eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Abortion, Complications

Author: Slava V Gaufberg, MD, Assistant Professor of Medicine, Harvard Medical School; Director of Transitional Residency Training Program, Cambridge Health Alliance
Contributor Information and Disclosures

Updated: Dec 12, 2008

Introduction

Background

Complications of spontaneous and therapeutic abortions include (1) complications of anesthesia, (2) postabortion triad (ie, pain, bleeding, low-grade fever), (3) hematometra, (4) retained products of conception, (5) uterine perforation, (6) bowel and bladder injury, (7) failed abortion, (8) septic abortion, (9) cervical shock, (10) cervical laceration, and (11) disseminated intravascular coagulation (DIC).

Pathophysiology

Postabortion complications develop as a result of 3 major mechanisms as follows: (1) incomplete evacuation of the uterus and uterine atony, which leads to hemorrhagic complications, (2) infection, and (3) instrumental injury.

Frequency

United States

Frequency of complications depends on gestational age (GA) at time of abortion and method of abortion. Complication rates according to GA at 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 (GA) at time of abortion. In the US, mortality rates per 100,000 abortions are as follows: (1) fewer than 8 weeks, 0.5; (2) 11-12 weeks, 2.2; (3) 16-20 weeks, 14; and (4) more than 21 weeks, 18.

Clinical

History

Presentation depends on the type of complication the patient develops.

• Intraoperative and early postoperative complications rarely are 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 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 convulsion, 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 GA than anticipated, or coagulopathy.
  • Hematometra: Patients usually present with persistent postabortion bleeding and increased lower midline abdominal pain.
  • 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: Patients present with fever, chills, abdominal pain, and vaginal bleeding.
  • Failed abortion (continued intrauterine or ectopic pregnancy): Failure to terminate pregnancy is relatively common with very early abortions (<6 wk GA). 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.
  • DIC: 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, however, 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 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 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.
• Rectal examination
  • Rectal examination must be performed if bowel injury is suspected.
  • Presence of rectal tenderness and blood (or guaiac-positive stool) makes the diagnosis of bowel injury almost certain.

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