MANAGING COMPLICATIONS BETWEEN 14 – 18 WEEKS
With second-trimester procedures, complication rates gradually increase with EGA, (NASEM 2018, Kapp 2020, Grimes 1984), while overall rates of serious complications remain low. At this EGA, most complications are similar to those at <13 weeks (See Ch 6: Managing Complications), with the following nuances:
|COMPLICATIONS||CLINICAL PRESENTATION||PREVENTION AND MANAGEMENT TIPS or OPTIONS||OCCURENCE RATE|
|Hemorrhage due to Atony||• EBL > 500 ml = hemorrhage||• Ensure good uterine tone without suspicious flow prior to removing instruments.
• If visualized LUS suggests 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.
Review 6T treatment steps and uterotonics
|0.07 – 0.4 %
NASEM 2018, Upadhyay 2015, Weitz 2013
|Hemorrhage due to Arteriovenous malformation (AVM)||• Rare, life-threatening source of profuse bleeding uncontrolled despite usual measures||• If standard 6T bleeding management steps don’t resolve, apply tamponade with foley, Bakri, or vaginal pack and transport for embolization/cautery||Rare; case reports|
|Cervical laceration/trauma||Low/Ant/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, decrease 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 body of the cervix; may require suturing. If extends up behind bladder and may require OR repair.
• High cervical tears caused by forceful mechanical dilation can result in uterine artery laceration. May require balloon tamponade or surgical management.
|0.8% early 2nd trimester with lams + dilation|
|Uterine perforation||• Instruments pass deeper than expected by EGA and pelvic exam
Patient may feel sudden sharp pain; may be painless
• Inadequate dilation
• Increased gestational age
• Uterine flexion
• Previous c-section
• Operator inexperience
• Uterine anomaly
• 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 contractuterus and control bleeding
• Consider antibiotics If unstable or perforation occurred with suction, transfer
|0.02 – 0.07%|
|Partial or Complete Placenta Previa||Patients > 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 patient in clinic and 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”.
• Under US guidance, remove placenta with forceps prior to initiating aspiration or D&E.
|0.05% of pregnancies
1-5 x higher with increasing # c-sections
|Placenta Accreta Spectrum (PAS)||• See PAS risk factors
• With concurrent low lying or anterior placenta (<2 cm above os) or placenta previa
• At risk for severe hemorrhage
|• See US and Doppler screening criteria
• Refer PAS to multi-disciplinary center, for scheduled procedure with transfusion services and surgical management to mitigate bleeding risk
|0.07-0.2% of pregnancies
0.3% if previous c-section
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).
As inequity and injustice in abortion access spread across the U.S., providers have an opportunity to consider non-traditional methods of expanding access to care. While in-person training with an experienced provider remains the gold standard for expanding D&E skills, alternate methods of increasing provision may include simulation models and incremental increases in gestational age using a gradual stepwise approach. Incremental expansion in gestational age by you as a provider and by clinics and organizations can improve patient access, travel, and stress, while minimizing fragmentation of care. Patients with higher-risk pregnancies can be managed or referred to a higher level of care depending on provider skills and regional resources. Depending on your legal constraints, providers may use formal or informal referral networks, with warm hand-off using pager or cell phone, or warm lines for second opinions. As a provider, you play an instrumental role in setting the tone at your clinic, helping staff with later abortion values exploration, normalizing the possibility of seeing more complex patients, and expanding the services offered.
(Beyond standard equipment for aspiration < 14 weeks)
Appendix B: Forceps
|Hern Van Lyth Evacuation Forceps 9½” (241mm) 9mm Jaws
Hern Van Lyth Evacuation Forceps 10″ (254mm) 11mm Jaws
|Small Finks Forceps 10½” (267mm) 13mm Jaws – smaller teeth|
|Fink Ovum Forceps 10½” (267mm) 13mm Jaws – larger teeth|
|Sopher Ovum Forceps 11-13″ (279-330mm) 12-14mm Jaws|
|Bierer Ovum Forceps 11-13″(279-330mm) 16-19mm Jaws – larger teeth|