Elective Abortion Follow-up
- Author: Frances E Casey, MD, MPH; Chief Editor: Michel E Rivlin, MD more...
Further Outpatient Care
Postoperative care of a patient after surgical abortion includes the following:
Observe patients for 30 minutes, checking for abdominal pain and unusual bleeding and observing vital signs. Immediate cervical stenosis with occlusion and hematometra can be treated by administration of oral or buccal misoprostol.
Anti-D immunoglobulin should be administered on the day of the procedure to patients who are Rh-negative.
Patients selecting immediate intrauterine device (IUD) insertion, depot-medroxyprogesterone acetate (DMPA), or contraceptive implant may begin their contraceptive on this day.
Postoperative appointments are usually 1-3 weeks after the procedure and are important to ensure timely involution, confirm the pregnancy termination has been completed, evaluate the patient for medical complications, offer continuing contraceptive care, and evaluate psychological status.
Patients who are seen at 1-3 weeks after a medical abortion have completion of the process documented by ultrasonography. The endometrial echo will still show a fairly thick decidual lining, but no gestational sac should be seen. Reaspiration should be based on patient symptoms of ongoing heavy bleeding or infection rather than thickness of the endometrium. If a pregnancy test is used, it should be the less sensitive test. Sensitive urine pregnancy tests can remain positive for many weeks. If a pregnancy test is negative, the ultrasound examination can probably be safely avoided. Patients who fail to see a provider should be urged to perform a pregnancy test in follow up.
Postoperatively, patients should be given instructions to contact their providers if they have severe pain, have a fever of 100.4°F or higher, or soak through more than 2 pads per hour or more than 12 pads in 24 hours. Patients may take NSAIDs for pain relief, such as ibuprofen or naproxen.
Provide patients with emergency contact numbers and instructions regarding where to go if they have an emergency and cannot reach the provider.
Patients may bleed very little, if at all, if they were very early in gestation, but the most common bleeding pattern is bleeding the day of the procedure, then not much until the fifth postoperative day, when heavier cramping and clotting occurs.
Patients should not have intercourse until a week post procedure and then it should be when they feel ready.
With antibiotic use as prophylaxis, postabortion infection rates in most population groups should be less than 1-2%. Antibiotic use for the procedure is usually limited to the day of the procedure or a 2- to 3-day course. The antibiotics used are typically broad in spectrum, and most centers use doxycycline at 100 mg bid, with azithromycin for those who are allergic. If bacterial vaginosis is discovered, then the use of Flagyl at 500 mg bid or Cleocin at 300 mg bid PO is selected. Some providers with caseloads of patients who come from far distances and are difficult to locate postoperatively may opt to administer longer antibiotic courses to cover the event of a positive chlamydia or gonorrhea test result after the patient has left the facility and either cannot or does not want to be contacted.
Most oral contraceptive pills can be started the day of the procedure or the following Sunday. IUDs or implants can be inserted that day or with the next menstrual period. DMPA shots can be given that day or up to 5 days later.
Regarding uterine perforation, if the patient had a fundal perforation with no suction applied, then observation for a few hours and evaluation of Hb levels is the standard of care.
When evaluating for acute abdominal pain postabortion, consider acute hematometra, retained products of conception, pelvic infection, or perforation with or without bowel involvement. In patients with prior cesarean deliveries, consider abnormal placentation.
Postoperative bleeding after a surgical abortion is different in timing, amount, and sequence to the bleeding post medical abortion. The amount and duration depends upon the gestational age of the pregnancy terminated.
Further Inpatient Care
Note the following:
Termination of pregnancy virtually never requires inpatient treatment. If the patient has a medical condition that requires hospitalization, then the indications for hospitalization for that condition should be followed. In cases of placenta previa, the patient may have to be observed in the hospital if cervical preparation is being undertaken (laminaria insertion).
Patients with a medical complication of pregnancy termination, such as a perforation, are cared for according to the treatment necessary. Initial evaluation with serial hemoglobin testing, attention to vital signs such as low blood pressure level and/or tachycardia, and repeat ultrasonography can help determine the diagnosis. A patient with temperature elevation either after laminaria insertion or immediately in the postoperative period should be evaluated for dehydration, medication reaction, infection, and sepsis. Evaluation of uterine contents can also help determine the completeness of the procedure.
Patients who have a fundal perforation, with an instrument that is not connected to suction, may require observation, but this is usually not necessary.
Patients with perforations that may be related to bowel injury may need exploratory surgery via laparoscopy (with an extremely experienced laparoscopist) or an exploratory laparotomy. Radiologic studies showing an unusual fluid collection in the pelvis, a broad-ligament hematoma, or evidence of free air increase the suspicion of a perforation. If these procedures are used, hospitalization may be required for 1-5 days to manage the usual postoperative course.
Antibiotic prophylaxis is recommended for any additional surgery, with broad-spectrum antibiotic coverage administered over at least 24 hours.
Inpatient & Outpatient Medications
The following are medications used to manage patients undergoing an elective abortion:
Long-term steroid contraception
Effective contraception is the only reasonable strategy for abortion prevention.
Studies show that providing long-acting reversible contraceptives (LARC)—which would include the copper T intrauterine device (IUD), the levonorgestrel-releasing IUD (LNG-IUD), and the single-rod subdermal implant—provide the best statistical prevention of repeat abortion as well as being a possible contraceptive alternative for the largest number of patients and being cost effective in the long term.
Complications of surgical abortion vary with the technique used, training of the provider, and the gestational age of the pregnancy. In general, the more advanced the gestational age at abortion, the higher the complication rate, and the more invasive the operative procedure, the higher the complication rate.
Complication rates are low: 0.071% for hospitalization and 0.846% for minor complications. Abortion complications requiring hospitalization include incomplete abortion (0.028%), sepsis (0.021%), uterine perforation (0.009%), vaginal bleeding (0.007%), inability to abort (0.003%), and combined pregnancy (0.002%). Minor abortion complications include infection (0.46%), repeat suction (0.18%), cervical stenosis (0.016%), cervical tear (0.01%), seizure (0.004%), and underestimate of dates (0.006%).
Manual vacuum aspiration has the following complication rates: infection, 0.7%; perforation, 0.05%; retained POC, 0.5%; and repeat aspiration, 0.5-0.25%.
In D&E and D&X, the skill and experience of the physician are the most important factors in maintaining a low complication rate. Complication rates are low but increase with gestational age. Abortion complications requiring hospitalization include perforation, hemorrhage, infection, retained POC, and inability to complete abortion. Overall rates of hospitalization are 0.6% at 13 weeks of gestation and 1.4% at 20-21 weeks of gestation. Coagulopathy is a rare complication in D&E, occurring in 191 of 100,000 cases.
Avoid complications by obtaining adequate cervical dilatation through using passive dilators in abortions at 14 weeks of gestation and longer and by using double placement of passive dilators at longer than 20 weeks of gestation. Have appropriate instruments available for morbidly obese patients because standard instruments may not be long enough. Match the surgeon's skill and experience to the gestational age of the pregnancy to be terminated. Choose an inpatient setting for patients with severe medical conditions, anemia, placenta praevia (or other abnormal placentation), pelvic masses or large leiomyomas, or vein problems (eg, no intravenous access).
Hemorrhage can be caused by atony, retained products, or perforation. Hemorrhage has been defined in a variety of ways, and the need for transfusion is exceedingly rare. If uterine hemorrhage rates include hemorrhage immediately postabortion, uterine atony rates of hemorrhage are as low as 5%. Initial hemorrhage should be evaluated by ensuring complete uterine evacuation.
General anesthesia increases the risk of atony. Blood loss of more than 300 mL in the first trimester is considered excessive. The next steps are typically medical in nature, ie, the use of intramuscular Methergine at 0.2 mg, the use of misoprostol 800 mcg placed rectally. Hemabate is also helpful. Treatment also can include uterine massage medications, removal of retained products, and repair of perforation as indicated. In the past, uterine packing has been used, but this can be accomplished effectively with the intrauterine inflation of a Foley balloon. Balloons of 5 mL can be inflated with 30 mL, or 30-mL balloons can be inflated with up to almost 100 mL of sterile saline. The inflation should correlate with uterine size. Now a Bakri Balloon designed for post abortion or postpartum hemorrhage can be used.
Uterine artery embolization can be used if placenta accreta is encountered, but very few of these procedures have been performed and statistical success rates are impossible to evaluate. If ineffective, hysterectomy should be performed as a life-saving measure.
Damage to cervix
The risk of cervical damage is increased with previous surgery to the cervix or laceration. Damage can be associated with forceful dilation with metal dilators and may be associated with damage to cervical vessels, with hemorrhage and parametrial hematoma formation. Repair damage using a transvaginal approach or laparoscopy/ laparotomy. Prevent damage by avoiding forceful dilation. Passively dilate the cervix using passive dilators and/or prostaglandin analogues. Delay the procedure if adequate dilation is not achieved.
Perforation has been estimated to occur in 1 per 250 cases. They are usually fundal and recognized by the provider at the time of the procedure. In a study by Pridmore and Chambers of 13,907 women who underwent outpatient termination of pregnancy, the perforation rate was 0.05% and, in the second trimester, ie, procedures from 13-20 weeks, the perforation rate was 0.32%.
Risk factors for perforation are previous terminations of pregnancy, lower-segment cesarean deliveries, and loop electrosurgical excision procedures of the cervix. The common denominator is thought to be scarring of the internal cervical os.
Fundal perforations only require observation. If the extent of the perforation cannot be determined, if the patient is medically unstable, if the suction was applied at the time of the perforation, or if bowel or fat content was obtained by forceps at the time of a perforation, surgical evaluation of the patient is necessary. The surgical evaluation may be performed by an experienced laparoscopist or by laparotomy.
Perforation can occur with sound, dilators, curette, suction tip, forceps, or passive dilators. Increased risk is associated with previous surgery or laceration involving the cervix, previous uterine surgery, and grand multiparity. In the first trimester, most perforations are in the body of the uterus. Perforation can be recognized when an instrument passes endlessly, heavy or persistent vaginal bleeding occurs, signs of peritoneal irritation appear, or fat or other tissue appears in the specimen. If perforation is made with the sound or dilator, stop the procedure and observe the patient for a minimum of 1 hour. Antibiotic prophylaxis and ultrasonography are options. Reschedule the procedure to be performed in 2-3 weeks. If perforation occurs with suction tip or curette, stop the procedure. Options include observation if the patient is stable and the abortion is complete, laparoscopy if hemorrhage is suspected or the abortion is incomplete, and laparotomy if the patient is unstable.
Retained products of conception
Evaluation of the obtained products of conception at the time of abortion and postabortion uterine scanning have reduced the retained products of conception rate to less than 1% of cases. In one series reported by Hakim, Tovell, and Burnhill of 170,000 cases, only 0.5% incidence occurred in the first trimester. In cases of second-trimester abortions, retained tissue rates are even lower, with rates of 0.2% according to Peterson and 0.5% according to Kafrissen et al.
Cases of delayed bleeding, even after a normal cycle, have been reported. Dilatation and curettage or hysteroscopy are necessary if bleeding is brisker or if the amount of tissue is determined by sonographic evaluation to warrant more extensive procedures.
Endometritis and pelvic inflammatory disease
Infections postabortion are rare, occurring in fewer than 1% of cases. These are usually due to preexisting infections, such as bacterial vaginosis, cervicitis or salpingitis, or a failure of antibiotic prophylaxis.
Fever greater than 102°F (39°C) within 72 hours of the abortion should be considered septic abortion due to retained products. Treatment requires reaspiration followed by intravenous antibiotics (cefoxitin, clindamycin, chloramphenicol, cephalosporin with ampicillin, or penicillinase-resistant penicillin). Fever less than 102°F (39°C) should be treated with reaspiration and oral antibiotics (doxycycline 100 mg bid for 10 d).
The usual criteria should be used for the diagnosis of pelvic inflammatory disease (PID). The Centers for Disease Control and Prevention provides treatment guidelines as well as self-study and ready-to-use modules for clinicians at their Pelvic Inflammatory Disease (PID) Treatment Webpage.
Fatal toxic shock
Rapidly progressing toxic shock due to the endotoxins produced by Clostridia species bacteria has been reported 7 times (for a rate of 1 per 750,000).
Coexistent ectopic pregnancy
Residual positive hCG titers are not uncommon, and clinicians need to be vigilant in their evaluation of persistent positive pregnancy test results to avoid missing an ectopic pregnancy.
Pelvic ultrasonography is the most helpful tool. The presence of significant tenderness during the postoperative examination, a history of continued pain, and the elevation or plateau of hCG titers should raise concern. Coexistent intrauterine and extrauterine pregnancies are observed only in extremely rare cases.
Postabortion uterine synechiae (or adhesions) that can obliterate part or all of the endometrial cavity have been reported. This is thought to be more likely secondary to endometritis than the instrumentation of the uterus, but sharp curetting after the abortion procedure should be avoided to avoid denuding the basal layer of the endometrium.
The diagnosis is made based on hysteroscopy or hysterosalpingogram findings in a patient who presents with postabortion amenorrhea.
Abortion-related hemorrhage due to retained tissue can occur up to several weeks after the procedure. In general, blood loss in excess of that of a normal menstrual period is considered significant and should prompt reaspiration.
Few long-term sequelae of abortions have been documented. Both studies of first trimester surgical and medical abortion found that risks of ectopic pregnancies and spontaneous abortions in future pregnancies were not increased. Some studies have suggested an association between induced abortion and subsequent preterm birth and low birth weight. However, these studies have been retrospective and unable to adequately adjust for confounders also contributing to these outcomes. Although a syndrome of posttraumatic stress has been reported, the literature has not been able to separate the stressors of the patient's social situation that lead to the abortion from the abortion procedure itself.
Although initial studies indicated a greater risk of breast cancer with elective termination than with term birth, a prospective cohort study indicates that no link exists between induced abortion and breast cancer. A prospective study (the Nurses' Health Study II) examined the association between induced and spontaneous abortion and the incidence of breast cancer. Most of the early data has been refuted.
Psychologic consequences of abortion
Generally, the psychological health of the abortion patient parallels her psychologic health prior to seeking an abortion. If the woman needed to have the abortion in secrecy, then long-term psychologic sequelae, such as intrusive thoughts, are more common.
Many studies have actually demonstrated improved psychological well-being after abortion. For the studies that have shown this, the improvement in psychological health is suggested to be more reflective of the patient dealing with the social issues that led her to select abortion.
Sometimes, confusion over normal emotions, such as sadness and grief versus psychological illnesses (eg, depression), seems to occur. The most common feeling experienced after an abortion is that of relief and confidence in the decision. Few women may experience feelings of grief and guilt postabortion, and these feelings usually pass within days to weeks in most cases and do not lead to psychological sequelae. One study demonstrated that the risk for serious psychiatric illness postabortion was 1%, whereas with live birth it was 10%. Considering that more than 1.5 million abortions are performed in the United States each year, if an epidemic of psychiatric sequelae due to the procedure occurred, it would be observed by now.
Many confounding factors are involved in a women's emotional status during the time of her abortion. Relationships, religion, age, social support, and previous psychological stability all play a part.
An entirely new set of circumstances and feelings exist in cases of rape and incest. These are often psychologically complex situations and unique to each case.
Providers can help women through abortions by presenting options and explaining the procedures. Counseling with a trained professional occurs before the abortion. This is a good time to identify factors that might lead to a patient having troubling feelings after the abortion. Some factors are low self-esteem, preexisting or past psychological illness, lack of emotional support, and past childhood sexual abuse. The counselor can then confront these issues before the procedure and help the patient assess specific needs and improve coping strategies.
Fertility is not impaired. Prognosis is excellent.
Give patients information about abortion and postabortion care. Educate patients about birth control options, and discuss when to start birth control postabortion.
Because most terminations of pregnancies in the United States are performed on unintended pregnancies, counseling regarding fertility and contraceptive management are mandatory. In 83% of women, ovulation occurs in the first menstrual cycle postabortion. In first-trimester abortions, contraception should be initiated immediately postoperatively. Intrauterine devices (IUDs) can be safely inserted at the time of the abortion procedure.
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