MANAGING COMPLICATIONS

Immediate Complications Clinical Presentation Management Options Occurrence Rate*
Vasovagal Episode Presentation may include:

  • Pale, clammy, dizzy,
    nauseated or with emesis
  • Pulse < 60
  • Rare syncope
  • During or after procedure
  • Usually resolves quickly and spontaneously

Etiology:

  • Parasympathetic nerve
    stimulation and painful stimuli
Pause procedure:

  • Apply cool compresses
  • Trendelenburg position or elevate the legs above the chest
  • Sniffing ammonium may help
  • Isometric extremity contractions

For persistent symptomatic bradycardia:

  • Atropine 0.2 mg IV or 0.4 mg IM, May repeat in 3-5 minutes (max dose of 2 mg)
Excessive Bleeding / Hemorrhage

EBL > 150 cc = excessive to 10 wks EBL ≥ 500 cc = hemorrhage

Remember 4T’s of etiology: (ALSO 2014)

  1. Tissue (not completely evacuated)
  2. Tone (inadequate uterine tone)
  3. Trauma (perforation or cervical lac)
  4. Thrombin (rare underlying bleeding disorder)

Hemorrhage risk groups:
(Kerns 2013)

  1. Low risk: no prior c/s,
  2. Moderate risk: ≥ 2 c/s, prior c/s and previa, bleeding disorder, history of obstetric hemorrhage not needing transfusion, increasing maternal age, GA>20 weeks, fibroids, obesity
  3. High risk: accreta/concern for accreta, history of obstetric hemorrhage needing transfusion, +/- others from moderate category

6T’s (Goodman 2015)

Tissue: Assure uterus is empty

  • Estimate EBL
  • Reaspirate (with US guidance; EVA for rapid evacuation); check POC

Tone: Uterotonics

  • Uterine massage
  • Medications: Methergine 0.2 mg IM/IC, Misoprostol 800 mcg SL/BU/PR, or Vasopressin 4-8 units (diluted in 5-10 cc NS) IC

Trauma: Assess source

  • Cannula test**
  • Clamp bleeding site at cervix with ring forceps

Thrombin

  • Review bleeding history
  • Additional tests as indicated (coags, repeat CBC, clot test***)

Treatment

  • IV fluid bolus
  • For uterine / cervical injury, inflate Foley catheter to tamponade

Transfer

  • Vitals every 5 minutes
  • Initiate transfer

0.07 – 0.4 %

Upadhyay 2015
Kerns 2013
Weitz 2013
Yonke 2013
Jejeebhoy 2011
Bennett 2009
Goldberg 2004
Goldman 2004
Hakim-Elahi 1990

Perforation Instruments pass deeper than expected by EGA and pelvic exam Patient may feel sudden sharp pain; may be painless Risk factors:

  • Inadequate dilation
  • Increased gestational age
  • Uterine flexion
  • Previous cesarean section
  • Operator inexperience
  • Uterine anomaly
Stop procedure:

  • Turn off suction
  • Assess patient: VS, pain, bleeding, abdominal exam
  • Check contents of aspirate for omentum or bowel, and for POC

If stable:

  • Evaluate with US
  • Experienced providers have safely explored uterus and completed procedure under US guidance
  • Observe for 1.5-2 hours
  • Consider uterotonics to contract uterus and control bleeding
  • Consider antibiotics

If unstable or perf with suction, transfer

0.02 – 0.07%

Upadhyay 2015
Weitz 2013
Yonke 2013
Jejeebhoy 2011
Goldberg 2004
Goldman 2004
Westfall 1998
Hakim-Elahi 1990

Delayed Complications Clinical Presentation Management Options Occurrence Rate*
Incomplete Abortion (Residual nonviable fetal tissue) At time of aspiration:

  • Inadequate POC

or
Days to weeks after:

  • Pelvic pain
  • Abnormal bleeding
  • Pregnancy symptoms
  • Enlarged or boggy uterus

US shows persistent IUP or debris [latter is non-specific; may be normal (Russo 2012; Paul 2009, pg. 228)]

Follow serial hCGs if any doubt that aspiration was complete Offer misoprostol or reaspiration to empty uterus Reaspiration preferred if:

  • Signs of infection
  • Hemorrhage
  • Severe pain

Significant anemia

0.2 – 4.4%

Upadhyay 2015
Weitz 2013
Yonke 2013
Jejeebhoy 2011
Bennett 2009
Warriner 2006
Goldberg 2004
Goldman 2004
MacIsaac 2000
Westfall 1998

Continuing Pregnancy Presentation:

  • Ongoing pregnancy symptoms
  • Enlarging uterus

Risk factors:

  • Early gestational age
  • Uterine anomalies/fibroids
  • Missed multiple gestation

Operator inexperience

 If inadequate POCs suspected at time of procedure, consider:

  • US
  • Serial hCGs
  • Ectopic precautions as needed

Counsel patient; reaspirate as appropriate

0.4 – 2.3%

Upadhyay 2015
Kerns 2013
Weitz 2013
Yonke 2013
Bennett 2009
Goldman 2004
MacIsaac 2000
Westfall 1998

Hematometra (Accumulation of blood in uterus following procedure) Immediate:

  • Minutes to hours post-ab
  • Severe lower abdominal or pelvic pain
  • Rectal pressure
  • Minimal to no post-procedural bleeding
  • +/- hypotension, vasovagal
  • US: large amount uterine clot
  • Uterine exam: enlarged, firm

Delayed:

  • Days to weeks post-ab
  • Pelvic pressure or cramping
  • +/- low grade fever
Prompt uterine aspiration of blood offers immediate reliefUterotonic medications post aspiration:

  • Methergine 0.2 mg IM / IC
  • Misoprostol 800 mcg PR or buccal

0.1   – 2.2 %

Weitz 2013
Yonke 2013
Bennett 2009
Goldberg 2004
Goldman 2004

Postabortal endometritis (Pelvic inflammatory disease) Presentation:

  • Lower abdominal / pelvic pain
  • Fever, malaise
  • Tenderness
  • Purulent discharge
  • Elevated WBC
Diagnose:

  • US for retained POC / clot
  • May need reaspiration
  • Wet mount
  • Test for GC/CT

Treat:

  • Antibiotics (CDC PID regimen)

0.09-2.6%

Upadhyay 2015
Weitz 2013
Yonke 2013
Bennett 2009
Goldberg 2004
Goldman 2004
Paul 2002
Westfall 1998

Missed Ectopic Pregnancy Suspect if inadequate POC at time of aspiration Possible late signs/symptoms:

  • Pelvic pain or shoulder pain
  • Syncope or shock
Transport immediately to hospital if:

  • Ectopic is suspected; for dx / tx
  • Concern for rupture
  • Clinically unstable

Methotrexate vs. surgical management

0.0 – 0.3%

(Scant data) Bennett 2009

*Summary occurrence rates from Taylor, 2010: Standardizing early aspiration abortion complication definitions and tracking.
** Cannula test: Watch blood return as you slowly withdraw cannula from fundus to cervix, to identify bleeding zone.
***Cost test: fill plain glass tube with whole blood; leave for 10 minutes. Complete clotting at 10 minutes rules out DIC at that time

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