors contribute to the development of septic abortion: retained products of conception and infection introduced into the uterus.

Retained products of conception due to incomplete spontaneous miscarriage or therapeutic abortion Introduction of infection into the uterus: Pathogens causing septic abortion usually are mixed and derived from normal vaginal flora and sexually transmitted bacteria. These organisms include the following: o Escherichia coli and other aerobic, enteric, gram-negative rods [3] o Group B beta-hemolytic streptococci [4] o Staphylococcal organisms o Bacteroides species o Neisseria gonorrhoeae o Chlamydia trachomatis o Clostridium perfringens o Mycoplasma hominis o Haemophilus influenzae

Prehospital Care
Prehospital care for patients with suspected abortion complications includes the following:

Monitor vital signs. Stabilize with intravenous fluids (eg, normal saline, Ringer's lactate), if the patient is hemodynamically unstable. Administer oxygen.

Emergency Department Care

Screen all patients with postabortion complications for Rh factor. Administer Rho(D) immune globulin (RhoGAM) if results indicate that the patient is Rh-negative and unsensitized. Patients with the postabortion triad (ie, pain, bleeding, low-grade fever) may respond to treatment with oral antibiotics and ergot preparations. Immediately initiate these agents. In most cases, however, blood clots or retained products of conception must be evacuated from the uterus. In these cases, administer medications parenterally, as the patient will undergo anesthesia. Hemorrhage or hematometra o Monitor vital signs and rate of bleeding. Administer fluids and blood as needed. o Administer intravenous oxytocin for treatment of uterine atony. o Alternative treatments for uterine atony include intracervical vasopressin or carboprost tromethamine and bimanual uterine massage. o If bleeding persists, screen for coagulopathy/DIC and obtain immediate gynecologic consultation with the intention of transferring the patient to the operating room (OR) for repeat curettage and, if necessary, hysterectomy. Uterine perforation, bowel injury, and bladder injury: If one or any combination of these complications is suspected or diagnosed in the ED, treat as follows: o Hemodynamically stabilize the patient.

Insert a Foley catheter. Transfer to the OR for laparoscopy/laparotomy and further treatment. Failed abortion, continued pregnancy, and ectopic pregnancy o If the patient is stable, perform ultrasonography and obtain a beta-human chorionic gonadotropin (hCG) level to establish the diagnosis and further treatment. o If the patient is unstable, transfer to the OR for dilation and curettage (D&C) and/or laparoscopy/laparotomy. Suspected septic abortion o Administer intravenous fluids through a large-bore angiocatheter. o For patients who are unstable, administer oxygen and insert a Foley catheter. o Early antibiotic treatment may be guided by Gram stain, but broad-spectrum coverage is recommended. o Perform evacuation of retained tissues from the uterine cavity, preferably by D&C. If D&C is not immediately available, high doses of oxytocin can be used. o Laparotomy may be needed if the above measures elicit no response. o A hysterectomy may be necessary in cases of uterine perforation, bowel injury, clostridial myometritis, and pelvic abscess. o Management of septic shock is discussed in Shock, Septic.

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Consultations

Consult an obstetrician/gynecologist (OB/GYN) in all cases of postabortion complications. Consult surgery and urology if bowel or bladder injury is diagnosed. Immediately administer broad-spectrum antibiotics to patients with severe postabortion infection. View full drug information

Cefoxitin (Mefoxin)
Indicated for infections caused by susceptible gram-positive cocci and gram-negative bacilli. Many infections caused by gram-negative bacteria resistant to some cephalosporins and penicillins respond to cefoxitin. View full drug information

Doxycycline (Bio-Tab, Doryx, Vibramycin)

Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Rickettsia, Chlamydia, and Mycoplasma species. View full drug information

Gentamicin sulfate (Garamycin, Gentacidin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and an agent that covers anaerobes. Not the DOC. Consider if penicillins (see note above) or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible

staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM. View full drug information

Ticarcillin and clavulanate potassium (Timentin)

Presumptive therapy prior to identification of organism. Inhibits biosynthesis of cell wall mucopeptide; effective during stage of active growth. View full drug information

Ampicillin and sulbactam sodium (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens. View full drug information

Imipenem and cilastatin sodium (Primaxin)

Treats multiple-organism infections for which other agents lack wide-spectrum coverage or are contraindicated due to potential toxicity. View full drug information

Piperacillin and tazobactam sodium (Zosyn)

Treats septicemia caused by susceptible organisms. View full drug information

Clindamycin (Cleocin)
Useful as treatment against aerobic streptococci and most staphylococci. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. View full drug information

Cefotaxime (Claforan)
Treats septicemia and gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. View full drug information

Vancomycin HCL (Vancocin, Vancoled)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or who have infections with resistant staphylococci. To avoid toxicity, current recommendation is to assay only vancomycin trough levels after the third dose, drawn 0.5 h before next dosing. Doses and dosing intervals may be adjusted based on CrCl. View full drug information

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Synthetic posterior pituitary hormones

Class Summary
When D&C is not immediately available, these hormones are used to induce contractions to help evacuate retained products of conception from the uterus. View full drug information

Oxytocin (Pitocin, Syntocinon)

Produces rhythmic uterine contractions and can stimulate the gravid uterus, as well as vasopressive and antidiuretic effects. Also can control postpartum bleeding or hemorrhage.

Ergot alkaloids
Class Summary
Ergot derivatives are used for oxytocic effects on uterine muscle. These agents prevent postabortion uterine atony and hemorrhage. View full drug information

Ergonovine (Ergotrate Maleate)

Prevents and treats postabortal hemorrhage due to uterine atony by producing a firm contraction of the uterus within minutes. Although intended primarily for IM administration, faster response can be achieved through IV administration. However, because IV route produces higher incidence of adverse effects, reserve for emergencies such as excessive uterine bleeding. Severe uterine bleeding may require repeated doses but seldom requires more than 1 injection q2-4h. View full drug information

Methylergonovine (Methergine)
Acts directly on the smooth muscle of the uterus; induces a rapid and sustained tetanic uterotonic effect that reduces bleeding.