Transcript AB Comp Workshop Powerpoint - TEACH | Training in Early

Abortion Complications
Management Workshop
Earlier Procedures are Safer-- CDC’s
Abortion Mortality Surveillance System
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Currently, gestational age = strongest risk
factor for abortion-related mortality
Lowest risk of death: abortions < 8 weeks
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Mortality risk is increases 38% for each
additional week of pregnancy
Bartlet 2004
Abortion Related Mortality
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1st Trimester:
Infection (33%)
 Hemorrhage (14%)
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2nd Trimester:
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Hemorrhage (40%)
Paul 2009
Emergency Prevention
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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 > 12 wks (Edelman 2006)
Uterotonics available
Transfer agreements w/ nearby hospitals
Procedural Pearls
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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
TEACH Simulation Innovations
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Papaya: a
memorable MVA
& PCB model
Historically used as
an abortifacient
In dialects means
“vagina”
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Pitaya = dragon fruit:
helpful model for
practicing comp
management steps
Also thought to be
helpful in pregnancy
Paul, 2005; Goodman NAF 2013
Case 1
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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?
Demo and Group Brainstorm
Causes of Hemorrhage
4 Ts
Tissue: Retained Clot, Tissue, Hematometra
Tone: Uterine Atony
Trauma: Perforation, Cervical Lacerations
Thrombin: Rare Bleeding Disorders, DIC
ALSO 2013
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
Algorithm – 7 T’s
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6 T’s : 2 steps each
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4 T’s (Tissue, Tone, Trauma, Thrombin)
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Treatment plan
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Transfer
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(Teamwork with a leadership role)
Tissue
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4 Ts: Think tissue first
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Re-aspiration
Tone (Atony)
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Medications
Misoprostol 800-1000 mcg SL/ BU/ PR
 Methergine 0.2 mg IM, IC, IV
(HTN)
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(Min evidence for 1 particular agent)
Massage
SFP Guideline 2012
Trauma
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Assess bleeding source
Walk cervix
 Cannula test
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Ultrasound
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Think perforation if free fluid
Free fluid in cul-de-sac
Thrombin
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Bleeding history?
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Appropriate tests
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clot test, repeat hgb, coags
Note: Women taking anticoags did not have
clinically significant increased VB < 12 weeks
Kaneshiro 2011, SFP Guideline 2012
Additionally
 Treatment
 Start IVF
 Balloon tamponade (30-80 cc)
 Transfer
 Assess VS q 5 minutes
 Initiate transfer
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 Communicate with patient & delegate roles
 Stay calm under pressure
Individual Simulation
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Groups of 3
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1 provider, 1 assistant, 1 tester
15 minutes for each provider; 1-2 run throughs
1 point for each step
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Please complete and hand-in assessment
These patients don’t respond to usual measures
Give provider opportunity to think it through
Review
Hemorrhage Algorithm – 7 T’s
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Recognize heavy bleeding; initiate algorithm
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6 T’s : 2 steps each
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4 T’s (Tissue, Tone, Trauma, Thrombin)
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Treatment
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Transfer
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(Teamwork)
Case 2
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22 y/o G2P0 woman after
uncomplicated 10 week abortion
Called from recovery to evaluate for
uterine pain with hypotension
DDx and evaluation?
Emergencies Specific to Surgical Abortion:
Tissue: Acute Hematometra
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Pathophysiology
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Relative cervical stenosis plus uterine hypotonia
Leads to retention of clotted blood in uterus
Diagnosis
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Usually within first hour post-procedure
US shows clotted blood in uterus
Emergencies Specific to Surgical Abortion:
Tissue: Acute Hematometra
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Diagnosis
Vital Signs
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May be hypotensive; orthostatic(HoTN with standing)
Signs
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Uterine enlargement / tenderness on exam
Symptoms
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Usually little or no vaginal bleeding
Patient may be asymptomatic when supine
Severe cramping, lower abdominal pain, rectal presssure
Dizziness/faintness
Emergencies Specific to Surgical Abortion:
Tissue: Acute Hematometra
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Management
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Re-aspiration usually provides complete resolution
If not resolving or to prevent re-accumulation,
consider uterotonics
Case 3
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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?
Trauma: Uterine Perforation
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1st Tri: Fundal 
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Advanced GA
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Few complications
More likely lateral
Bleed more
Incidence
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0.1 – 3 / 1000
SFP Guideline 2012
Emergencies Specific to Surgical Abortion:
Trauma: Uterine Perforation
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Three types
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“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
How to Prevent?
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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
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
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 Alternatively,
at clinician discretion,
complete procedure under US guidance
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
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At clinician discretion, complete procedure under
US guidance or with laparoscopic visualization
Emergencies Specific to Surgical Abortion:
Trauma: Uterine Perforation
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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)
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Stable patient may be evaluated using laparoscopy
But usually lapartomy to run bowel
As needed: UA Embolization, Hysterectomy
Emergencies Specific to Surgical Abortion:
Trauma: Cervical Laceration
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Pathophysiology
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May occur inadvertently during sounding or
dilation
Or withdrawing sharp fetal parts
Diagnosis
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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:
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start at fundus, slowly withdraw to ID site
Emergencies Specific to Surgical Abortion:
Trauma: Cervical Laceration
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Management
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External/Low
Cervical lac < 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
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High
Consider vasopressin, clamping
 Often require surgical repair in OR
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Hospital Transfer
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Call for ambulance
Inform front office
Duplicate pertinent charting
Notify ER / OB
Notify medical director
Summary
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Hemorrhage is a common cause of
abortion-related mortality.
50% of women have no risk factors
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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
Key Points
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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
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If you do enough, you’ll have comps
Questions
Thank you
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Please fill out evaluations!