Elective Abortion Follow-up

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.

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.

The following are medications used to manage patients undergoing an elective abortion:

• Antibiotic therapy

• Uterotonics

• Analgesia

• Antiemetics

• Antianxiolytics

• Oral contraceptives

• 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. ^[30]