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Abortion Complications Management Workshop

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Presentation on theme: "Abortion Complications Management Workshop"— Presentation transcript:

1 Abortion 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

2 Earlier Procedures are Safer-- CDC’s Abortion Mortality Surveillance System
Currently, gestational age = strongest risk factor for abortion-related mortality Lowest risk of death: abortions < 8 weeks Mortality risk is increases 38% for each additional week of pregnancy CORE SLIDE This 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 referent 9-10 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

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

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

5 Procedural Pearls Careful exam for uterine axis Cautious dilation
Avoid overconfidence Develop 6th sense Low threshold to use os finders, US, hCGs Careful evaluation of POC Proceed quickly to next action 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
Cause Risk 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 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
4 T’s (Tissue, Tone, Trauma, Thrombin) Treatment plan Transfer (Teamwork with a leadership role)

12 Tissue 4 Ts: Think tissue first Re-aspiration

13 Tone (Atony) Medications Massage Misoprostol 800-1000 mcg SL/ BU/ PR
Methergine 0.2 mg IM, IC, IV (HTN) (Min evidence for 1 particular agent) Massage SFP Guideline 2012

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

15 Free fluid in cul-de-sac

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

17 Additionally Treatment Transfer (Teamwork with a leadership role)
Start IVF Balloon tamponade (30-80 cc) Transfer Assess VS q 5 minutes Initiate transfer (Teamwork with a leadership role) Communicate with patient & delegate roles 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 6 T’s : 2 steps each 4 T’s (Tissue, Tone, Trauma, Thrombin) Treatment Transfer (Teamwork)

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

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

22 Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra
Diagnosis Vital Signs May be hypotensive; orthostatic(HoTN with standing) Signs Uterine enlargement / tenderness on exam Symptoms Usually little or no vaginal bleeding Patient may be asymptomatic when supine Severe cramping, lower abdominal pain, rectal presssure Dizziness/faintness The patient may exhibit signs and or symptoms of hypovolemia and will usually have an enlarged, tender uterus on exam.

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

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
1st 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 “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 occurs Uterine 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.

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

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

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

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

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

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

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

34 Summary Hemorrhage is a common cause of abortion-related mortality.
50% of women have no risk factors Critical to prepare 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. Frick 2010; SFP Guideline 2012

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

36 Questions Thank you Please fill out evaluations!

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