Transcript Complications presentation - TEACH | Training in Early Abortion for

Managing Hemorrhage as a
Complication of Uterine Aspiration
Uterine Aspiration

Indications:
Miscarriage management
 Incomplete abortion
 Failed medication abortion
 Therapeutic abortion


Safety:

Minimal risk <0.05% of major
complications (needing hospital care)
Weitz T AJPH 2013
Safety? Mortality / 100,000
Uterine Aspirations or Births
Deaths per 100,000
14
12.7
12
10
8
6.6
6
4
2
3.7
0.2
0.3
0.6
1.8
0.6
0
<9
11-12
16-20
Births
Weeks since last menstrual period
Guttmacher 2014
Bartlett 2004
Relative Risk of
Fatal Complication
Pregnancy & Childbirth
11
<1.0
Abortion
2.6
Laparoscopic Sterilization
1.5
Hormonal Contraception
1
6
11
Per 100,000 Woman Years by Exposure
Guttmacher Institute 2014
Earlier Procedures are Safer-- CDC’s
Abortion Mortality Surveillance System
Currently,
gestational age = strongest risk
factor for abortion-related mortality
Lowest
risk of death: abortions < 8 weeks
Mortality
risk is increased 38% for each
additional week of pregnancy
Bartlett LA, Obstet Gynecol. 2004
Abortion-Related Mortality

1st Trimester:
Infection 1st (33%)
 Hemorrhage 2nd (14%)


2nd Trimester:

Hemorrhage 1st (40%)
Paul M. NAF Textbook. 2009
Emergency Prevention









Emergency carts; memory cards on site
Appropriate patient selection
Careful dating (clinical +/- ultrasound (US))
Pre-op labs: Hgb
Adequate cervical preparation
Vasopressin in cervical block > 12 wks (Edelman 2006)
Uterotonics available
Use closed-loop emergency communications
Transfer agreements w/ nearby hospitals
Procedural Pearls






Correlate exam and dilation for axis
Avoid overconfidence
Develop 6th sense
Low threshold to use aids: os finders, US
Careful eval. of products of conception
Develop stress readiness
TEACH Simulation Innovations


Papaya: a
memorable model to
practice MVA & PCB
Historically used as
an abortifacient


Dragon fruit = Pitaya:
helpful model to practice
complication mgmt
Historically thought to be
helpful in pregnancy
Paul M, Fam Med 2005;
Goodman S, NAF 2013
Case 1





24 y/o G4P3, 8w5d days in your office to
manage an early pregnancy loss (intrauterine
fetal demise) confirmed by ultrasound.
During her procedure, she has unexpected
bleeding, the MVA quickly fills up with blood
You empty it, recharge and it again fills.
You ask your assistant to prepare another MVA
but it promptly fills when attached to cannula.
What do you suspect? What do you do?
Demonstration
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, AAFP, 2014
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)
Kerns J, SFP Guideline 2012
ALSO, AAFP, 2014
Algorithm – 6 T’s

6 T’s : 2 steps each

4 T’s (Tissue, Tone, Trauma, Thrombin)

Treatment plan

Transfer
Tissue


4 Ts: Think tissue first in
uterine aspiration setting
Re-aspiration
Tone (Atony)

Medications
Misoprostol 800-1000 mcg SL/ BU/ PR
 Methergine 0.2 mg IM, IC, IV
(HTN)



Minimal evidence for 1 agent over other
Massage
Kerns J, SFP Guideline, 2012
Trauma

Assess bleeding source
Walk cervix (or clamp if active bleeing)
 Cannula test


Ultrasound

Think perforation if free fluid
Free fluid in cul-de-sac
Thrombin

Bleeding history

Appropriate tests


clot test, repeat hgb, coagulation tests
Note: Women taking anticoagulants did not have
clinically significant increased VB < 12 weeks
Kaneshiro B, Contraception, 2011
Kern J, SFP Guideline 2012
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
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 don’t respond to usual measures
Give provider opportunity to think through steps
Review
Hemorrhage Algorithm – 6 T’s

Recognize heavy bleeding; initiate algorithm

6 T’s : 2 steps each

4 T’s (Tissue, Tone, Trauma, Thrombin)

Treatment

Transfer
Case 2



22 y/o G2P0 woman after uncomplicated
uterine aspiration for a failed medication
abortion
During her procedure, she has unexpected
bleeding, and does not respond to
management steps.
DDx? Evaluation?
Case 3





33 y/o G4P3 woman, h/o cesarean section x 2, 10 wk
EGA, for abortion, with a retroflexed uterus
Dilation is 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 and points to her lower abdomen.
Prevention? DDx?
What do you do?
Trauma: Uterine Perforation

1st Tri: Fundal 

Advanced GA



Few complications
More likely lateral
Bleed more
Incidence

0.1 – 3 / 1000
Kerns J, SFP Guideline 2012
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
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
Use ultrasound 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 follow-up x 1-2 days
Reschedule procedure 1-2 weeks later
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
At clinician discretion, complete procedure under US
guidance or with laparoscopic visualization
Emergencies Specific to Surgical Abortion:
Trauma: Uterine Perforation

Type 3 - “Serious Risk”







Perforation with suction on
Intra-abdominal contents seen in cervix or POC
+/- Severe pain or excessive bleeding
Stop procedure immediately
US to identify uterine cavity, evaluate bleeding
Antibiotics; re-check hgb & abdomenal 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
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
Emergencies Specific to Surgical Abortion:
Trauma: Cervical Laceration

Management

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


High
Consider vasopressin, clamping
 Often require surgical repair in OR

Hospital Transfer




Inform front office staff
Duplicate pertinent charting
Notify ER / OB physician
Notify your medical director
Summary





Uterine aspiration is a relatively safe procedure
Hemorrhage is one cause of abortion-related
mortality.
50% have no risk factors so critical to prepare
“Tissue” is more common cause after aspiration
than postpartum, where tone (atony) 70%.
40% of post-aspiration hemorrhage may be
controlled by medications alone.
Kerns, SFP Guideline 2012
Key Points

Keep good habits:







Develop 6th sense
Avoid procedural overconfidence
Have low threshold to use tools: os finders, ultrasound
Call consultants as needed
Check POC & quantitative hCGs as needed
Develop stress readiness
Delegate and used closed-loop communications
Questions? Thank you











Please fill out evaluations
References
Weitz TA et al., Safety of aspiration abortion performed by NPs, CNMs, and Pas under
a California legal waiver, AJPH, 2013, 103(3):454–461.
Guttmacher Institute; An overview of abortion in the US, Feb 2014
Bartlett LA et al. Risk factors for legal induced abortion-related mortality in the US.
Obstet Gynecol. 2004 Apr;103(4):729-37.
Paul M. Management of unintended &abnormal pregnancy, NAF Textbook, 2009
Paul M, Papaya: a simulation model for training in uterine aspiration. Fam Med 2005
Apr;37(4):242-4.
Goodman S, Teaching surgical skills with simulation models - Reproductive education
in medical education. Pre-Conference Workshop, 37th Annual NAF Meeting, April
2013
ALSO, AAFP, Postpartum Hemorrhage Chapter, 2014
Kerns J. Management of postabortion hemorrhage: release date November 2012 SFP
Guideline. Contraception. 2013 Mar;87(3):331-42.
Kaneshiro B et al. Blood loss at the time of first-trimester surgical abortion in
anticoagulated women.Contraception. 2011 May;83(5):431-5.