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MANAGING COMPLICATIONS

Also see Ch 5: Medications for Emergency Management

IMMEDIATE COMPLICATIONS CLINICAL PRESENTATION MANAGEMENT OPTIONS OCCURENCE RATE*
Vasovagal Episode Presentation may include:

  • Pale, clammy, dizzy, nausea/vomiting,
  • Pulse < 60
  • Syncope (rare)
  • During or after procedure
  • Usually resolves quickly and spontaneously

Etiology:

  • Parasympathetic nerve stimulation and painful stimuli
 Pause procedure:

  • Apply cool compresses
  • Trendelenburg position or elevate the legs above the chest
  • Sniffing ammonium or an alcohol pad may help
  • Isometric extremity contractions (Cason 2019)

For persistent symptomatic bradycardia:
Atropine 0.2 mg IV or 0.4 mg IM, May repeat in 3-5 min (max 2 mg)

 Not reported (Cason 2019)
Excessive Bleeding/ Hemorrhage Blood loss ≥ 500 cc = hemorrhage

Remember 4 T’s of etiology:

(ALSO 2023)

  1. Tissue (not completely evacuated)
  2. Tone (inadequate uterine tone)
  3. Trauma (perforation or cervical lac)
  4. Thrombin (rare underlying bleeding disorder)

Hemorrhage risk group; Prevention and Preparation Measures:

(See Ch 3; SFP 2024)

 6T’s (Goodman 2015)

Tissue: Assure uterus is empty

  • Determine EBL
  • Reaspirate (US guidance; EVA for rapid evacuation); check POC

Tone: Uterotonics

  • Uterine massage
  • Medications: TXA 1000mg (in 100cc NS) run over 10 mins. Methergine 0.2 mg IM/IC, Misoprostol 600-1000 mcg SL/BU/PR, and/or Vasopressin

4-8 units (in 5-10 cc NS) IC, or 20-40 units in 1L NS IV,

Trauma: Assess source

  • Cannula test*
  • Clamp bleeding site at cervix with ring forceps until able to repair

Thrombin

  • Review bleeding history
  • Additional tests as indicated (coags, repeat CBC, clot test**)

Treatment

  • IV fluid bolus
  • For uterine / cervical injury, inflate Foley/intrauterine balloon to tamponade

Transfer

  • Vitals every 5 minutes
  • Initiate transfer if initial measures are unsuccessful.
 0.07 – 0.4 %

(NASEM 2018,

Upadhyay 2015,

Weitz 2013)
Perforation Instruments pass deeper than expected by EGD and pelvic exam (see Ch 12 image)

Person may feel sudden sharp pain; may be painless

Risk factors:

  • Inadequate dilation
  • Increased gestational duration
  • Uterine flexion
  • Previous cesarean section
  • Operator inexperience
  • Uterine anomaly
 Stop procedure:

  • Turn off suction
  • Assess person: VS, pain, bleeding, abdominal exam
  • Check contents of aspirate for omentum or bowel, and for POC

If stable:

  • Evaluate with US
  • Experienced providers have safely completed procedure under US guidance
  • Observe for 1.5-2 hours
  • Consider uterotonics to contract uterus and control bleeding
  • Consider preventative antibiotics

Reasons for hospital transfer:

  • Clinically unstable
  • Free fluid
  • Bowel in uterus, POC, or cannula
  • Pregnancy tissue in abdomen
  • Unable to complete procedure
 0.02 – 0.07%

(NASEM 2018,

Upadhyay 2015,

Weitz 2013)
DELAYED COMPLICATIONS CLINICAL PRESENTATION MANAGEMENT OPTIONS OCCURENCE RATE*
Incomplete Abortion (Residual nonviable fetal tissue) At time of aspiration:

  • Inadequate POC or

Days to weeks after:

  • Pelvic pain, fever
  • Abnormal bleeding
  • Pregnancy symptoms

Enlarged or boggy uterus, ultrasound shows persistent IUP or debris [latter is non-specific; may be normal (Russo 2012; Paul 2009)

 Offer misoprostol, re-aspiration to empty uterus, or expectant management

Re-aspiration if:

  • Signs of infection
  • Hemorrhage
  • Severe pain
  • Significant anemia
 0.2 – 4.4%

(Upadhyay 2015,

Weitz 2013)
Continuing Pregnancy Presentation:

  • Ongoing pregnancy symptoms
  • Enlarging uterus

Risk factors:

  • Early gestation
  • Uterine anomalies/fibroids
  • Missed multiple gestation
  • Operator inexperience
 If inadequate POCs suspected at time of procedure, consider:

  • US
  • Serial hCGs
  • Ectopic precautions as needed
  • Reaspirate as appropriate
  • Counsel person receiving care
 0.4 – 2.3%

(Kerns 2013,

Upadhyay 2015, Weitz 2013)
Hematometra (Accumulation of blood in uterus following procedure) Immediate:

  • Minutes to hours post-ab
  • Severe lower abdominal or pelvic pain
  • Rectal pressure
  • Minimal to no post-procedural bleeding
  • +/- hypotension, vasovagal
  • US: large amount uterine clot
  • Uterine exam: enlarged, firm

Delayed:

  • Days to weeks post-ab
  • Pelvic pressure or cramping
  • +/- low grade fever
 Prompt uterine aspiration of blood offers immediate relief

Uterotonic medications post aspi- ration:

  • Methergine 0.2 mg IM / IC
  • Misoprostol 800 mcg PR or buccal
 1.1 – 2.2 %

(Bennett 2009, Weitz 2013, Yonke 2013)
Post-abortion endometritis Presentation:

  • Typically >24+ hours after procedure
  • Lower abdominal / pelvic pain
  • Fever, malaise
  • Tenderness
  • Purulent discharge
  • Elevated WBC
 Diagnose:

  • US for retained POC / clot
  • Wet mount
  • Test for GC/CT

Treat:

  • Antibiotics (CDC; PID regimen)
  • Re-aspiration if indicated
 0.09-2.6%

(Upadhyay 2015, Weitz 2013, Yonke 2013)
Missed Ectopic Pregnancy Suspect if inadequate POC at time of aspiration

Possible late signs/symptoms:

  • Pelvic pain or shoulder pain
  • Syncope or shock
 Referral for appropriate care if:

  • Ectopic is suspected (for diagnosis and/or treatment)
  • Immediate transfer or referral to hospital for Methotrexate vs. surgical management if:
    • Concern for rupture
    • Clinically unstable
 0.0 – 0.3%

(Scant data)

Bennett 2009

* Cannula test: Watch blood return as you slowly withdraw cannula from fundus to cervix, to identify bleeding zone.

**Clot test: Fill a plain glass tube with whole blood; leave 10 minutes. Complete clotting at 10 minutes rules out DIC at that time.

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