Managing hemorrhage as a complication of uterine aspiration

1. Managing Hemorrhage as a
Complication of Uterine Aspiration

2. 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

3. Safety? Mortality / 100,000
Uterine Aspirations or Births
0.2 0.3 0.6
1.8
3.7
12.7
0.6
6.6
0
2
4
6
8
10
12
14
Deaths
per
100,000
<9 11-12 16-20 Births
Weeks since last menstrual period
Guttmacher 2014
Bartlett 2004

4. Relative Risk of
Fatal Complication
1 6 11
Hormonal Contraception
Laparoscopic Sterilization
Abortion
Pregnancy & Childbirth 11
<1.0
2.6
1.5
Guttmacher Institute 2014
Per 100,000 Woman Years by Exposure

5. 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

6. Abortion-Related Mortality
 1st Trimester:
 Infection 1st (33%)
 Hemorrhage 2nd (14%)
 2nd Trimester:
 Hemorrhage 1st (40%)
Paul M. NAF Textbook. 2009

7. 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

8. 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

9. 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

10. 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?

11. Demonstration
and Group Brainstorm

12. 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

13. 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

14. Algorithm – 6 T’s
 6 T’s : 2 steps each
 4 T’s (Tissue, Tone, Trauma, Thrombin)
 Treatment plan
 Transfer

15. Tissue
 4 Ts: Think tissue first in
uterine aspiration setting
 Re-aspiration

16. 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

17. Trauma
 Assess bleeding source
 Walk cervix (or clamp if active bleeing)
 Cannula test
 Ultrasound
 Think perforation if free fluid

18. Free fluid in cul-de-sac

19. 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

20. 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

21. 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

22. 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

23. 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?

24. 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?

25. Trauma: Uterine Perforation
 1st Tri: Fundal -
 Few complications
 Advanced GA
 More likely lateral
 Bleed more
 Incidence
 0.1 – 3 / 1000
Kerns J, SFP Guideline 2012

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Hospital Transfer
 Inform front office staff
 Duplicate pertinent charting
 Notify ER / OB physician
 Notify your medical director

34. 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

35. 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

36. 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.