eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Abortion, Complications
Updated: Feb 5, 2010
Introduction
Background
Complications of spontaneous miscarriages and therapeutic abortions include the following:
- Complications of anesthesia
- Postabortion triad (ie, pain, bleeding, low-grade fever)
- Hematometra
- Retained products of conception
- Uterine perforation
- Bowel and bladder injury
- Failed abortion
- Septic abortion
- Cervical shock
- Cervical laceration
- Disseminated intravascular coagulation (DIC)
The term "septic abortion" refers to a spontaneous miscarriage or therapeutic/artificial abortion complicated by a pelvic infection.
Pathophysiology
Postabortion complications develop as a result of 3 major mechanisms as follows: incomplete evacuation of the uterus and uterine atony, which leads to hemorrhagic complications; infection; and injury due to instruments used during the procedure.
In septic abortion, infection usually begins as endometritis and involves the endometrium and any retained products of conception. If not treated, the infection may spread further into the myometrium and parametrium. Parametritis may progress into peritonitis. The patient may develop bacteremia and sepsis at any stage of septic abortion. Pelvic inflammatory disease (PID) is the most common complication of septic abortion.
Frequency
United States
Frequency of complications depends on gestational age (GA) at the time of miscarriage or abortion and method of abortion. Complication rates according to gestational age at the time of abortion are as follows:
- 8 weeks and under - Less than 1%
- 8-12 weeks - 1.5-2%
- 12-13 weeks - 3-6%
- Second trimester - Up to 50%, possibly higher
Mortality/Morbidity
Mortality and morbidity depend on gestational age at the time of miscarriage or abortion. In the United States, mortality rates per 100,000 abortions are as follows: fewer than 8 weeks, 0.5%; 11-12 weeks, 2.2%; 16-20 weeks, 14%; and more than 21 weeks, 18%.
Septic abortion was once the leading cause of maternal death around the world. The condition remains a primary cause of maternal mortality in the developing world, mostly as a result of illegal abortions. According to the World Health Organization, about 68,000 women die each year due to complications from unsafe abortions, with sepsis as the main cause of death.1 In the United States in 2005, 7 women reportedly died from complications of legal induced abortion.2
In the United States, mortality from septic abortion rapidly declined after legalization of abortion. Death now occurs in less than 1 per 100,000 abortions. Figures for most European countries are similar to US rates.
The risk of death from septic abortion rises with the progression of gestation.
Clinical
History
Presentation depends on the type of complication the patient develops. Intraoperative and early postoperative complications are rarely seen in the ED, but some patients develop these types of complications and present to the ED for treatment. Complications include the following:
- Local anesthesia: Paracervical block is a common method of anesthesia for therapeutic abortion. Accidental intravascular injection of anesthetic is a potentially life-threatening complication of this method that could lead to seizure, cardiopulmonary arrest, and death.
- General anesthesia: Complications with general anesthesia may lead to uterine atony with severe hemorrhage.
- Cervical shock: Vasovagal syncope produced by stimulation of the cervical canal during dilatation may occur. Rapid recovery usually follows.
- Postabortion triad: Pain, bleeding, and low-grade fevers are the most common presenting complaints. Postabortion triad usually is caused by retained products of conception.
- Hemorrhage: Excessive hemorrhage during or after abortion may signify uterine atony, cervical laceration, uterine perforation, cervical pregnancy, a more advanced gestational age than anticipated, or coagulopathy.
- Hematometra: Also known as post abortion syndrome, this is the result of retained products of conception or uterine atony for other causes. The endometrium is distended with blood, and the uterus is unable to contract to expel the contents. Patients usually present with increasing lower midline abdominal pain, absent or decreased vaginal bleeding, and, at times, hemodynamic compromise. This may develop immediately after miscarriage or abortion, or it may develop insidiously.
- Perforation: Patients with uterine perforation missed during the procedure usually present to the ED with increased abdominal pain, bleeding (possibly ranging from very mild to absent), and fever. If perforation results in injury to major blood vessels, patients may present in hemorrhagic shock.
- Bowel injury: This may accompany uterine perforation. If initially unrecognized, patients present with abdominal pain, fever, blood in the stool, nausea, and vomiting.
- Bladder injury: This occurs as a result of uterine or cervical perforation. Patients present with suprapubic pain and hematuria.
- Septic abortion: This is endometritis. Patients present with fever, chills, abdominal pain, vaginal discharge, vaginal bleeding, and history of recent pregnancy.
- Failed abortion (continued intrauterine or ectopic pregnancy): Failure to terminate the pregnancy is relatively common with very early abortions (<6 wk gestational age). Such patients may present to the ED with symptoms of continuing pregnancy such as hyperemesis, increased abdominal girth, and breast engorgement. In addition, an unrecognized ectopic pregnancy in the postabortion period presents in the usual manner.
- Disseminated intravascular coagulation: Suspect DIC in all patients who present with severe postabortion bleeding, especially after midtrimester abortions. Incidence is approximately 200 cases per 100,000 abortions; this rate is even higher for saline instillation techniques (660 per 100,000 abortions).
Physical
- Vital signs
- Monitoring of vital signs is essential for patients with postabortion complications.
- Increasing fever could be a sign of progressing infection.
- Tachycardia and hypotension may be signs of severe hemorrhage or septic shock.
- Abdominal examination
- Suprapubic tenderness is common in the postabortion period. Severe tenderness is unusual and may be a sign of hematometra, bladder perforation, or bowel injury.
- Tenderness in other areas of the abdomen (eg, rebound tenderness, guarding) strongly indicates instrumental injury complications (eg, perforation, bowel injury, bladder injury).
- A tender mass in the suprapubic area suggests hematometra.
- Diminished or absent bowel sounds are a sign of developing peritonitis.
- Vaginal examination
- Assess the quantity and rate of hemorrhage.
- Look for possible vaginal or cervical injury.
- Identify the source of bleeding (eg, uterine; cervical os; lesions of the vulva, vagina, or vaginal portion of cervix).
- Cervical motion tenderness on bimanual examination may be suggestive of pelvic infection or ectopic pregnancy.
- A large tender uterus may be a sign of hematometra.
- Adnexal tenderness or masses may suggest ectopic pregnancy, pelvic inflammatory disease (PID), cyst, or hematoma.
- Assess the quantity and rate of hemorrhage.
- Rectal examination
- A rectal examination must be performed if bowel injury is suspected.
- The presence of rectal tenderness and blood (or guaiac-positive stool) makes the diagnosis of bowel injury almost certain.
Causes
Two major factors contribute to the development of septic abortion: retained products of conception and infection introduced into the uterus.
- Retained products of conception due to incomplete spontaneous miscarriage or therapeutic abortion
- Introduction of infection into the uterus: Pathogens causing septic abortion usually are mixed and derived from normal vaginal flora and sexually transmitted bacteria. These organisms include the following:
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References
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Further Reading
Keywords
miscarriage, abortion complications, spontaneous abortion, therapeutic abortion, postabortion complications, septic abortion, postabortion triad, retained products of conception, artificial uterine perforation, failed abortion, cervical laceration
