Managing Hemorrhage as a Complication of Uterine Aspiration

1. Managing Hemorrhage as a Complication of Uterine Aspiration

2. Uterine Aspiration Weitz T AJPH 2013 • Indications: • Miscarriage management • Incomplete abortion • Failed medication abortion • Therapeutic abortion • Safety: • Minimal risk <0.05% of major complications (needing hospital care)

3. Safety? Mortality / 100,000 Uterine Aspirations or Births Guttmacher 2014 Bartlett 2004

4. Relative Risk ofFatal Complication 11 <1.0 2.6 1.5 Per 100,000 Woman Years by Exposure Guttmacher Institute 2014

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 Paul M. NAF Textbook. 2009 • 1st Trimester: • Infection 1st (33%) • Hemorrhage 2nd (14%) • 2nd Trimester: • Hemorrhage 1st (40%)

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: osfinders, 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 ALSO, AAFP, 2014 4 Ts Tissue: Retained Clot, Tissue, Hematometra Tone: Uterine Atony Trauma: Perforation, Cervical Lacerations Thrombin: Rare Bleeding Disorders, DIC

13. Risk Factors for Hemorrhage 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 agentover 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 Kaneshiro B, Contraception, 2011 Kern J, SFP Guideline 2012 • Bleeding history • Appropriate tests • clot test, repeat hgb, coagulation tests • Note: Women taking anticoagulants did not have clinically significant increased VB < 12 weeks

20. Additionally • Treatment • Start IVF • Balloontamponade (30-80 cc) • Transfer • AssessVS 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.