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MANAGING COMPLICATIONS
BETWEEN 14 – 18 WEEKS

While overall rates of serious complications remain low with procedural abortion between 14 to18 weeks, complication rates gradually increase with advancing gestation (NASEM 2018, Kapp 2020, Grimes 1984). Between 14 to18 weeks gestation, most complications are similar to those at <14 weeks (SFP 2023; See Ch 6: Managing Complications), with the following nuances:

COMPLICATIONS CLINICAL PRESENTATION PREVENTION AND MANAGEMENT TIPS or OPTIONS OCCURENCE RATE

Procedural Abortion > 14 weeks
Hemorrhage due to Atony • EBL > 500 ml = hemorrhage

• Review risk stratification and etiologies (4Ts)

 • Ensure good uterine tone without ongoing blood flow prior to removing instruments.

• If LUS still appears dilated, suggesting atony, immediately provide vigorous bi-directional bimanual massage with ball of gauze in ring forceps in posterior fornix and low abdominal compression by free hand or US probe.

• Watch until the tone returns, performing standard 6T management steps and uterotonics

• Consider TXA 1000 mg (in 100cc NS) run over 10 mins, and / or Oxytocin 10 units IM, or 20-40 units in 1L NS IV.

 0.07 – 0.4 %

NASEM 2018, Upadhyay 2015,
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
Hemorrhage due to Arteriovenous malformation (AVM) • Rare, life-threatening source of profuse bleeding uncontrolled despite usual measures • Review 6T bleeding management steps See Ch 6. If no resolution, apply tamponade with foley bulb or vaginal packing and transport for embolization/cautery Rare; case reports

Hashim 2013
Cervical laceration/trauma Low/Anterior/endocerv tear:

  • Vaginal bleeding in the setting of a well-contracted uterus. May see cervical laceration or visualize bleeding from external os.

 

High cervical tear

  • Hemodynamic instability in absence of external hemorrhage and in setting of a well-contracted uterus suggestive and/or
  • Abdominal US showing free fluid behind posterior uterus or in cul-de-sac.
  • Prevention: large grasp of cervix with tenaculum, use of atraumatic tenaculum, adequate cervical prep, decreased passes through cervix.
  • Low or anterior cx: apply direct pressure and/or silver nitrate or Monsel’s solution.
  • Endocervical tears caused by a bony fetal part, can lead to lacerations into the body of the cervix; may require suturing with adequate pain management. If a tear extends up behind bladder, may require OR repair.
  • High cervical tears caused by forceful mechanical dilation can result in uterine artery laceration. May require balloon tamponade and surgical management.
 0.8% early 2nd trimester with lams + dilation

Grossman 2008

Peterson 1983
Uterine perforation

(See Figure 7)

 Instruments pass deeper than expected by gestation and pelvic exam
Person may feel sudden sharp pain; may be painlessRisk factors:

  • Inadequate dilation
  • Increased gestation
  • Uterine flexion
  • Previous c-section
  • Operator inexperience
  • Uterine anomaly
 Stop procedure:

  • Turn off suction
  • Evaluate with US to visualize instruments/cannula location
  • Assess patient: VS, pain,bleeding, abdominal exam
    • Check aspirate for omentum or bowel, and for POC. If stable:

–Indications for transfer include

-Free fluid seen on US

-Pregnancy tissue outside of uterus in abdomen seen on US

-Visualization of bowel in uterus, cannula or collection of POCs

-Heavy bleeding diagnosed (from cervix) or suspected (intraabdominal)

-VS unstable

Inability to complete the procedure after pregnancy disrupted after 13 weeks

–Depending on degree of perforation, experienced providers have safely explored uterus and completed procedure under US guidance

  • If no indications for transfer, patient is stable, and procedure has been completed, observe for 1.5-2 hours
    • Consider uterotonics to contract

uterus and control bleeding

  • Consider additional antibiotics
 0.02 – 0.07%

NASEM 2018 Upadhyay 2015
Partial or Complete Placenta Previa People with gestations > 14 weeks with history of c-section and complete previa at high risk for PAS (see below)
  • See US and Doppler screening criteria
  • If no PAS, consider outpatient mgmt with the following expert guidance:
  • Anticipate scant to moderate bleeding with cervical prep and dilation.
  • Keep the person in the clinic to monitor bleeding during cervical prep.
  • Consider using synthetic osmotic dilators (Dilapan-S®) in addition to misoprostol to expedite dilation.
  • Initiate procedure if bleeding increases prior to full cervical prep “wait time”.

-If possible remove placenta first either with forceps or aspiration.

 0.05% of pregnancies

 

In setting of previa, 1-5 x higher risk with increasing # c-sections

 

Jauniaux 2019
Placenta Accreta Spectrum (PAS)
  • See PAS risk factors
  • With concurrent low lying or anterior placenta (<2 cm above os) or previa
  • At risk for severe hemorrhage
 • See US and Doppler screening

• Refer people with PAS to multi-disciplinary center, for procedure in an OR with transfusion services and surgical management to mitigate bleeding risk

 

 0.07-0.2% of pregnancies

0.3% if previous c-section

Jauniaux 2019, Matsuzaki 2021,

Silver 2018
MAB > 14 weeks
Retained Placenta after fetal expulsion Delay in placental delivery after fetal expulsion
  • Safe to wait at least 4 hours after fetal expulsion.
  • Can be treated safely with 400 mcg miso q3 hours or aspiration without subsequent hemorrhage or need for transfusion.
  • Some reduction with routine administration of oxytocin 10 units after fetal delivery (to 10%).
 12%–33%

 

SFP 2023,

Dickinson 2009

 

 Figure 7. Possible sites of uterine perforation: fundal (lateral regions are more vascular than midline), at internal os (often due to overstretching junction of cervix and lower uterine segment, injuring ascending branches of uterine artery), and low cervical perforation (can injure descending branches of uterine artery).

CONCLUSION

With challenges to abortion access globally, providers have an opportunity to consider both traditional methods of training and non-traditional methods of expanding access to care. While in-person training with an experienced provider remains the gold standard for expanding abortion skills, alternate methods of increasing provision may include simulation models and incremental increases in gestational duration using a gradual stepwise approach with informed patient consent. Incremental expansion in gestational duration for both procedural and medication abortion can improve access to abortion, reduce the need for travel and stress, while minimizing fragmentation of care. People with higher-risk pregnancies can be managed or referred to a higher level of care depending on provider skills and regional resources. Depending on legal constraints, providers may use formal or informal referral networks, and/or hotlines for second opinions. Clinicians play an instrumental role in setting the tone of care, helping staff with later abortion values exploration, normalizing the possibility of seeing more complex medical cases, and expanding the services offered.

Appendix A: Instruments and Supplies for Abortion > 14 weeks

(Beyond standard equipment for aspiration < 14 weeks)
  • Larger dilators (up to #49/51 Fr. Pratt (see Fig. 1)
  • Forceps (See Appendix B and Procedural Steps for forceps recommendations by EGD)
  • Rigid curved cannulas up to size 16 (Optional)
  • ¾” tubing to accommodate larger cannulas (see Fig. 2)
    • +/- Adapters to connect smaller cannulas to large tubing
  • EVA machine suction container lids to fit large tubing (see Fig. 2)
  • An array of speculums to include short bivalve (see Fig 3)
  • Cervical ripening agents:
    • misoprostol 200 mcg tabs,
    • mifepristone 200mg tabs,
    • osmotic dilators (synthetic (Dilapan-S) and/or laminaria),
    • and/or foley bulbs with stat lock catheter stabilizers
  • Table basin or emesis-type basin
  • Medications and IV supplies, including:
    • moderate sedation medications and reversal agents
    • hemorrhage medications (methergine, misoprostol, hemabate, TXA, (+/- oxytocin)
    • IV fluids: 500-1000mL bags of isotonic solution for fluid resuscitation
    • Medications for paracervical block (+/- vasopressin, bicarbonate)
  • Sample tray (See Fig. 3 & 4)
Appendix B. Dilation, Cannula Size, and Recommended Forceps by Gestation
Gestation Dilation Cannula Recommended Forceps
< 14w 14 Denniston

43 Pratt

 14 curved

May follow with smaller cannula

 None

(If needed Ring, Hern, Van Lyth)
14w-14w6d 43-45 Pratt Either 14 curved or

12 curved w/ forceps

May follow with smaller cannula

 None

(If needed Ring, Hern Van Lyth)
15w – 15w6d 45-47 Pratt Either 15 curved or 12 curved w/ forceps

May follow with smaller cannula

 None or Small finks (or Ring, Hern Van Lyth)
16w – 16w6d 49 Pratt Either 12, 14 or 16 curved w/ forceps

May follow with smaller cannula

 Small Finks (or Regular Finks or Sophers)
17w – 17w6d 49/51 Pratt Either 16 curved w/ forceps or 12 curved and forceps

May follow with 8 flexible

 Small finks (or Regular Finks or Sophers)
Appendix C: Forceps

Name

Forceps Body

Jaws

PROS* / CONS*
Ring Forceps

Sizes vary. Generally ~10” (254mm) with varying ring size, small/fine teeth.

 Pros:

-Good for 14-15 wk procedures

-Readily accessible

-Grasps recalcitrant calvarium

Cons:

-Handle locking mechanism

-Ringed jaw can be uncomfortable passing through cervix; size may require dilation to 14 dennison/43 pratt

-Hinge placement makes deep instrumentation difficult
Hern Van Lyth Forceps 9½” (241mm) 9mm Jaws
Hern Van Lyth Forceps 10″ (254mm) 11mm Jaws		  

 Pros:

-Slim forceps with generous jaws

-Good for 14-15 wk procedures
Small Finks Forceps 10½” (267mm) 13mm Jaws – smaller teeth Pros:

-Excellent toothy grasping

-Good for 15-17+ wk procedures

-Interchangeable with Sopher
Sopher Ovum Forceps 11-13″ (279-330mm) 12-14mm Jaws Pros:

-Good for 15-17+ wk procedures

-Interchangeable with Small Finks (for size/gest)

Cons:

– slightly less toothy than small finks
Fink Ovum Forceps 10½” (267mm) 13mm Jaws – larger teeth Pros:

– Excellent toothy grasp

-Good for 18-19 wk procedures, better grasp of larger, more calcified parts

-Slim head, large teeth
Bierer Ovum Forceps 11-13″ (279-330mm) 16-19mm Jaws – larger teeth Pros:

-Excellent for larger tissue

-Good for 20-24 wk procedures (helpful to have smaller forceps, like Finks, as back up)

*Pros/Cons of surgical instruments are personal. Instrument choice is often dependent on provider preference, availability of instruments, patient anatomy, and gestation duration. Generally it is good practice to use the smallest forceps that will comfortably complete the procedure (smaller head and larger teeth is ideal). Nuances (such as presence/absence of locking or ratcheting mechanism, curve of handles, and size of handle rings) become personal preferences with practice and exposure. Photo credit: Drs. J. McDonald and S. Mischell

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