Difficulty with cervical dilation is most likely to occur among nulliparous women and women who have undergone cesarean section or other surgery affecting the cervix. In these circumstances prostaglandin use leaves few recalcitrant cases. However, direct ultrasound observation of dilator placement may be used to facilitate dilation and avoid creation of a false tract or perforation. The most common prostaglandin used today is misoprostol (Cytotec), an E1 prostaglandin analog that is inexpensive, stable at room temperature and well tolerated. Although not FDA approved as an abortifacient, misoprostol has been safely used for more than a decade. In our experience, in the first trimester 400 μg of buccal misoprostol used at least 90 minutes prior to the procedure leaves the cervix sufficiently softened so that dilation is often no longer necessary.

In second-trimester gestations, osmostic dilators, natural or synthetic, such as Laminaria japonicum, Dilapan or Lamicel may be used prior to prostaglandin use. These materials are compressed tents that slowly expand with the absorption of fluid, dilating the cervix for up to 24 hours prior to the procedure. If more dilation is needed in later terminations, a new set of the osmotic dilators can be placed the morning of the procedure. Misoprostol is often added in later terminations for additional cervical softening and dilation, prior to dilation and evacuation (D&E).

Hemorrhage is defined as greater than 500 mL of blood loss. It is an infrequent event during or after pregnancy termination, particularly during a first-trimester procedure (<1%) in which blood loss is routinely less than 15 mL. In second-trimester procedures, specifically those 18 weeks’ gestation and greater, the use of contractile agents such as 20–30 units of oxytocin diluted in a liter of saline or lactated Ringer’s solution started prior or during the procedure, and 0.2 mg ergonovine maleate (Methergine), given intramuscularly or intracervically after completion of the procedure, significantly reduces the risk of substantial blood loss (1–2%). The inclusion of four units of vasopressin in the paracervical anesthesia decreases blood loss by half during both first- and second-trimester procedures.

The most likely cause of minor bleeding is trauma to the external os, usually due to the tenaculum. This diagnosis is made by simple observation and treated with pressure, with or without the application of procoagulants such as silver nitrate or Monsel’s solution. Suture placement is rarely necessary. If the anatomy allows, the instrument holding the cervix can be a curved Allis clamp or ring forceps instead of a tenaculum.

The most common cause of hemorrhage in the second trimester is uterine atony, for which a careful bimanual exam is diagnostic. In this case, vigorous bimanual massage and the above-mentioned uterotonics are extremely helpful first-line therapies. Other treatments include 800–1000 μg of rectal misoprostol or 250 μg of carboprost tromethamine (Hemabate), a 15-methyl F2-α prostaglandin, given intramuscularly at 15-minute intervals for up to eight doses.

If bleeding continues, other causes such as uterine perforation, abnormal placental attachment, i.e. placenta accreta, incomplete evacuation, and cervical laceration must be considered. Uterine perforation just above the internal cervical os may cause hemorrhage into the broad ligament. Diagnosis of broad ligament hematomas can be elusive, as the bleeding is often into the peritoneal cavity instead of into the vagina. The possibility of bowel damage exists as well. If these problems are suspected, definitive diagnosis will necessitate laparoscopy or most commonly exploratory laparotomy.

Cervical laceration at the utero-cervical junction, where the cervical branch of the uterine artery is located, is significantly more likely to occur during second-trimester than first-trimester procedures. This laceration is usually caused by a stretch injury at the time of dilation or in later procedures, removal of sharp calcified fetal parts that have not been adequately crushed prior to removal. Laparoscopy or laparotomy may be required in the presence of ongoing brisk bleeding or signs of hemodynamic instability. These are surgical emergencies and if suspected, expeditious movement is required. Uterine artery embolization can be performed, but only if a team with expertise and experience can be rapidly mobilized. Failure to recognize these emergencies can result in significant morbidity and possibly death. Cervical lacerations are preventable preoperatively with adequate cervical preparation using misoprostol in combination with osmotic dilators, and intraoperatively with sufficient decompression of bony fetal parts prior to removal.