Complications of Elective Medical Abortions

A 21-year-old female, G1P0A1, presents to the emergency department with a chief complaint of vaginal bleeding.

The patient reports she had a medical abortion 5 days ago and has been bleeding since. She was 7 weeks gestation by her last menstrual period at that time. She decided to come in today because last night she soaked through 8 pads in 3 hours, so she is becoming increasingly nervous that something could be wrong. Patient reports she has abdominal cramping that has not been relieved by taking Advil. She believes she has had a fever but does not have a thermometer at home. She denies nausea and vomiting at this time.

Introduction
There are two methods to terminate a pregnancy: medical and surgical abortion. Surgical abortion, also known as uterine aspiration, is the most common type of abortion. It is usually performed in the first trimester, meaning up to 14 weeks of gestation in an outpatient setting. According to the Guttmacher Institute, two-thirds of all abortions (surgical and medical) occurred at 8 weeks of pregnancy or earlier, and 88% occurred in the first 12 weeks.¹ The procedure consists of premedications, infection prevention, cervical block, paracervical dilation, and finally, manual or electrical vacuum aspiration.²

Medical terminations can be used earlier in pregnancy and require no surgical procedure. Two medications are typically used: 200 mg of mifepristone, a progesterone antagonist, followed by 800 mcg of misoprostol, a prostaglandin analog, 24 to 48 hours later. The combination of mifepristone and misoprostol are FDA-approved to terminate a pregnancy up to 70 days (10 weeks) of gestation.³ Although the majority of abortions are completed surgically, the number of medical abortions increased by 123% from 2010 to 2019. Of early first-trimester abortions completed, where an early abortion is defined as occurring at 9 weeks gestation or less, 53.7% were medical abortions.⁴

Patients may present to the emergency department following an abortion due to adverse events. Post-medical abortion visits are more frequent than post-surgical abortion visits due to both typical and atypical symptoms.⁵ Typical symptoms include self-limiting abdominal pain, cramping, vaginal bleeding, fever, headache, dizziness, nausea, vomiting, and diarrhea. It is atypical for any of these symptoms to be severe enough that oral, over-the-counter medications cannot provide relief.

While treating patients who have recently had a medical abortion, it is important to elicit key details such as when the abortion occurred and their last menstrual period to approximate the gestational age. Mifepristone and misoprostol have expected side effects, but also red flag signs. Patients must be counseled on what to monitor for at home that would prompt them to present to an ED. Incomplete abortions, where some products of conception are not expelled, are more likely with medical abortions and can lead to life-threatening complications. Therefore, emergency medicine providers should be prepared to evaluate and treat patients who have had medical abortions with a keen awareness of the anticipated adverse events and the less common, though more dangerous, complications.

Expected Adverse Events
Self-limiting signs and symptoms are expected after a medical abortion. A patient should be prepared based on appropriate physician counseling prior to the abortion. Patients' symptoms tend to be more severe with increased age of gestation.

Symptoms may include:
• Cramping and abdominal pain that will gradually improve over 3 to 14 days
• Bleeding, usually heaviest 3 to 8 hours after taking misoprostol
• Self-limiting low-grade fever
• Self-limiting mild headache and dizziness without loss of consciousness
• Self-limiting nausea, vomiting, and diarrhea

Significant Adverse Events
Major adverse events in patients who underwent a medical abortion may be life-threatening, requiring urgent and appropriate evaluation and careful monitoring by the physician. Rare, however possible, events include hemorrhage, incomplete abortion, and infection.

Symptoms may include:
• Heavy bleeding, defined as soaking through 2 menstrual pads (thick pads, not thin liners) per hour for at least 2 hours
• Cramping and abdominal pain that cannot be controlled with oral over-the-counter pain medications (such as acetaminophen or ibuprofen)
• A persistent temperature above 38.0℃ for more than 4 hours despite appropriate dosing of antipyretics.

ED Management
When a patient presents to the ED with a complaint following a recent medical abortion, a thorough history and physical exam are essential. History should include gestational age, time, dosing, and route of administration for each medication, as well as pertinent medical history, such as bleeding, coagulopathy disorders, and conditions that would increase likelihood of infection like diabetes or chronic immunosuppression. Additionally, previous gynecological surgeries and prior obstetric history, including route of delivery of children and prior elective or spontaneous abortions, should be noted.

The physical exam includes vital signs, abdominal exams, and pelvic exams. A pelvic exam will provide further information about the quantity of bleeding and whether there is uterine atony. Presence of blood pooling in the vaginal vault and active or even brisk oozing from the cervical os can help characterize the degree of bleeding. A pelvic ultrasound study should be conducted to determine if there are retained products of conception, accumulation of blood in the uterus, or free fluid in the abdomen. Laboratory values should be studied and include CBC, quantitative beta HCG, coagulation studies, and type and screen.⁶ A type and screen test is for the purpose of assessing need for Rhogam for possible Rh isoimmunization and preparing in case a blood transfusion is needed.

Management of the patient will depend on the physical findings and studies completed. For patients who need further treatment due to complications — like a laceration, or needing a dilation and curettage (D&C) for retained production of contraception — obstetrics and gynecology will be consulted. For uterine artery embolization, interventional radiology would be consulted, typically after discussing the case with obstetrics and gynecology. If the patient has a significant hemorrhage, she may require a blood transfusion in the ED and admission to an ICU. In the case of infection, the typical diagnosis is endometritis, or an infection of the endometrial lining, which can occur whether or not retained products of conception remain in place. For endometritis, patients require broad-spectrum antibiotics and fluids. If either a massive hemorrhage occurs or the patient becomes septic and does not improve after 24-48 hours of antibiotic treatment, a hysterectomy may have to be performed.⁶

Summary
It is typical for a patient to have side effects after a medical abortion. Differentiating expected versus significant adverse events is crucial to providing proper treatment. Patient education prior to administration of medications to terminate a pregnancy is vital, as many patients present to the ED afterward with anticipated adverse events. These visits could be limited if patients had a more in-depth understanding of what to expect throughout the process and for the days to weeks after undergoing a medical abortion. Providers must discuss red flag signs with these patients in case their symptoms persist and become severe, requiring additional medical attention after they have been discharged.

Vignette Conclusion
The patient was evaluated in the ED. She was hemodynamically stable and currently afebrile, her hemoglobin demonstrated mild anemia and a decrease from baseline, and a transvaginal ultrasound showed signs of retained products of conception. She was taken to the operating room for a suction dilation & curettage for an incomplete abortion. Intraoperative ultrasound demonstrated a thin endometrial stripe, also known as an empty uterus. She was discharged home with strict return precautions, including heavy bleeding exceeding saturating 2 pads in an hour for at least 2 hours, severe cramping or abdominal pain that cannot be controlled with oral over-the-counter pain medications, or a temperature exceeding 38.0℃ that cannot be controlled with antipyretics.

References

1. Jatlaoui TC, Ewing A, Mandel MG, et al. Abortion surveillance—United States, 2013. Morbidity and Mortality Weekly Report. 2016;(65)SS-12.
2. Shih G, Wallace R. First-trimester pregnancy termination: Uterine aspiration. In: UpToDate, Editor Steinauer J, Chakrabarti A. 2022.
3. Bartz DA, Blumenthal PD. First-trimester pregnancy termination: Medication abortion. In: UpToDate, Editor Steinauer J, Chakrabarti A. 2022.
4. Kortsmit K, Mandel MG, Reeves JA, et al. Abortion Surveillance — United States, 2019. MMWR Surveill Summ. 2021;70(No. SS-9):1–29.
5. Studnicki J, Harrison DJ, Longbons T, et al. A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015. Health Serv Res Manag Epidemiol. 2021;8:23333928211053965.
6. Orlowski MH, Soares WE, Kerrigan KL, Zerden ML. Management of Postabortion Complications for the Emergency Medicine Clinician. Ann Emerg Med. 2021;77(2):221-232.