Learning Outcome
- Describe the ways to perform abortions
- Recall the types of complications of abortions
- Summarize the nursing diagnosis of abortion complications
Introduction
Roughly a million abortions are performed each year in the United States alone (CDC 2015).[1][2] This number may be underestimated since the reporting of abortions is not mandatory in the USA. Although deemed safe, therapeutic abortions, as well as spontaneous miscarriages, can lead to a variety of complications. Most complications are considered minor such as pain, bleeding, infection, and post-anesthesia complications. Others are major, including uterine atony and subsequent hemorrhage, uterine perforation, injuries to adjacent organs (bladder or bowels), cervical laceration, failed abortion, septic abortion, and disseminated intravascular coagulation (DIC).[3][4][5] The total abortion-related complication rate of all sources of care including emergency departments and the original abortion facility is estimated to be about 2%.[6] The incidence of abortion-related emergency department visits within six weeks of the initial abortion procedure is about 40%.[7]
Nursing Diagnosis
- The risk for infection (including pelvic inflammatory disease) related to the dilated cervix and open uterine vessels
- Acute pain related to uterine cramping secondary to the expulsion of some products of conception
- Fluid volume deficit related to profuse vaginal bleeding secondary to incomplete abortion
- Nausea and vomiting
- Fever
- Vaginal discharge
- Anxiety
Causes
Post-abortion complications develop as a result of three major mechanisms:
- Infection.
- Incomplete evacuation of the products of conception, leading to hemorrhagic complication.
- Injury from the surgical procedure itself.
Risk Factors
The frequency and severity of abortion complications depend on gestational age at the time of the abortion and the method of abortion.[8][9]
Complications based on gestational age are as follows:
- Eight weeks and under - Less than 1%
- 8-12 weeks - 1.5-2%
- 12-13 weeks - 3-6%
- 2nd trimester - Up to 50%
The estimated abortion complication rate for all healthcare sources is about 2% for medication abortion, 1.3% for first-trimester aspiration abortion, and 1.5% for second-trimester or later abortions
In the United States, mortality rates per 100,000 abortions are as follows: fewer than 8 weeks - 0.5%; 11-12 weeks - 2%; 16-20 weeks - 14%; and more than 21 weeks - 18%.
In the United States, mortality from septic abortion rapidly declined after the legalization of abortions. Death now occurs in fewer than 1 per 100,000 abortions. The risk of death from septic abortion increases with the progression of gestation.
Curiously, one study reports that women aged 30–39 years were more likely to have a complication after an abortion compared with women ages 20–24 years, and Hispanic women were significantly less likely to have a complication compared with white women.
Assessment
A good history is essential to make a timely and correct diagnosis. The emergency department nurse must ask the timing of the abortion, whether it was performed by an appropriate abortion provider at the appropriate facility, and whether any intraoperative or early postoperative complications took place. A thorough past medical and past surgical history are important to obtain, including chronic conditions or past surgeries that may complicate the current condition further. Careful medication history is of paramount importance, such as fertility medications and anticoagulants.
The presentation depends on the type of complication that a patient develops. Intraoperative and early postoperative complications are usually not seen in the emergency department (ED) as they are identified and managed by abortion providers during or immediately following the procedure.
However, the post-abortion triad (pain, bleeding, low-grade fever) frequently is seen in the ED, and the diagnosis of retained products of conception must be sought promptly as a source of the symptoms. Excessive bleeding (postoperative hemorrhage) may be indicative of uterine atony, uterine perforation, ectopic pregnancy, coagulopathy, or iatrogenic surgical instrumentation injury. The post-abortion syndrome can present as progressively worsening lower abdominal pain and hemodynamic compromise absent vaginal bleeding. This is due to the collection of blood and/or retained products of conception in the uterus, causing overdistention of the uterine cavity, which is unable to contract in order to expel its contents.
Bowel or bladder injury may initially present as bleeding and pain, but may quickly progress to infection and septic shock.
Failed abortion is more common with early gestational age, and patients may present to ED with symptoms of continued pregnancy.
The physical exam must include the following:
- Vital signs - Frequent vital signs in ED are essential as patients that were afebrile in triage may develop a fever while in the ED. Tachycardia and hypotension are indicative of a hemodynamic compromise.
- Abdominal exam - Look for peritoneal signs, absent bowel sounds, palpable masses, or severe tenderness.
- Pelvic exam - Assess for the severity of vaginal bleeding, look for obvious vaginal or cervical injury, determine whether the cervical opening to the uterus is open or closed, and note the size and tonus of the uterus as well as uterine tenderness and/or adnexal tenderness.
- A rectal exam may be necessary if a bowel injury is suspected.
Evaluation
The following lab tests are helpful in the evaluation of post-abortion complications:
- Complete blood count (CBC) to assess a drop in hemoglobin/hematocrit which may be indicative of ongoing hemorrhage.
- Complete metabolic panel to assess any renal, hepatic, or electrolyte abnormalities.
- Beta-human chorionic gonadotropin (Beta-hCG) to establish a baseline to monitor the predicted decline in level or to compare with the pre-existing level.
- Coagulation studies, especially if a patient is expected to go to the operating room.
- Blood type/Rh with antibody screen to establish the need for Rhogam and/or for possible impending blood transfusion.
- Blood cultures if sepsis is suspected.
- If DIC is suspected, fibrinogen, fibrin-split products, and d-dimer should be obtained.
Imaging Studies
- Abdominal X-rays should be obtained to rule out bowel perforation.
- Pelvic ultrasound (US) should be done to rule out an ectopic pregnancy.
- Computed tomography (CT) scan should be done to assess for fluid collection in the pelvis, retained byproducts, and adnexal mass.
Medical Management
As always, ABC is first. The patient's hemodynamic status must be assessed immediately, and intravenous access obtained. If the patient exhibits signs of volume depletion, the practitioner must start resuscitation with intravenous crystalloid fluids and assess the volume of blood loss. The potential for blood transfusion must be anticipated. The patient's vital signs, the rate of bleeding, and the overall condition must be monitored constantly for improvement or deterioration. Consider oxytocin administration in consultation with Ob/Gyn colleagues if uterine atony is highly suspected. If the bleeding persists, DIC should be considered, and the patient should be prepared for transfer to the operating room/intensive care unit.[10][11]
In addition to volume resuscitation, patients with a triad of pain, bleeding, low-grade fever should be treated for pain with either non-steroidal anti-inflammatory drugs or opioids, and broad-spectrum antibiotics must be started immediately, preferably intravenously. In most cases, the patient will require the evacuation of blood clots and/or retained products of conception. Thus an early Ob/Gyn consultation should be sought.
If uterine perforation, or bladder or bowel injury are suspected, patients need hemodynamic resuscitation and expedited transfer to the operating room.
If a septic abortion is suspected, sepsis treatment must be instituted according to institutional guidelines. Broad-spectrum antibiotics must be initiated as early as the diagnosis is considered, and arrangements need to be made to transfer the patient to the operating room.
In a hemodynamically stable patient, pelvic ultrasonography should be obtained to look for retained products of conception, failed abortion, continued pregnancy, or ectopic pregnancy.
Nursing Management
Abortion may seem to be a minor procedure but many management issues are surrounding this procedure and they include the following:
- The vital signs have to be frequently monitored.
- All patients should have 2 large-bore IVs and oxygen, even if they initially appear to be stable. Blood must be crossed and typed in cases of bleeding.
- Always obtain a thorough gynecological and obstetric history so as not to miss any other cause of the symptoms.
- The rate and amount of bleeding can be easily underestimated especially when the patient is in the supine position. Thus, clinicians should always perform a pelvic exam in a post-abortion patient to determine that no blood has collected in the vagina or uterus. The nurse should check the vaginal area for blood.
- Uterine perforation if missed can be life-threatening. If the patient has abdominal pain post-abortion, the gynecologist should be consulted as soon as possible and a CT scan ordered. Some patients may benefit from a diagnostic laparoscopy.
- In any post-abortion patient, clinicians should never rule out an ectopic pregnancy.
- If the patient appears septic, broad-spectrum antibiotics need to be started even before the diagnostic workup is complete.
- Consider the fact that the patient may have retained products of conception, which may be the cause of complications.
- Bowel injury in post-abortion should be considered; nurses may note that the patient has a tender abdomen with peritoneal signs and should consult with the clinician immediately because if missed, it carries a high mortality.
- Provide psychological support as the patient may go through anxiety and maintain the confidentiality of the patient.
When To Seek Help
- If the patient is hemodynamically unstable
- Acute vaginal bleeding
- Diffusely tender abdomen
- High-grade fever
- If the patient is unresponsive
- No urine output
Outcome Identification
In the US, the mortality from post-abortion complications has dropped significantly chiefly because illegal abortions are not performed to a high extent. In addition, most emergency department triage systems have streamlined the process of managing acutely ill patients immediately. However, delay in treatment can lead to septic shock which does carry a high mortality. The other factor that has lowered mortality is patient education on when to seek help following an abortion.
Monitoring
When a patient presents with a post-abortion complication, the hemodynamic stability can change in an instant due to hemorrhage. Hence, all patients, stable and unstable need close monitoring with regular vital signs.
Coordination of Care
While most abortions are straightforward, there are some which are associated with complications, which can be life-threatening. Because of the high morbidity of abortion complications, an interprofessional team that includes an obstetrician, radiologist, general surgeon, urologist, and an infectious disease expert is recommended. All patients who develop an abortion-related complication need to be closely monitored to ensure that there are no missed injuries.
Over the past 3 decades, the mortality rates associated with abortions have significantly dropped in the US. However, outside North America and Europe, septic abortions continue to be associated with high rates of maternal mortality, chiefly because of illegal abortions performed in unsanitary environments. According to the WHO, each year nearly 70,000 women die globally from septic abortions. The risk of septic abortions is markedly increased with advanced gestational age.[7][12][13] [Level 5]
Health Teaching and Health Promotion
Once the post-abortion complication has been managed, the interprofessional team including the nurse practitioner should:
- Educate the patient on proper contraceptive measures as a means of birth control, to avoid unwanted pregnancies. The patient should be urged to remain compliant with antibiotic therapy if the abortion was septic.
- Educate the patient to pay more attention to nutrition (iron-containing diet) to prevent anemia.
- Encourage adequate fluid intake to maintain fluid and electrolyte balance in the body.
- Avoid exertion and heavy exercises and promote rest for 2 weeks.
- Avoid long travels.
- Avoid drinking alcohol for at least 48 hours as it may increase the risk of heavy bleeding.
Risk Management
- Close monitoring is vital as bleeding can be sudden and heavy.
- All patients must have 2 large-bore IVs and oxygen.
- Orthostatic vital signs need to be monitored.
- The abdominal exam must be done to ensure the patient does not have peritonitis due to bowel perforation.
Discharge Planning
Once the post-abortion complication has been managed, the interprofessional team including the nurse practitioner should educate the patient on proper contraceptive measures as a means of birth control, to avoid unwanted pregnancies. Avoid sexual intercourse and inserting any artificial things into the vagina for 2 weeks.
Pearls and Other issues
Curiously, after reviewing multiple articles on the complications of abortion, it is worth mentioning that some studies show that legally induced abortions are markedly safer than childbirth.[14]
