eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Abortion, Complications: Treatment & Medication
Updated: Dec 12, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Monitor vital signs and provide fluid resuscitation if the patient is hemodynamically unstable.
Emergency Department Care
Screen all patients with postabortion complications for Rh factor. Administer Rho(D) immune globulin (RhoGAM) if results indicate that the patient is Rh-negative and unsensitized.
- Patients with the postabortion triad (ie, pain, bleeding, low-grade fever) may respond to treatment with oral antibiotics and ergot preparations. Immediately initiate these agents. In most cases, however, blood clots or retained products of conception must be evacuated from the uterus. In these cases, administer medications parenterally, as the patient will undergo anesthesia.
- Hemorrhage or hematometra
- Monitor vital signs and rate of bleeding. Administer fluids and blood as needed.
- Administer IV oxytocin for treatment of uterine atony.
- Alternative treatments for uterine atony include intracervical vasopressin or carboprost tromethamine and bimanual uterine massage.
- If bleeding persists, screen for coagulopathy/DIC and obtain immediate gynecologic consultation with the intention of transferring the patient to the operating room (OR) for repeat curettage and, if necessary, hysterectomy.
- Uterine perforation, bowel injury, and bladder injury: If one or any combination of these complications is suspected or diagnosed in the ED, treat as follows.
- Hemodynamically stabilize the patient.
- Insert a Foley catheter.
- Transfer to the OR for laparoscopy/laparotomy and further treatment.
- Failed abortion, continued pregnancy, and ectopic pregnancy
- If the patient is stable, perform ultrasound and a beta-human chorionic gonadotropin (hCG) test to establish diagnosis and further treatment.
- If the patient is unstable, transfer to the OR for dilation and curettage (D&C) and/or laparoscopy/laparotomy.
Consultations
- Consult an obstetrician/gynecologist (OB/GYN) in all cases of postabortion complications.
- Consult surgery and urology if bowel or bladder injury is diagnosed.
Medication
The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.
Antibiotics
Immediately administer broad-spectrum antibiotics to patients with severe postabortion infection.
Cefoxitin (Mefoxin)
Indicated for infections caused by susceptible gram-positive cocci and gram-negative bacilli. Many infections caused by gram-negative bacteria resistant to some cephalosporins and penicillins respond to cefoxitin.
Adult
2 g IV q6h and 100 mg IV doxycycline q12h; continue at least 4 d and at least 48 h after improvement; then 100 mg PO doxycycline bid 10-14 d
Pediatric
Not established
Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Rickettsia, Chlamydia, and Mycoplasma species.
Adult
100 mg IV q12h and 2 g IV cefoxitin q6h; continue at least 4 d and at least 48 h after patient improves; then 100 mg PO doxycycline bid 10-14 d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Bioavailability decreases with antacids containing Al, Ca, Mg, Fe, or Bi subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity, severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Gentamicin sulfate (Garamycin, Gentacidin)
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and an agent that covers anaerobes. Not the DOC. Consider if penicillins (see note above) or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.
Adult
Serious infections and normal renal function: 3 mg/kg/d IV q8h; monitor renal levels
Life-threatening infections: 5 mg/kg/d IV q6-8h; monitor renal levels
Maintenance dose: 1-2.5 mg/kg IV and 1-1.5 mg/kg IV, respectively, q8h; monitor renal levels
Pediatric
<12 years: Not established
>12 years: 1.5-2.5 mg/kg/dose IV q8h or 6-7.5 mg/kg/d IV divided q8h; not to exceed 300 mg/d; monitor renal levels, adjust for renal function as needed; monitor renal levels as in adults
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents; thus, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity, non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Ticarcillin and clavulanate potassium (Timentin)
Presumptive therapy prior to identification of organism. Inhibits biosynthesis of cell wall mucopeptide; effective during stage of active growth.
Adult
<60 kg: 200-300 mg/kg/d IV divided q4-6h
>60 kg: 3.1 g IV q4-6h or 200-300 mg/kg/d in equally divided doses q4-6h; not to exceed 18-24 g/d
Pediatric
Administer as in adults
Tetracyclines may decrease effects; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with PO penicillins during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform UA and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Ampicillin and sulbactam sodium (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam
Pediatric
Not established for pediatric patients with intra-abdominal infections
>40 kg: Administer as in adults
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Imipenem and cilastatin sodium (Primaxin)
Treats multiple-organism infections for which other agents lack wide-spectrum coverage or are contraindicated due to potential toxicity.
Adult
250-500 mg IV divided q6h; not to exceed 3-4 g/d, based on severity of infection
Alternatively, administer 500-750 mg IM or intra-abdominally q12h
Pediatric
15-25 mg/kg/dose IV q6h; maximum daily dose for fully susceptible organisms is 2 g/d; for infections with moderately susceptible organisms, maximum dose is 4 g/d
Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency
Piperacillin and tazobactam sodium (Zosyn)
Treats septicemia caused by susceptible organisms.
Adult
12 g piperacillin + 1.5 g tazobactam IV in equally divided doses of 3 g q6h for 7-10 d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform UA and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Clindamycin (Cleocin)
Useful as treatment against aerobic streptococci and most staphylococci. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
Serious infections due to aerobic and anaerobic organisms: 600-1200 mg/d IV divided q6-8h
Pediatric
8-16 mg/kg/d IV divided tid/qid
Severe infections: 16-20 mg/kg/d divided tid/qid
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; pseudomembranous colitis; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Cefotaxime (Claforan)
Treats septicemia and gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth.
Adult
Moderate-to-severe infections: 1-2 g IV/IM q6-8h
Life-threatening infections: 1-2 g IV/IM q4h
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal impairment; has been associated with severe colitis
Vancomycin HCL (Vancocin, Vancoled)
Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or who have infections with resistant staphylococci. To avoid toxicity, current recommendation is to assay only vancomycin trough levels after the third dose, drawn 0.5 h before next dosing. Doses and dosing intervals may be adjusted based on CrCl.
Adult
500 mg/d to 2 g/d IV tid/qid for 7-10 d
Pediatric
40 mg/kg/d IV divided tid/qid for 7-10 d
Erythema, histaminelike flushing and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; "red man" syndrome is caused by too rapid IV infusion (dose administered over a few min) but rarely happens when dose given as 2-h administration or as PO or IP administration; red man syndrome is not an allergic reaction
Ergot alkaloids
Ergot derivatives are used for oxytocic effects on uterine muscle. These agents prevent postabortion uterine atony and hemorrhage.
Ergonovine maleate (Ergotrate Maleate)
Prevents and treats postabortal hemorrhage due to uterine atony by producing a firm contraction of the uterus within minutes. Although intended primarily for IM administration, faster response can be achieved through IV administration. However, because IV route produces higher incidence of adverse effects, reserve for emergencies such as excessive uterine bleeding. Severe uterine bleeding may require repeated doses but seldom requires more than 1 injection q2-4h.
Adult
0.2 mg IM/IV repeat q2-4h if needed
Pediatric
Not established
Concurrent administration of methylergonovine with vasoconstrictors or other ergot alkaloids may produce additive effect
Documented hypersensitivity; not to be used in cases of threatened spontaneous abortion
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Discontinue if ergotism develops; caution in heart disease, hypertension, mitral-valve stenosis, venoatrial shunts, sepsis, obliterative vascular disease, or hepatic or renal impairment
Methylergonovine (Methergine)
Acts directly on the smooth muscle of the uterus; induces a rapid and sustained tetanic uterotonic effect that reduces bleeding.
Adult
0.2 mg IM
Severe uterine bleeding: Repeat doses q2-4h; same dose may be administered IV to produce quicker response; however, because IV route produces higher incidence of adverse effects, reserve for emergencies such as excessive uterine bleeding
Pediatric
Not established
Concurrent administration of methylergonovine with vasoconstrictors or other ergot alkaloids may produce additive effect
Documented hypersensitivity; glaucoma; Tourette syndrome; anxiety
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in sepsis, obliterative vascular disease, or hepatic or renal insufficiency
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References
Darney PD, ed. Handbook of Office and Ambulatory Gynecologic Surgery. Blackwell Science Inc; 1987:108.
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].
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. Aug 16 2006;[Medline].
Stuart GS, Sheffield JS, Hill JB, et al. 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].
Further Reading
Keywords
miscarriage, abortion complications, spontaneous abortion, therapeutic abortion, postabortion complications, complications of anesthesia, postabortion triad, vaginal bleeding, hematometra, retained products of conception, uterine perforation, bowel and bladder injury, failed abortion, septic abortion, cervical shock, cervical laceration, disseminated intravascular coagulation, DIC, complications of abortion
