Abortion%20Complications%20Management%20Workshop

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Abortion Complications Management Workshop
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Earlier Procedures are Safer-- CDCs Abortion
Mortality Surveillance System

• Currently, gestational age strongest risk
  factor for abortion-related mortality
• Lowest risk of death abortions lt 8 weeks
• Mortality risk is increases 38 for each
  additional week of pregnancy

Bartlet 2004
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Abortion Related Mortality

• 1st Trimester
• Infection (33)
• Hemorrhage (14)
• 2nd Trimester
• Hemorrhage (40)

Paul 2009
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Emergency Prevention

• Emergency carts, boxes, cards on site
• Appropriate history patient selection
• Pre-op labs Hgb
• Careful dating (clinical /- dating)
• Adequate cervical prep (miso, lam)
• Vasopressin in PCB gt 12 wks (Edelman 2006)
• Uterotonics available
• Transfer agreements w/ nearby hospitals

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Procedural Pearls

• Careful exam for uterine axis
• Cautious dilation
• Avoid overconfidence
• Develop 6th sense
• Low threshold to use os finders, US, hCGs
• Careful evaluation of POC
• Proceed quickly to next action
• Develop stress readiness

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TEACH Simulation Innovations

• Papaya a memorable MVA PCB model
• Historically used as an abortifacient
• In dialects means vagina

• Pitaya dragon fruit helpful model for
  practicing comp management steps
• Also thought to be helpful in pregnancy

Paul, 2005 Goodman NAF 2013
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Case 1

• 24 y/o G4P3, 2 prior c/s, 8w5d desiring AB
• MVA quickly fills up with blood
• You empty it, recharge and it again fills with
  blood.
• You ask your assistant to prepare another MVA but
  it promptly fills with blood when attached to the
  cannula.
• What do you suspect? What do you do?

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Demo and Group Brainstorm
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Causes of Hemorrhage

• 4 Ts
• Tissue Retained Clot, Tissue, Hematometra
• Tone Uterine Atony
• Trauma Perforation, Cervical Lacerations
• Thrombin Rare Bleeding Disorders, DIC

ALSO 2013
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Risk Factors for Hemorrhage
Cause Risk Factors
Tissue Incomplete procedure Less surgical experience Hematometra Abnormal placentation
Tone Increasing EGA Prior C/S Previous obstetrical hemorrhage Increasing maternal age General anesthesia
Trauma Uterine flexion Increasing EGA Nulliparity Inadequate cervical dilation
Thrombin Personal / FH bleeding or disorder Anticoagulation (esp. increasing EGA)
SFP Guideline 2012
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Algorithm 7 Ts

• 6 Ts 2 steps each
• 4 Ts (Tissue, Tone, Trauma, Thrombin)
• Treatment plan
• Transfer
• (Teamwork with a leadership role)

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Tissue

• 4 Ts Think tissue first
• Re-aspiration

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Tone (Atony)

• Medications
• Misoprostol 800-1000 mcg SL/ BU/ PR
• Methergine 0.2 mg IM, IC, IV (HTN)
• (Min evidence for 1 particular agent)
• Massage

SFP Guideline 2012
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Trauma

• Assess bleeding source
• Walk cervix
• Cannula test
• Ultrasound
• Think perforation if free fluid

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Free fluid in cul-de-sac
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Thrombin

• Bleeding history?
• Appropriate tests
• clot test, repeat hgb, coags
• Note Women taking anticoags did not have
  clinically significant increased VB lt 12 weeks

Kaneshiro 2011, SFP Guideline 2012
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Additionally

• Treatment
• Start IVF
• Balloon tamponade (30-80 cc)
• Transfer
• Assess VS q 5 minutes
• Initiate transfer
• (Teamwork with a leadership role)
• Communicate with patient delegate roles
• Stay calm under pressure

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Individual Simulation

• Groups of 3
• 1 provider, 1 assistant, 1 tester
• 15 minutes for each provider 1-2 run throughs
• 1 point for each step
• Please complete and hand-in assessment
• These patients dont respond to usual measures
• Give provider opportunity to think it through

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Review Hemorrhage Algorithm 7 Ts

• Recognize heavy bleeding initiate algorithm
• 6 Ts 2 steps each
• 4 Ts (Tissue, Tone, Trauma, Thrombin)
• Treatment
• Transfer
• (Teamwork)

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Case 2

• 22 y/o G2P0 woman after uncomplicated 10 week
  abortion
• Called from recovery to evaluate for uterine pain
  with hypotension
• DDx and evaluation?

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Emergencies Specific to Surgical
AbortionTissue Acute Hematometra

• Pathophysiology
• Relative cervical stenosis plus uterine
  hypotonia
• Leads to retention of clotted blood in uterus
• Diagnosis
• Usually within first hour post-procedure
• US shows clotted blood in uterus

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Emergencies Specific to Surgical Abortion
Tissue Acute Hematometra

• Diagnosis
• Vital Signs
• May be hypotensive orthostatic(HoTN with
  standing)
• Signs
• Uterine enlargement / tenderness on exam
• Symptoms
• Usually little or no vaginal bleeding
• Patient may be asymptomatic when supine
• Severe cramping, lower abdominal pain, rectal
  presssure
• Dizziness/faintness

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Emergencies Specific to Surgical Abortion
Tissue Acute Hematometra

• Management
• Re-aspiration usually provides complete
  resolution
• If not resolving or to prevent re-accumulation,
  consider uterotonics

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Case 3

• 33 y/o G4P3, h/o CS x 2, 12 wk EGA
• Dilation mildly difficult
• While inserting cannula into retroflexed uterus,
  you feel cannula get hung up at one point, and
  then slide in easily without a stopping point.
  Patient feels something sharp.
• Prevention? DDx?
• What should you do now?

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Trauma Uterine Perforation

• 1st Tri Fundal -
• Few complications
• Advanced GA
• More likely lateral
• Bleed more
• Incidence
• 0.1 3 / 1000

SFP Guideline 2012
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Emergencies Specific to Surgical Abortion
Trauma Uterine Perforation

• Three types
• Benign - midline with blunt instrument, no
  suction
• Intermediate perforation with suction on, no
  abdominal contents are seen or serious bleeding
• Serious - perforation with suction on, and
  abdominal contents (bowel, omentum, etc.) seen or
  heavy bleeding occurs

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How to Prevent?

• Increasing experience
• Careful exam re-examine if necessary
• Shorter wide speculum
• Traction on tenaculum
• Posterior placement for a retro-flexed uterus
• Os finder
• US guidance early
• Consider rigid curved cannula to get angle
• Cervical ripening with misoprostol

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Emergencies Specific to Surgical Abortion
Trauma Uterine Perforation

• If prior to start of abortion
• STOP immediately
• INFORM of what is happening
• US re-identify uterine cavity, evaluate bleeding
• OBSERVE in recovery room 1-1/2- 2 hours
• Antibiotics
• If stable, d/c home with phone f/u x 1-2 days
• Reschedule abortion 1-2 weeks later
• Alternatively, at clinician discretion, complete
  procedure under US guidance

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Emergencies Specific to Surgical Abortion
Trauma Uterine Perforation

• Type 2 - Intermediate Risk
• Suction on no excess bleeding or abd contents
• Stop suction
• Remove cannula without suction
• US to re-identify uterine cavity, evaluate
  bleeding
• May occur at end of procedure ? uterus empty
• OBSERVE 1-1/2- 2 hours or send for observation
• Antibiotics
• At clinician discretion, complete procedure under
  US guidance or with laparoscopic visualization

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Emergencies Specific to Surgical Abortion
Trauma Uterine Perforation

• Type 3 - Serious Risk
• Perforation with suction on
• Intra-abdominal contents seen in cx or POC
• /- Severe pain or excessive bleeding
• Stop procedure immediately
• US to identify uterine cavity, evaluate bleeding
• Antibiotics re-check hgb abd exam
• Must be transferred, usually operated on (at the
  discretion of the admitting physician)
• Stable patient may be evaluated using laparoscopy
• But usually lapartomy to run bowel
• As needed UA Embolization, Hysterectomy

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Emergencies Specific to Surgical Abortion
Trauma Cervical Laceration

• Pathophysiology
• May occur inadvertently during sounding or
  dilation
• Or withdrawing sharp fetal parts
• Diagnosis
• Laceration obvious at time of procedure or after
• Persistent, bright red bleeding after procedure
• Examination
• Walk cervix with o-rings
• If visible note location, length
• If not visible cannula test
• start at fundus, slowly withdraw to ID site

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Emergencies Specific to Surgical Abortion
Trauma Cervical Laceration

• Management
• External/Low
• Cervical lac lt 2 cm in length usually heal
  without leaving a defect and require no repair
• Pressure /- vasopressin, silver nitrate, monsels
• Exception ? brisk bleeding that continues ?
  repair
• High
• Consider vasopressin, clamping
• Often require surgical repair in OR

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Hospital Transfer

• Call for ambulance
• Inform front office
• Duplicate pertinent charting
• Notify ER / OB
• Notify medical director

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Summary

• Hemorrhage is a common cause of abortion-related
  mortality.
• 50 of women have no risk factors
• Critical to prepare
• Tissue is more common cause after abortion than
  postpartum, where tone (atony is 70).
• 40 of post-abortal hemorrhage may be controlled
  by medications alone.

Frick 2010 SFP Guideline 2012
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Key Points

• Keep good habits
• Develop 6th sense
• Avoid overconfidence negative self-talk
• Have low threshold to use tools os finders, US
• Have a life line (by phone)
• POC eval hCGs as needed
• Develop stress readiness quarterly scenarios
• If you do enough, youll have comps

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Questions Thank you

• Please fill out evaluations!