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Abortion Complications Management Workshop

Abortion Complications Management Workshop. 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

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Abortion Complications Management Workshop

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  1. Abortion Complications Management Workshop

  2. 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 increases 38% for each additional week of pregnancy Bartlet 2004

  3. Abortion Related Mortality • 1st Trimester: • Infection (33%) • Hemorrhage (14%) • 2nd Trimester: • Hemorrhage (40%) Paul 2009

  4. Emergency Prevention • 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

  5. Procedural Pearls • 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

  6. TEACH Simulation Innovations • Papaya: a memorable MVA & PCB model • Historically used as an abortifacient • In dialects means “vagina” • Pitaya = dragon fruit: helpful model for practicing comp management steps • Also thought to be helpful in pregnancy Paul, 2005; Goodman NAF 2013

  7. Case 1 • 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?

  8. Demo and Group Brainstorm

  9. Causes of Hemorrhage ALSO 2013 4 Ts Tissue: Retained Clot, Tissue, Hematometra Tone: Uterine Atony Trauma: Perforation, Cervical Lacerations Thrombin: Rare Bleeding Disorders, DIC

  10. Risk Factors for Hemorrhage SFP Guideline 2012

  11. Algorithm – 7 T’s • 6 T’s : 2 steps each • 4 T’s (Tissue, Tone, Trauma, Thrombin) • Treatment plan • Transfer • (Teamwork with a leadership role)

  12. Tissue 4 Ts: Think tissue first Re-aspiration

  13. Tone (Atony) • Medications • Misoprostol 800-1000 mcg SL/ BU/ PR • Methergine 0.2 mg IM, IC, IV (HTN) • (Min evidence for 1 particular agent) • Massage SFP Guideline 2012

  14. Trauma • Assess bleeding source • Walk cervix • Cannula test • Ultrasound • Think perforation if free fluid

  15. Free fluid in cul-de-sac

  16. Thrombin Kaneshiro 2011, SFP Guideline 2012 • Bleeding history? • Appropriate tests • clot test, repeat hgb, coags • Note: Women taking anticoags did not have clinically significant increased VB < 12 weeks

  17. 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

  18. 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 it through

  19. Review Hemorrhage Algorithm – 7 T’s • Recognize heavy bleeding; initiate algorithm • 6 T’s : 2 steps each • 4 T’s (Tissue, Tone, Trauma, Thrombin) • Treatment • Transfer • (Teamwork)

  20. Case 2 22 y/o G2P0 woman after uncomplicated 10 week abortion Called from recovery to evaluate for uterine pain with hypotension DDx and evaluation?

  21. Emergencies Specific to Surgical Abortion:Tissue: Acute Hematometra • Pathophysiology • Relative cervical stenosis plus uterine hypotonia • Leads to retention of clotted blood in uterus • Diagnosis • Usually within first hour post-procedure • US shows clotted blood in uterus

  22. Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra • Diagnosis Vital Signs • May be hypotensive; orthostatic(HoTN with standing) Signs • Uterine enlargement / tenderness on exam Symptoms • Usually little or no vaginal bleeding • Patient may be asymptomatic when supine • Severe cramping, lower abdominal pain, rectal presssure • Dizziness/faintness

  23. Emergencies Specific to Surgical Abortion: Tissue: Acute Hematometra • Management • Re-aspiration usually provides complete resolution • If not resolving or to prevent re-accumulation, consider uterotonics

  24. Case 3 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?

  25. Trauma: Uterine Perforation • 1st Tri: Fundal - • Few complications • Advanced GA • More likely lateral • Bleed more • Incidence • 0.1 – 3 / 1000 • 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 US 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 f/u x 1-2 days • Reschedule abortion 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 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) • 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 • Call for ambulance • Inform front office • Duplicate pertinent charting • Notify ER / OB • Notify medical director

  34. Summary • Hemorrhage is a common cause of abortion-related mortality. • 50% of women have no risk factors • 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

  35. Key Points • 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 • If you do enough, you’ll have comps

  36. Questions Thank you Please fill out evaluations!

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