Management of postabortion hemorrhage

Blood loss at the time of surgical abortion up to 14 weeks in anticoagulated patients: a case series

OBJECTIVE

To describe estimated blood loss (EBL) with surgical abortion ≤14 weeks' gestation in anticoagulated patients.

STUDY DESIGN

We invited 170 clinicians involved in a professional listserv to report cases when they performed a surgical abortion on a patient ≤14 weeks' gestation taking an anticoagulant. Clinicians reported EBL and bleeding-related complications (need for a blood transfusion, additional surgical procedures to treat bleeding). We contacted clinicians 30 days postprocedure to capture postoperative complications.

RESULTS

Clinicians reported 52 cases between February 2011 and October 2013. Thirty percent of patients (16/52) stopped the anticoagulant with adequate time for the effects to abate prior to surgery (6 h for heparin, 24 h for low-molecular-weight heparin, International Normalized Ratio ≤1.7 the day prior to surgery for warfarin), while 69% (36/52) continued the anticoagulant either at therapeutic (25/36) or subtherapeutic (16/36) doses. Seventy-eight percent (28/36) of patients who continued the anticoagulant had an EBL of 50 mL or less compared to 88% (14/16) of those who stopped the anticoagulant with adequate time for its effects to abate (p=.73). Bleeding-related complications occurred in four anticoagulated patients and none of the patients who discontinued anticoagulant therapy.

CONCLUSION

Continuation of anticoagulation for planned surgical abortion under 84 days does not appear to be associated with heavy bleeding.

Efficacy of Prophylactic Uterine Artery Embolization before Obstetrical Procedures with High Risk for Massive Bleeding

Objective

To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE) before obstetrical procedures with high risk for massive bleeding.

Materials and Methods

A retrospective review of 29 female patients who underwent prophylactic UAE from June 2009 to February 2014 was performed. Indications for prophylactic UAE were as follows: dilatation and curettage (D&C) associated with ectopic pregnancy (cesarean scar pregnancy, n = 9; cervical pregnancy, n = 6), termination of pregnancy with abnormal placentation (placenta previa, n = 8), D&C for retained placenta with vascularity (n = 5), and D&C for suspected gestational trophoblastic disease (n = 1). Their medical records were reviewed to evaluate the safety and efficacy of UAE.

Results

All women received successful bilateral prophylactic UAE followed by D&C with preservation of the uterus. In all patients, UAE followed by obstetrical procedure prevented significant vaginal bleeding on gynecologic examination. There was no major complication related to UAE. Vaginal spotting continued for 3 months in three cases. Although oligomenorrhea continued for six months in one patient, normal menstruation resumed in all patients afterwards. During follow-up, four had subsequent successful natural pregnancies. Spontaneous abortion occurred in one of them during the first trimester.

Conclusion

Prophylactic UAE before an obstetrical procedure in patients with high risk of bleeding or symptomatic bleeding may be a safe and effective way to manage or prevent serious bleeding, especially for women who wish to preserve their fertility.

[Complications of termination of pregnancy]

The legalization of abortion in France allowed to disappear almost maternal deaths caused by induced abortions. Nevertheless, the practice of abortion in a medical framework is encumbered with a number of immediate complications. Similarly, the late consequences of the practice of surgical abortion have generated an abundant literature, which it is important to analyse, both to meet the legitimate concerns of patients as to prevent any spread of false ideas under the influence of movements opposed to abortion.

Effect of Uterine Cavity Sonographic Measurements on Medical Management Failure in Women With Early Pregnancy Loss

OBJECTIVES

Medical management is commonly used among women with early pregnancy failure. The purpose of our study was to evaluate uterine content sonographic measurements for predicting medical management failure in early pregnancy loss.

METHODS

We conducted a retrospective cohort study in a university-affiliated hospital center including all women discharged from the emergency department (ED) with a diagnosis of early pregnancy failure who had medical management with misoprostol between 2011 and 2013. Only women with sonograms available for review were included in our study. All images were reviewed and the following cavity measurements, excluding the endometrial lining, were measured: cavity anteroposterior distance, cavity longitudinal distance, cavity transverse distance, and cavity volume. Logistic regression analysis was used to identify measurements that were independently associated with a subsequent need for dilation and curettage (D&C) and an unplanned return to the ED.

RESULTS

Among 823 women presenting to the ED with first-trimester bleeding, 227 met inclusion criteria. Of all measurements evaluated, the cavity anteroposterior distance was found to be independently associated with D&C and an unplanned return to the ED. When a cavity anteroposterior distance cutoff of 15 mm was used, women were more likely to require D&C (adjusted odds ratio, 2.65; 95% confidence interval, 1.31-5.36; P< .01) and to have an unplanned return to the ED (adjusted odds ratio, 2.59; 95% confidence interval, 1.41-4.79; P < .01). In women with a cavity anteroposterior distance of less than 15 mm, 87.1% had successful medical management of early pregnancy loss, and 80.0% did not require an unplanned return to the ED.

CONCLUSIONS

Although there is a need for further validation, patients identified as having a cavity anteroposterior distance of less than 15 mm should be considered good candidates for successful medical management.

Oral contraception following abortion: A systematic review and meta-analysis

Oral contraceptives (OCs) following induced abortion offer a reliable method to avoid repeated abortion. However, limited data exist supporting the effective use of OCs postabortion. We conducted this systematic review and meta-analysis in the present study reported immediate administration of OCs or combined OCs postabortion may reduce vaginal bleeding time and amount, shorten the menstruation recovery period, increase endometrial thickness 2 to 3 weeks after abortion, and reduce the risk of complications and unintended pregnancies.A total of 8 major authorized Chinese and English databases were screened from January 1960 to November 2014. Randomized controlled trials in which patients had undergone medical or surgical abortions were included. Chinese studies that met the inclusion criteria were divided into 3 groups: administration of OC postmedical abortion (group I; n = 1712), administration of OC postsurgical abortion (group II; n = 8788), and administration of OC in combination with traditional Chinese medicine postsurgical abortion (group III; n = 19,707).In total, 119 of 6160 publications were included in this analysis. Significant difference was observed in group I for vaginal bleeding time (P = 0.0001), the amount of vaginal bleeding (P = 0.03), and menstruation recovery period (P < 0.00001) compared with the control groups. Group II demonstrated a significant difference in vaginal bleeding time (P < 0.00001), the amount of vaginal bleeding (P = 0.0002), menstruation recovery period (P < 0.00001), and endometrial thickness at 2 (P = 0.003) and 3 (P < 0.00001) weeks postabortion compared with the control group. Similarly, a significant difference was observed in group III for reducing vaginal bleeding time (P < 0.00001) and the amount of vaginal bleeding (P < 0.00001), shortening the menstruation recovery period (P < 0.00001), and increasing endometrial thickness 2 and 3 weeks after surgical abortion (P < 0.00001, all).Immediate administration of OCs postabortion may reduce vaginal bleeding time and amount, shorten the menstruation recovery period, increase endometrial thickness 2 to 3 weeks after abortion, and reduce the risk of complications and unintended pregnancies.

Loss of Limb by Inadvertent Embolization of the Persistent Sciatic Artery

Persistent sciatic artery (PSA) is a rare anatomic variant and is normally clinically silent. It can be found occasionally during uterine arteries embolization (UAE) and can lead to technical failure or complications. The authors present a patient with bilateral PSAs who was referred for emergency UAE because of uncontrollable postabortion hemorrhage. Inadvertent embolization of the right PSA led to unsalvageable ischemia and amputation of the right lower limb 12 days later.

[Fetal death beyond 14 weeks of gestation: induction of labor and obtaining of uterine vacuity]

The objective of this review was to assess benefits and harms of different management options for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14 weeks of gestation. In second-trimester, the data are numerous but low methodological quality. In terms of efficiency (induction-expulsion time and uterine evacuation within 24 hours rate) and tolerance in the absence of antecedent of caesarean section, the best protocol for induction of labor in the second-trimester of pregnancy appears to be mifepristone 200mg orally followed 24-48 hours later by vaginal administration of misoprostol 200 to 400 μg every 4 to 6 hours. In third-trimester, there is very little data. The circumstances are similar to induction of labor with living fetus. A term or near term, oxytocin and dinoprostone have a marketing authorization in this indication but misoprostol may be an alternative as the Bishop score and dose of induction of labor with living fetus. In case of previous caesarean section, the risk of uterine rupture is increased in case of a medical induction of labor with prostaglandins. The lowest effective doses should be used (100 to 200 μg every 4 to 6 hours). Prior cervical preparation by the administration of mifepristone and possibly the use of laminar seems essential in this situation.

A randomized trial of misoprostol versus laminaria before dilation and evacuation in South Africa

OBJECTIVE

To compare complication rates, efficacy and acceptability of buccal misoprostol to laminaria for cervical preparation before dilation and evacuation (D&E) in South Africa.

STUDY DESIGN

We performed a randomized, single-blind trial comparing buccal misoprostol 400 mcg (1-2 doses, administered at least 3 h before D&E) to laminaria inserted the day before D&E among women at 13-19 weeks gestation. The primary outcome was expulsion of the fetus prior to surgery; secondary outcomes included other complications, need for mechanical dilation, procedure duration, side effects and satisfaction. Required sample size was 176 to detect a difference in expulsion of 20% to 5%, with a two-sided alpha of 0.05 and 80% power.

RESULTS

Due to slow enrollment and low incidence of primary outcome, the study was stopped early. One hundred fifty-nine women were randomized, and 156 received treatment (78 in each group). Mean gestational age was 14.8 weeks (range, 13.0-18.6 weeks). Complications were rare and did not differ by group [three in each group; odds ratio (OR), 1; 95% confidence interval (CI), 0.20-5.11]; this included two expulsions in the misoprostol group (2.6%). Misoprostol participants were more likely to require mechanical dilation compared to those receiving laminaria (35% vs. 8%; OR, 6.4; 95% CI, 2.4-16.5). The proportion of women reporting each side effect was similar except for diarrhea (21.3% in misoprostol group vs. 5.2% in laminaria group, p=0.004). Procedure time and satisfaction did not differ between groups.

CONCLUSIONS

Both misoprostol and laminaria are associated with a low complication rate in this setting, although misoprostol requires more mechanical dilation and causes more diarrhea.

IMPLICATIONS

Cervical preparation using either laminaria or misoprostol can be safely used before D&E up to at least 19 weeks. Physicians using misoprostol must be skilled at mechanical dilation, since this is commonly required.