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
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.
Epidemiology
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.
Other Problems to be Considered
Perforated viscus
Acute peritonitis
Medical/Legal Pitfalls
- Do not underestimate the amount and rate of bleeding. In the supine position, more than 500 mL of blood may collect in the vagina without severe external bleeding. Always perform a pelvic examination on a postabortion patient who is bleeding.
- Failure to aggressively treat vaginal bleeding, even if it seems minimal: Stabilize the patient with 2 large-bore IVs and with oxygen. Closely monitor vital signs.
- Failure to diagnose uterine perforation may lead to life-threatening complications: In postabortion patients with abdominal pain beyond the pelvic area, suspect perforation and evaluate with kidney, ureter, and bladder (KUB)/upright radiographs and pelvic ultrasonography. Consult a gynecologist and, if suspicion is high, insist on laparoscopy.
- Failure to diagnose ectopic pregnancy: The chance of a missed ectopic pregnancy always exists. Do not presume intrauterine pregnancy in a patient who has just had an abortion; she may have had a missed ectopic pregnancy.
- Failure to promptly administer broad-spectrum antibiotic therapy may result in complications, including sepsis and septic shock. Do not delay administration of antibiotics if a patient has signs of severe postabortion infection. Administer broad-spectrum antibiotics before completing diagnostic workup.
- Failure to obtain information about recent termination of pregnancy may lead to a wrong diagnosis or delayed/inappropriate treatment.
- Failure to evacuate retained products of conception from the uterus leads to treatment failure and possible complications.
- Failure to diagnose bowel injury may lead to life-threatening complications.
Saultes TA, Devita D, Heiner JD. The back alley revisited: sepsis after attempted self-induced abortion. West J Emerg Med. Nov 2009;10(4):278-80. [Medline].
Pazol K, Gamble SB, Parker WY, Cook DA, Zane SB, Hamdan S. Abortion surveillance - United States, 2006. MMWR Surveill Summ. Nov 27 2009;58(8):1-35. [Medline].
McKenna T, O'Brien K. Case report: group B streptococcal bacteremia and sacroiliitis after mid-trimester dilation and evacuation. J Perinatol. Sep 2009;29(9):643-5. [Medline].
Daif JL, Levie M, Chudnoff S, Kaiser B, Shahabi S. Group a Streptococcus causing necrotizing fasciitis and toxic shock syndrome after medical termination of pregnancy. Obstet Gynecol. Feb 2009;113(2 Pt 2):504-6. [Medline].
Darney PD, ed. Handbook of Office and Ambulatory Gynecologic Surgery. Blackwell Science Inc; 1987:108.
Finkielman JD, De Feo FD, Heller PG, Afessa B. The clinical course of patients with septic abortion admitted to an intensive care unit. Intensive Care Med. Jun 2004;30(6):1097-102. [Medline].
Grimes DA, Cates W Jr. Deaths from paracervical anesthesia used for first-trimester abortion, 1972-1975. N Engl J Med. Dec 16 1976;295(25):1397-9. [Medline].
Grossman D, Blanchard K, Blumenthal P. Complications after second trimester surgical and medical abortion. Reprod Health Matters. May 2008;16(31 Suppl):173-82. [Medline].
Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol. Jul 1990;76(1):129-35. [Medline].
Lohr PA. Surgical abortion in the second trimester. Reprod Health Matters. May 2008;16(31 Suppl):151-61. [Medline].
Osazuwa H, Aziken M. Septic abortion: a review of social and demographic characteristics. Arch Gynecol Obstet. Feb 2007;275(2):117-9. [Medline].
Rana A, Pradhan N, Gurung G, Singh M. Induced septic abortion: a major factor in maternal mortality and morbidity. J Obstet Gynaecol Res. Feb 2004;30(1):3-8. [Medline].
Sam C, Hamid MA, Swan N. Pyometra associated with retained products of conception. Obstet Gynecol. May 1999;93(5 Pt 2):840. [Medline].
Shannon C, Brothers LP, Philip NM, Winikoff B. Infection after medical abortion: a review of the literature. Contraception. Sep 2004;70(3):183-90. [Medline].
Shulman SG, Bell CL, Hampf FE. Uterine perforation and small bowel incarceration: sonographic and surgical findings. Emerg Radiol. Oct 2006;13(1):43-5. [Medline].
Stuart GS, Sheffield JS, Hill JB, McIntire DD, McElwee B, Wendel GD. Morbidity that is associated with curettage for the management of spontaneous and induced abortion in women who are infected with HIV. Am J Obstet Gynecol. Sep 2004;191(3):993-7. [Medline].
Stubblefield PG. First and second trimester abortion. In: Nichols DH, ed. Gynecologic and Obstetric Surgery. Mosby-Year Book; 1993:1016-1030.
Stubblefield PG. Pregnancy termination. In: Obstetrics: Normal and Problem Pregnancies. 3rd ed. Churchill Livingstone; 1996:1249-1276.
Stubblefield PG, Grimes DA. Septic abortion. N Engl J Med. Aug 4 1994;331(5):310-4. [Medline].
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