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Abortion Complications Management Workshop. Earlier Procedures are Safer-- CDC’s Abortion Mortality Surveillance System Currently, gestational age = strongest.

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Presentation on theme: "Abortion Complications Management Workshop. Earlier Procedures are Safer-- CDC’s Abortion Mortality Surveillance System Currently, gestational age = strongest."— Presentation transcript:

1 Abortion Complications Management Workshop

2 Earlier Procedures are Safer-- CDC’s Abortion Mortality Surveillance System Currently, gestational age = strongest risk factor for abortion-related mortality Currently, gestational age = strongest risk factor for abortion-related mortality Lowest risk of death: abortions < 8 weeks Lowest risk of death: abortions < 8 weeks Mortality risk is increases 38% for each additional week of pregnancy Mortality risk is increases 38% for each additional week of pregnancy Bartlet 2004

3 Abortion Related Mortality 1 st Trimester: 1 st Trimester: Infection (33%) Infection (33%) Hemorrhage (14%) Hemorrhage (14%) 2 nd Trimester: 2 nd Trimester: Hemorrhage (40%) Hemorrhage (40%) Paul 2009

4 Emergency Prevention Emergency carts, boxes, cards on site Emergency carts, boxes, cards on site Appropriate history; patient selection Appropriate history; patient selection Pre-op labs: Hgb Pre-op labs: Hgb Careful dating (clinical +/- dating) Careful dating (clinical +/- dating) Adequate cervical prep (miso, lam) Adequate cervical prep (miso, lam) Vasopressin in PCB > 12 wks (Edelman 2006) Vasopressin in PCB > 12 wks (Edelman 2006) Uterotonics available Uterotonics available Transfer agreements w/ nearby hospitals Transfer agreements w/ nearby hospitals

5 Procedural Pearls Careful exam for uterine axis Careful exam for uterine axis Cautious dilation Cautious dilation Avoid overconfidence Avoid overconfidence Develop 6 th sense Develop 6 th sense Low threshold to use os finders, US, hCGs Low threshold to use os finders, US, hCGs Careful evaluation of POC Careful evaluation of POC Proceed quickly to next action Proceed quickly to next action Develop stress readiness Develop stress readiness

6 TEACH Simulation Innovations Papaya: a memorable MVA & PCB model Historically used as an abortifacient In dialects means “vagina” Pitaya = dragon fruit: helpful model for practicing comp management steps Also thought to be helpful in pregnancy Paul, 2005; Goodman NAF 2013

7 Case 1 24 y/o G4P3, 2 prior c/s, 8w5d desiring AB MVA quickly fills up with blood You 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?

8 Demo and Group Brainstorm

9 Causes of Hemorrhage 4 Ts Tissue: Retained Clot, Tissue, Hematometra Tone: Uterine Atony Trauma: Perforation, Cervical Lacerations Thrombin: Rare Bleeding Disorders, DIC ALSO 2013

10 Risk Factors for Hemorrhage CauseRisk Factors Tissue Incomplete procedure Less surgical experience Hematometra Abnormal placentation Tone Increasing EGA Prior C/S Previous obstetrical hemorrhage Increasing maternal age * General anesthesia Trauma Uterine flexion Increasing EGA Nulliparity Inadequate cervical dilation Thrombin Personal / FH bleeding or disorder Anticoagulation (esp. increasing EGA) SFP Guideline 2012

11 Algorithm – 7 T’s 6 T’s : 2 steps each 6 T’s : 2 steps each 4 T’s (Tissue, Tone, Trauma, Thrombin) 4 T’s (Tissue, Tone, Trauma, Thrombin) Treatment plan Treatment plan Transfer Transfer (Teamwork with a leadership role) (Teamwork with a leadership role)

12 Tissue 4 Ts: Think tissue first 4 Ts: Think tissue first Re-aspiration Re-aspiration

13 Tone (Atony) Medications Medications Misoprostol mcg SL/ BU/ PR Misoprostol mcg SL/ BU/ PR Methergine 0.2 mg IM, IC, IV (HTN) Methergine 0.2 mg IM, IC, IV (HTN) (Min evidence for 1 particular agent) (Min evidence for 1 particular agent) Massage Massage SFP Guideline 2012

14 Trauma Assess bleeding source Assess bleeding source Walk cervix Walk cervix Cannula test Cannula test Ultrasound Ultrasound Think perforation if free fluid Think perforation if free fluid

15 Free fluid in cul-de-sac

16 Thrombin Bleeding history? Bleeding history? Appropriate tests Appropriate tests clot test, repeat hgb, coags clot test, repeat hgb, coags Note: Women taking anticoags did not have clinically significant increased VB < 12 weeks Note: Women taking anticoags did not have clinically significant increased VB < 12 weeks Kaneshiro 2011, SFP Guideline 2012

17 Additionally Treatment Treatment Start IVF Start IVF Balloon tamponade (30-80 cc) Balloon tamponade (30-80 cc) Transfer Transfer Assess VS q 5 minutes Assess VS q 5 minutes Initiate transfer Initiate transfer (Teamwork with a leadership role) (Teamwork with a leadership role) Communicate with patient & delegate roles Communicate with patient & delegate roles Stay calm under pressure Stay calm under pressure

18 Individual Simulation  Groups of 3  1 provider, 1 assistant, 1 tester  15 minutes for each provider; 1-2 run throughs  1 point for each step  Please complete and hand-in assessment  These patients don’t respond to usual measures  Give provider opportunity to think it through

19 Review Hemorrhage Algorithm – 7 T’s Recognize heavy bleeding; initiate algorithm Recognize heavy bleeding; initiate algorithm 6 T’s : 2 steps each 6 T’s : 2 steps each 4 T’s (Tissue, Tone, Trauma, Thrombin) 4 T’s (Tissue, Tone, Trauma, Thrombin) Treatment Treatment Transfer Transfer (Teamwork) (Teamwork)

20 Case 2 22 y/o G2P0 woman after uncomplicated 10 week abortion 22 y/o G2P0 woman after uncomplicated 10 week abortion Called from recovery to evaluate for uterine pain with hypotension Called from recovery to evaluate for uterine pain with hypotension DDx and evaluation? DDx and evaluation?

21 Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra Pathophysiology Pathophysiology Relative cervical stenosis plus uterine hypotonia Relative cervical stenosis plus uterine hypotonia Leads to retention of clotted blood in uterus Leads to retention of clotted blood in uterus Diagnosis Diagnosis Usually within first hour post-procedure Usually within first hour post-procedure US shows clotted blood in uterus US shows clotted blood in uterus

22 Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra Diagnosis Diagnosis Vital Signs May be hypotensive; orthostatic(HoTN with standing) May be hypotensive; orthostatic(HoTN with standing)Signs Uterine enlargement / tenderness on exam Uterine enlargement / tenderness on examSymptoms Usually little or no vaginal bleeding Usually little or no vaginal bleeding Patient may be asymptomatic when supine Patient may be asymptomatic when supine Severe cramping, lower abdominal pain, rectal presssure Severe cramping, lower abdominal pain, rectal presssure Dizziness/faintness Dizziness/faintness

23 Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra Management Management Re-aspiration usually provides complete resolution Re-aspiration usually provides complete resolution If not resolving or to prevent re-accumulation, consider uterotonics If not resolving or to prevent re-accumulation, consider uterotonics

24 Case 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?

25 Trauma: Uterine Perforation 1 st Tri: Fundal - Few complications Advanced GA More likely lateral Bleed more Incidence 0.1 – 3 / 1000 SFP Guideline 2012

26 Emergencies Specific to Surgical Abortion: Trauma: Uterine Perforation Three types Three types “ Benign ” - midline with blunt instrument, no suction “ Benign ” - midline with blunt instrument, no suction “ Intermediate ” – perforation with suction on, no abdominal contents are seen or serious bleeding “ 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 occurs “ Serious ” - perforation with suction on, and abdominal contents (bowel, omentum, etc.) seen or heavy bleeding occurs

27 How to Prevent? Increasing experience Increasing experience Careful exam; re-examine if necessary Careful exam; re-examine if necessary Shorter wide speculum Shorter wide speculum Traction on tenaculum Traction on tenaculum Posterior placement for a retro-flexed uterus Posterior placement for a retro-flexed uterus Os finder Os finder US guidance early US guidance early Consider rigid curved cannula to get angle Consider rigid curved cannula to get angle Cervical ripening with misoprostol Cervical ripening with misoprostol

28 Emergencies Specific to Surgical Abortion: Trauma: Uterine Perforation If prior to start of abortion: If prior to start of abortion: STOP immediately STOP immediately INFORM of what is happening INFORM of what is happening US: re-identify uterine cavity, evaluate bleeding US: re-identify uterine cavity, evaluate bleeding OBSERVE in recovery room 1-1/2- 2 hours OBSERVE in recovery room 1-1/2- 2 hours Antibiotics Antibiotics If stable, d/c home with phone f/u x 1-2 days If stable, d/c home with phone f/u x 1-2 days Reschedule abortion 1-2 weeks later Reschedule abortion 1-2 weeks later Alternatively, at clinician discretion, complete procedure under US guidance Alternatively, at clinician discretion, complete procedure under US guidance

29 Emergencies Specific to Surgical Abortion: Trauma: Uterine Perforation Type 2 - “Intermediate Risk” Suction on; no excess bleeding or abd contents Suction on; no excess bleeding or abd contents Stop suction Stop suction Remove cannula without suction Remove cannula without suction US to re-identify uterine cavity, evaluate bleeding US to re-identify uterine cavity, evaluate bleeding May occur at end of procedure → uterus empty May occur at end of procedure → uterus empty OBSERVE 1-1/2- 2 hours or send for observation OBSERVE 1-1/2- 2 hours or send for observation Antibiotics Antibiotics At clinician discretion, complete procedure under US guidance or with laparoscopic visualization At clinician discretion, complete procedure under US guidance or with laparoscopic visualization

30 Emergencies Specific to Surgical Abortion: Trauma: Uterine Perforation Type 3 - “ Serious Risk ” Type 3 - “ Serious Risk ” Perforation with suction on Perforation with suction on Intra-abdominal contents seen in cx or POC Intra-abdominal contents seen in cx or POC +/- Severe pain or excessive bleeding +/- Severe pain or excessive bleeding Stop procedure immediately Stop procedure immediately US to identify uterine cavity, evaluate bleeding US to identify uterine cavity, evaluate bleeding Antibiotics; re-check hgb & abd exam Antibiotics; re-check hgb & abd exam Must be transferred, usually operated on (at the discretion of the admitting physician) Must be transferred, usually operated on (at the discretion of the admitting physician) Stable patient may be evaluated using laparoscopy Stable patient may be evaluated using laparoscopy But usually lapartomy to run bowel But usually lapartomy to run bowel As needed: UA Embolization, Hysterectomy As needed: UA Embolization, Hysterectomy

31 Emergencies Specific to Surgical Abortion: Trauma: Cervical Laceration Pathophysiology Pathophysiology May occur inadvertently during sounding or dilation May occur inadvertently during sounding or dilation Or withdrawing sharp fetal parts Or withdrawing sharp fetal parts Diagnosis Diagnosis Laceration obvious at time of procedure or after Laceration obvious at time of procedure or after Persistent, bright red bleeding after procedure Persistent, bright red bleeding after procedure Examination Examination Walk cervix with o-rings Walk cervix with o-rings If visible: note location, length If visible: note location, length If not visible: cannula test: If not visible: cannula test: start at fundus, slowly withdraw to ID site start at fundus, slowly withdraw to ID site

32 Emergencies Specific to Surgical Abortion: Trauma: Cervical Laceration Management Management External/Low External/Low Cervical lac < 2 cm in length usually heal without leaving a defect and require no repair Cervical lac < 2 cm in length usually heal without leaving a defect and require no repair Pressure +/- vasopressin, silver nitrate, monsels Pressure +/- vasopressin, silver nitrate, monsels Exception → brisk bleeding that continues → repair Exception → brisk bleeding that continues → repair High High Consider vasopressin, clamping Consider vasopressin, clamping Often require surgical repair in OR Often require surgical repair in OR

33 Hospital Transfer Call for ambulance Call for ambulance Inform front office Inform front office Duplicate pertinent charting Duplicate pertinent charting Notify ER / OB Notify ER / OB Notify medical director Notify medical director

34 Summary Hemorrhage is a common cause of abortion-related mortality. Hemorrhage is a common cause of abortion-related mortality. 50% of women have no risk factors 50% of women have no risk factors Critical to prepare Critical to prepare Tissue is more common cause after abortion than postpartum, where tone (atony is 70%). Tissue is more common cause after abortion than postpartum, where tone (atony is 70%). 40% of post-abortal hemorrhage may be controlled by medications alone. 40% of post-abortal hemorrhage may be controlled by medications alone. Frick 2010; SFP Guideline 2012

35 Key Points Keep good habits: Keep good habits: Develop 6 th sense Develop 6 th sense Avoid overconfidence & negative self-talk Avoid overconfidence & negative self-talk Have low threshold to use tools: os finders, US Have low threshold to use tools: os finders, US Have a life line (by phone) Have a life line (by phone) POC eval & hCGs as needed POC eval & hCGs as needed Develop stress readiness: quarterly scenarios Develop stress readiness: quarterly scenarios If you do enough, you’ll have comps If you do enough, you’ll have comps

36 Questions Thank you Please fill out evaluations! Please fill out evaluations!


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