Fig. 31.1
Relation of rate of abortion complications and gestational age
Table 31.1
Complications of MTP/abortion
Immediate | Remote | |
|---|---|---|
1. Injury to the cervix (cervical lacerations) 2. Vasovagal shock 3. Hemorrhage and shock 4. Retained products of conception 5. Infection 6. Uterine perforation 7. Injury to bladder/bowel 8. Postabortion triad with pain 9. Thrombosis and embolism 10. Hematometra | A. Gynecological 1. Menstrual disturbances 2. PID 3. Infertility 4. Scar endometriosis 5. Incisional hernia 6. Uterine synechiae leading to secondary amenorrhea B. Psychological/emotional trauma | C. Obstetrical 1. Recurrent midtrimester abortion due to cervical incompetence 2. Ectopic pregnancy 3. Preterm labor 4. Increased perinatal loss 5. Rupture uterus 6. Rh isoimmunization 7. Abruptio placenta 8. Failed abortion and continued pregnancy 9. Placenta acreta |
Complications of spontaneous miscarriages and therapeutic abortions include the following:
Immediate
1.
Injury to the cervix (cervical lacerations): The cervix is sometimes torn during the procedure. The most common complication after dilatation and evacuation was cervical laceration that required suturing [5], but in most cases, the tear is minimal and heals quickly on its own without treatment.
2.
Vasovagal shock (cervical shock): Vasovagal syncope produced by stimulation of the cervical canal during dilatation may occur. Rapid recovery usually follows.
3.
Uterine perforation and/or injury to the bladder/bowel: Rarely, an instrument may puncture the wall of the uterus. The frequency of this event is about one in one thousand cases. Hospitalization is usually necessary for observation and/or completion of the abortion. To inspect the condition of the uterus in this situation, laparoscopy can be done. If damage is serious, an abdominal operation may be required to repair the damage. This can include hysterectomy.
4.
Postabortion triad (i.e., pain, bleeding, low-grade fever) due to retained clots or products.
5.
Thrombosis and embolism.
6.
Hematometra: Also known as postabortion syndrome, this is the result of retained products of conception or uterine atony for other causes. The endometrium is distended with blood, and the uterus is unable to contract to expel the contents.
7.
Retained products of conception: During a nonsurgical abortion, medication will induce the uterus to contract and naturally slough and empty of blood and tissue. Occasionally, however, this process is incomplete and can lead to infection, hemorrhage, or both especially if fetal tissue remains in the uterus. The thickened lining of the uterus is never completely removed during a surgical abortion, and therefore, it is normal for the uterus to naturally shed excess blood and tissue while healing. This process can lead to infection, hemorrhage, or both. To remove remaining tissue, it will be necessary to repeat the misoprostol or perform a uterine aspiration at the office. In rare instances, hospitalization or surgery is required.
8.
Infection: Infection is caused by germs from the vagina and cervix getting into the uterus, and this can occur when the cervix is dilated to pass the pregnancy. If a woman has gonorrhea, syphilis, or chlamydia, a serious tubal infection can occur. The risk of infection associated with early medical abortion is very low. Such infections usually respond to aspiration and antibiotics, but in some instances, hospitalization can be necessary. Surgery may also be required in extreme cases. It is very important to observe all follow-up instructions and return for your check up to ensure that your risk of infection is minimized. In severe form, it may cause septic abortion and peritonitis.
9.
Hemorrhage and shock due to trauma, incomplete abortion, atonic uterus, or coagulation failure (DIC). Bleeding from the uterus heavy enough to require treatment occurs rarely. Hemorrhage, heavy enough to require a blood transfusion, occurs in less than one in one thousand cases. A bleeding problem may require medications to help the uterus contract, a repeat aspiration or dilation and curettage or, rarely, surgery to correct the bleeding
10.
Related to methods employed
(i)
Prostaglandins
1.
Vomiting
2.
Diarrhea
3.
Fever
4.
Abdominal pain
5.
Cervico-uterine injury
(ii)
Oxytocin
1.
Water intoxication
2.
Convulsions
(iii)
Hysterotomy
Hemorrhage and shock
Complications of anesthesia
Peritonitis
Intestinal Obstruction
(iv)
Saline
Hypernatremia
Pulmonary edema
Endotoxic shock
DIC
Renal failure
Cerebral edema
Remote
(i)
Gynecological
1.
Menstrual disturbances.
2.
PID: 5 % of women suffer PID following induced (or surgical) abortion. PID can lead to fever and infertility.
3.
Infertility due to cornual block.
4.
Scar endometriosis especially in hysterotomy (1 %).
5.
Incisional hernia.
6.
Uterine synechiae leading to secondary amenorrhea.
(ii)
Obstetrical
1.
Recurrent midtrimester abortion due to cervical incompetence.
2.
Ectopic pregnancy: Studies point out that the risk of an ectopic pregnancy is 30 % higher for women who have had one abortion and up to four times higher for women with two or more abortions. When a woman has an ectopic pregnancy, she has a 12 % risk of dying in a future pregnancy.
3.
Preterm labor.
4.
Increased perinatal loss.
5.
Rupture uterus.
6.
Rh isoimmunization in Rh-negative women, if not prophylactically protected with immunoglobulin.
7.
Abruptio placenta: Abruptio placenta can result in extreme and severe life-threatening bleeding. Women who have experienced abortion have a 600 % increase in their risk for abruptio placenta in future pregnancies.
8.
Failed abortion and continued pregnancy. Failed MTP is defined when there is failure to achieve termination of pregnancy within 48 h. Sometimes, an early abortion does not succeed in terminating the pregnancy. The likelihood of this event is less than one in one thousand cases. In such cases, another abortion procedure is recommended, because the first attempted abortion can adversely affect the normal development of the pregnancy. Alternately, this can also be a sign of a tubal pregnancy, which would require hospitalization and abdominal surgery.
9.
Placenta acreta
(iii)
Psychological/emotional trauma: 50 % of women who have had abortions report experiencing emotional and psychological problems lasting for months or years. These emotions include, but aren’t limited to:
1.
Acute feeling of grief
2.
Depression
3.
Anger
4.
Fear of disclosure
5.
Preoccupation with babies or getting pregnant again
6.
Nightmares
7.
Sexual dysfunction
8.
Termination of relationships
9.
Emotional coldness
10.
Increased alcohol and drug abuse
11.
Eating disorders
12.
Anxiety
13.
Flashbacks of the abortion procedure
14.
Suicide
Many of these women go on to report that they regret their choice and would do anything to go back and undo the decision that resulted in so much pain.
Severity of complications is another important measure of effects on health. The proportion of women classified with severe complications if:
Fever of 38 °C or more
Organ or system failure
Generalized peritonitis
Pulse 120 per min or more
Shock
Evidence of a foreign body
Mechanical injury
Out of the abovementioned life-threatening complications are uterine hemorrhage due to perforation, severe sepsis, peritonitis, visceral injuries, hemorrhagic and septic shock, renal failure, DIC, hepatic failure, and encephalopathy.
Mortality
Early abortion is one of the safest procedures. Maternal death is lowest (0.6/100,000 procedures) in the first trimester termination while mortality rate increases 5–6 times in midtrimester termination of pregnancy.
Pathophysiology
Postabortion complications develop as a result of three 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.
Prevention of Complications
Primary Prevention
It includes reduction in the need for unsafe abortion through contraception, legalization of abortion on request, the use of safer techniques, and improvement of provider skills. Access to safe, effective contraception can substantially reduce – but never eliminate – the need for abortion to regulate fertility.
All abortion patients – whether seeking treatment of a complication or an elective induced abortion – should be offered contraceptive counseling and a choice of appropriate methods. Contraceptive counseling and provision at the time of treatment reduced unintended pregnancies and repeat abortions by 50 % over 1 year in Zimbabwe, compared with postabortion patients who did not receive such services.
The advent of vacuum aspiration in the 1960s revolutionized the primary prevention of complications in developing countries. Vacuum aspiration is safer than sharp curettage, and the WHO recommends vacuum aspiration as the preferred method for uterine evacuation before 12 weeks of pregnancy. This method is faster, safer, more comfortable, and associated with shorter hospital stay for induced abortion than sharp curettage. Additional advantages compared with sharp curettage are its ease of use as an outpatient procedure, the need for less analgesia and anesthesia, and its lower cost per procedure especially if done on an outpatient basis.
The combined use of mifepristone and misoprostol has become the standard WHO-recommended medical regimen for early medication abortion and is better than either drug alone. Regimens with misoprostol alone as an abortifacient have varied widely, with reported success rates ranging between 87 and 97 %. Increased access to misoprostol has been associated with improved women’s health in developing countries, and studies are being done to refine the regimen for misoprostol alone to induce abortion.
Secondary Prevention
Secondary Prevention entails prompt and appropriate treatment of complications. This includes timely evacuation of the uterus after incomplete abortion. WHO has issued technical and clinical guidelines for the provision of safe abortion care and treatment of abortion complications. Misoprostol can be used for the management of incomplete abortion, and vacuum aspiration is better than sharp curettage.
Postabortion care is spreading worldwide. It included postabortion assessment and diagnosis, uterine evacuation procedures and techniques, pain management, infection prevention, management of complications, referral to other sexual and reproductive health services, contraceptive counseling and provision, and follow-up care.
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