Managing Hemorrhage as a Complication of Uterine Aspiration

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Managing Hemorrhage as a Complication of
Uterine Aspiration
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Uterine Aspiration

• Indications
• Miscarriage management
• Incomplete abortion
• Failed medication abortion
• Therapeutic abortion
• Safety
• Minimal risk lt0.05 of major complications
  (needing hospital care)

Weitz T AJPH 2013
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Safety? Mortality / 100,000 Uterine Aspirations
or Births
Guttmacher 2014 Bartlett 2004
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Relative Risk ofFatal Complication
11
lt1.0
2.6
1.5
Per 100,000 Woman Years by Exposure
Guttmacher Institute 2014
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Earlier Procedures are Safer-- CDCs Abortion
Mortality Surveillance System

• Currently, gestational age strongest risk
  factor for abortion-related mortality
• Lowest risk of death abortions lt 8 weeks
• Mortality risk is increased 38 for each
  additional week of pregnancy

Bartlett LA, Obstet Gynecol. 2004
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Abortion-Related Mortality

• 1st Trimester
• Infection 1st (33)
• Hemorrhage 2nd (14)
• 2nd Trimester
• Hemorrhage 1st (40)

Paul M. NAF Textbook. 2009
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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 gt 12 wks (Edelman
  2006)
• Uterotonics available
• Use closed-loop emergency communications
• Transfer agreements w/ nearby hospitals

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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

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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
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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?

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Demonstration and Group Brainstorm
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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
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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
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Algorithm 6 Ts

• 6 Ts 2 steps each
• 4 Ts (Tissue, Tone, Trauma, Thrombin)
• Treatment plan
• Transfer

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Tissue

• 4 Ts Think tissue first in uterine aspiration
  setting
• Re-aspiration

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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
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Trauma

• Assess bleeding source
• Walk cervix (or clamp if active bleeing)
• Cannula test
• Ultrasound
• Think perforation if free fluid

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Free fluid in cul-de-sac
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Thrombin

• Bleeding history
• Appropriate tests
• clot test, repeat hgb, coagulation tests
• Note Women taking anticoagulants did not have
  clinically significant increased VB lt 12 weeks

Kaneshiro B, Contraception, 2011 Kern J, SFP
Guideline 2012
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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

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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 dont respond to usual measures
• Give provider opportunity to think through steps

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Review Hemorrhage Algorithm 6 Ts

• Recognize heavy bleeding initiate algorithm
• 6 Ts 2 steps each
• 4 Ts (Tissue, Tone, Trauma, Thrombin)
• Treatment
• Transfer

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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?

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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?

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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
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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

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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

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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

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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

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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

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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

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Emergencies Specific to Surgical Abortion
Trauma Cervical Laceration

• Management
• External/Low
• Cervical lac lt 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

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Hospital Transfer

• Inform front office staff
• Duplicate pertinent charting
• Notify ER / OB physician
• Notify your medical director

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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
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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

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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)454461.
• 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 Apr103(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
  Apr37(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 Mar87(3)331-42.
• Kaneshiro B et al. Blood loss at the time of
  first-trimester surgical abortion in
  anticoagulated women.Contraception. 2011
  May83(5)431-5.