Presentation on theme: "Abortion Complications Management Workshop"— Presentation transcript:
1Abortion Complications Management Workshop This slide presentation has been developed by the medical directors of the Planned Parenthood affiliates of the state of California for the purpose of educating community physicians in the management of patients presenting with complaints following a medical or surgical abortion
2Earlier Procedures are Safer-- CDC’s Abortion Mortality Surveillance System Currently, gestational age = strongest risk factor for abortion-related mortalityLowest risk of death: abortions < 8 weeksMortality risk is increases 38% for each additional week of pregnancyCORE SLIDEThis slide summarizes data obtained regarding abortion mortality in the U.S. from 1972 to The authors are from the CDC and the Epidemic Intelligence Service; they summarized findings from the Abortion Surveillance System.In 1997 (the most recent year for which data is available in the U.S.) the overall rate of mortality from abortion is 0.6/100,000 procedures. The lowest rates of abortion-related mortality are among women who have their abortions in the first trimester of pregnancy, particularly within the first 8 weeks of pregnancy:Gestational Age Mortality Rate Relative Risk(deaths/100,000 procedures)At or under 8 wks referent9-10 wks (0.5, 4.2)(1.2, 9.7)Source:Bartlett L, Berg CJ, Shulman HB, Zane SB, Green CA, Whitehead S, Atrash HK. Risk Factor for Legal Induced Abortion-Related Mortality in the United States. Obstetrics & Gynecology ;103(4):Bartlet 2004
3Abortion Related Mortality 1st Trimester:Infection (33%)Hemorrhage (14%)2nd Trimester:Hemorrhage (40%)Paul 2009
4Emergency Prevention Emergency carts, boxes, cards on site Appropriate history; patient selectionPre-op labs: HgbCareful dating (clinical +/- dating)Adequate cervical prep (miso, lam)Vasopressin in PCB > 12 wks (Edelman 2006)Uterotonics availableTransfer agreements w/ nearby hospitals
5Procedural Pearls Careful exam for uterine axis Cautious dilation Avoid overconfidenceDevelop 6th senseLow threshold to use os finders, US, hCGsCareful evaluation of POCProceed quickly to next actionDevelop stress readiness
6TEACH Simulation Innovations Papaya: a memorable MVA & PCB modelHistorically used as an abortifacientIn dialects means “vagina”Pitaya = dragon fruit: helpful model for practicing comp management stepsAlso thought to be helpful in pregnancyPaul, 2005; Goodman NAF 2013
7Case 1 24 y/o G4P3, 2 prior c/s, 8w5d desiring AB MVA quickly fills up with bloodYou empty it, recharge and it again fills with blood.You ask your assistant to prepare another MVA but it promptly fills with blood when attached to the cannula.What do you suspect? What do you do?
16Thrombin Bleeding history? Appropriate tests clot test, repeat hgb, coagsNote: Women taking anticoags did not have clinically significant increased VB < 12 weeksKaneshiro 2011, SFP Guideline 2012
17Additionally Treatment Transfer (Teamwork with a leadership role) Start IVFBalloon tamponade (30-80 cc)TransferAssess VS q 5 minutesInitiate transfer(Teamwork with a leadership role)Communicate with patient & delegate rolesStay calm under pressure
18Individual Simulation Groups of 31 provider, 1 assistant, 1 tester15 minutes for each provider; 1-2 run throughs1 point for each stepPlease complete and hand-in assessmentThese patients don’t respond to usual measuresGive provider opportunity to think it through
20Case 2 22 y/o G2P0 woman after uncomplicated 10 week abortion Called from recovery to evaluate for uterine pain with hypotensionDDx and evaluation?
21Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra PathophysiologyRelative cervical stenosis plus uterine hypotoniaLeads to retention of clotted blood in uterusDiagnosisUsually within first hour post-procedureUS shows clotted blood in uterusAcute hematometra occurs when there is hypotonia of the uterus (which results in continued bleeding) but the cervix has closed and does not allow the accumulated blood to pass. This leads to the accumulation of blood and clots in the uterine cavity.This usually occurs within the first hour following an abortion procedure.The patient may experience cramping or may be asymptomatic until they attempt to stand and experience orthostatic hypotension.
22Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra DiagnosisVital SignsMay be hypotensive; orthostatic(HoTN with standing)SignsUterine enlargement / tenderness on examSymptomsUsually little or no vaginal bleedingPatient may be asymptomatic when supineSevere cramping, lower abdominal pain, rectal presssureDizziness/faintnessThe patient may exhibit signs and or symptoms of hypovolemia and will usually have an enlarged, tender uterus on exam.
23Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra ManagementRe-aspiration usually provides complete resolutionIf not resolving or to prevent re-accumulation, consider uterotonicsIf the patient exhibits signs of hypovolemia, they should receive fluid resuscitation.An ultrasound examination should be performed to confirm the diagnosis. If there is a large amount of blood/clots in the uterus (2 cm or greater), a physician should be consulted and reaspiration performed.In most cases, a single reaspiration will result in resolution of the condition. Respiration should be followed with uterotonic medication to prevent recurrence.If hematometra continues following reaspiration, consider treatment with methergine or misoprostol to improve and maintain uterine tone.
24Case 3 33 y/o G4P3, h/o CS x 2, 12 wk EGA Dilation mildly difficult While inserting cannula into retroflexed uterus, you feel cannula get hung up at one point, and then slide in easily without a “stopping point.” Patient feels something sharp.Prevention? DDx?What should you do now?
26Emergencies Specific to Surgical Abortion: Trauma: Uterine Perforation Three types“Benign” - midline with blunt instrument, no suction“Intermediate” – perforation with suction on, no abdominal contents are seen or serious bleeding“Serious” - perforation with suction on, and abdominal contents (bowel, omentum, etc.) seen or heavy bleeding occursUterine perforations can be categorized as one of 3 types, benign, intermediate or serious.Benign uterine perforations occur in the midline of the uterus and were caused by a blunt instrument. No suction was applied.Intermediate type perforations occur at the end of a procedure with the suction on. No abdominal contents are seen in the cannula or protruding through the cervix, and there is no serious bleeding.Serious type perforations occur with the suction on and abdominal contents are seen or heavy bleeding occurs.
27How to Prevent? Increasing experience Careful exam; re-examine if necessaryShorter wide speculumTraction on tenaculumPosterior placement for a retro-flexed uterusOs finderUS guidance earlyConsider rigid curved cannula to get angleCervical ripening with misoprostol
28Emergencies Specific to Surgical Abortion: Trauma: Uterine Perforation If prior to start of abortion:STOP immediatelyINFORM of what is happeningUS: re-identify uterine cavity, evaluate bleedingOBSERVE in recovery room 1-1/2- 2 hoursAntibioticsIf stable, d/c home with phone f/u x 1-2 daysReschedule abortion 1-2 weeks laterAlternatively, at clinician discretion, complete procedure under US guidanceIf perforation occurs prior to the start of an abortion, the procedure should not be started unless the patient is stable and physician feels comfortable completing the procedure under ultrasound guidance.
29Emergencies Specific to Surgical Abortion: Trauma: Uterine Perforation Type 2 - “Intermediate Risk”Suction on; no excess bleeding or abd contentsStop suctionRemove cannula without suctionUS to re-identify uterine cavity, evaluate bleedingMay occur at end of procedure → uterus emptyOBSERVE 1-1/2- 2 hours or send for observationAntibioticsAt clinician discretion, complete procedure under US guidance or with laparoscopic visualizationPatients experiencing intermediate risk perforations should at the least be transferred to a hospital for observation.If the procedure has not been completed, it must be completed under ultrasound guidance or with laparascopic visualization.
30Emergencies Specific to Surgical Abortion: Trauma: Uterine Perforation Type 3 - “Serious Risk”Perforation with suction onIntra-abdominal contents seen in cx or POC+/- Severe pain or excessive bleedingStop procedure immediatelyUS to identify uterine cavity, evaluate bleedingAntibiotics; re-check hgb & abd examMust be transferred, usually operated on (at the discretion of the admitting physician)Stable patient may be evaluated using laparoscopyBut usually lapartomy to run bowelAs needed: UA Embolization, HysterectomyPatients experiencing serious type perforations must be transferred to a hospital and at the least, evaluated using laparoscopy.
31Emergencies Specific to Surgical Abortion: Trauma: Cervical Laceration PathophysiologyMay occur inadvertently during sounding or dilationOr withdrawing sharp fetal partsDiagnosisLaceration obvious at time of procedure or afterPersistent, bright red bleeding after procedureExaminationWalk cervix with o-ringsIf visible: note location, lengthIf not visible: cannula test:start at fundus, slowly withdraw to ID siteCervical lacerations may occur inadvertently during cervical dilation, or as sharp fetal parts are withdrawn during a D & E.They may be immediately obvious as persistent, bright red bleeding or present later, for example, if vasopressin was used as a component of the paracervical block.A thorough exam should be performed to determine the location, length and depth of the laceration and confirm that it is the source of hemorrhage.
32Emergencies Specific to Surgical Abortion: Trauma: Cervical Laceration ManagementExternal/LowCervical lac < 2 cm in length usually heal without leaving a defect and require no repairPressure +/- vasopressin, silver nitrate, monselsException → brisk bleeding that continues → repairHighConsider vasopressin, clampingOften require surgical repair in ORLow or external lacerations less than 2 cm in length will usually heal spontaneously without leaving a visible defect.Unless there is brisk bleeding noted from the laceration, no repair is necessary.However, larger or actively bleeding lacerations should be repaired.Higher lacerations will often require repair in an operating room with greater exposure and temporizing measures such as clamping the laceration or injecting a vasopressor such as vasopressin can be useful.
33Hospital Transfer Call for ambulance Inform front office Duplicate pertinent chartingNotify ER / OBNotify medical director
34Summary Hemorrhage is a common cause of abortion-related mortality. 50% of women have no risk factorsCritical to prepareTissue is more common cause after abortion than postpartum, where tone (atony is 70%).40% of post-abortal hemorrhage may be controlled by medications alone.Frick 2010; SFP Guideline 2012
35Key Points Keep good habits: If you do enough, you’ll have comps Develop 6th senseAvoid overconfidence & negative self-talkHave low threshold to use tools: os finders, USHave a life line (by phone)POC eval & hCGs as neededDevelop stress readiness: quarterly scenariosIf you do enough, you’ll have comps