MANAGING COMPLICATIONS

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

  • Pale, clammy, dizzy, nauseated or with emesis
  • Pulse < 60
  • Rare syncope
  • 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 may help
  • Isometric extremity contractions

For persistent symptomatic bradycardia:

  • Atropine 0.2 mg IV or 0.4 mg IM,
  • May repeat in 3-5 minutes (max dose of 2 mg)
 Not reported

Cason 2019
Excessive Bleeding/ Hemorrhage EBL > 150 cc = excessive to 10 wks

EBL ≥ 500 cc = hemorrhage

Remember 4T’s of etiology:

(ALSO 2020)

1. Tissue (not completely evacuated)

2. Tone (inadequate uterine tone)

3. Trauma (perforation or cervical lac)

4. Thrombin (rare underlying bleeding disorder)

Hemorrhage risk groups:

(Kerns 2013)

1. Low risk: no prior c/s, <2 prior c/s and no previa/accreta, no bleeding disorder, no history of obstetric hemorrhage

2. Moderate risk: ≥ 2 c/s, prior c/s and previa, bleeding disorder, history of obstetric hemorrhage not needing transfusion, increasing maternal age, GA>20 weeks, fibroids, obesity

3. High risk: accreta/concern for accreta, history of obstetric hemorrhage needing transfusion, +/- others from moderate category

 6T’s (Goodman 2015)

Tissue: Assure uterus is empty

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

Tone: Uterotonics

  • Uterine massage
  • Medications: 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, after 1st tri: Oxytocin 10 units IM, or 20-40 units in 1L NS IV, TXA 1000mg (in 100cc NS) run over 10 mins

Trauma: Assess source

  • Cannula test**
  • Clamp bleeding site at cervix with ring forceps

Thrombin

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

Treatment

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

Transfer

  • Vitals every 5 minutes
  • Initiate transfer
 0.07 – 0.4 %

NASEM 2018

Upadhyay 2015

Weitz 2013
Perforation Instruments pass deeper than expected by EGA and pelvic exam

Patient may feel sudden sharp pain; may be painless

Risk factors:

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

  • Turn off suction
  • Assess patient: 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 explored uterus and completed procedure under US guidance
  • Observe for 1.5-2 hours
  • Consider uterotonics to contract uterus and control bleeding
  • Consider antibiotics

If unstable or perf with suction, transfer

 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

US shows persistent IUP or debris [latter is non-specific; may be normal (Russo 2012; Paul 2009, pg. 228)]

 Offer misoprostol, reaspiration to empty uterus, or expectant management

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

  • US
  • Serial hCGs
  • Ectopic precautions as needed

Counsel patient; reaspirate as appropriate

 0.4 – 2.3%

Upadhyay 2015

Kerns 2013

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 aspiration:

  • Methergine 0.2 mg IM / IC
  • Misoprostol 800 mcg PR or buccal
  1. – 2.2 %

Weitz 2013

Yonke 2013

Bennett 2009
Postabortal endometritis Presentation:

  • Lower abdominal / pelvic pain
  • Fever, malaise
  • Tenderness
  • Purulent discharge
  • Elevated WBC
 Diagnose:

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

Treat:

  • Antibiotics (CDC PID regimen)
  • Reaspiration 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 hospital care if:
    • Concern for rupture
    • Clinically unstable

Methotrexate vs. surgical management

 0.0 – 0.3%

(Scant data)

Bennett 2009

 

*Summary occurrence rates from Taylor, 2010: Standardizing early aspiration abortion complication definitions and tracking. 

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

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



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