Emergency Treatment Module 2 - Session 6 Postabortion Complications and Management

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Emergency TreatmentModule 2 - Session
6Postabortion Complications and Management
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Module 2 - Session 6Objectives

• At the end of this session, participants will be
  able to
• Describe possible complications and their
  signs/symptoms
• Describe initial treatment and other measures
  for
• a. Shock
• b. Severe vaginal bleeding
• c. Infection and sepsis
• d. Intra-abdominal injury
• e. Uterine perforation
• Explain elements of emergency resuscitation/prepar
  ation for referral and transport to tertiary care
  hospital

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Common Postabortion Complications

• Regardless of the type of abortion, complications
  can develop at any time, even before the woman
  seeks care.
• If prompt actions are not taken, they can become
  life-threatening within minutes.
• When a woman presents for care, the provider must
  be able to both recognize and manage
  complications.
• Initiating treatment for life-threatening
  conditions immediately is essential to keep the
  womans condition from worsening.

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Initial Treatment

• Initial steps are similar, regardless of
  complication.
• Definitive treatment may vary
• Follow local protocols/guidelines.
• The goal is to recognize the problem and prevent
  it from worsening while saving the womans life.

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Presenting Complications of PAC Clients

• Complications may include
• Shock
• Severe vaginal bleeding
• Infection and sepsis
• Intra-abdominal injury
• Uterine perforation

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Shock

• A life-threatening condition that requires
  immediate and intensive treatment to save the
  clients life.
• It is characterized by failure of the circulatory
  system to maintain adequate blood flow to vital
  organs, depriving them of oxygen.
• With incomplete abortion, shock is usually caused
  by blood loss (hemorrhage), dilation of the blood
  vessels (vasodilation) from infection/sepsis or
  trauma.

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Shock (2)

• Clients suffering from shock must be treated
  immediately and closely monitored because their
  condition can worsen quickly.
• The primary goal in treating shock is to
  stabilize the client that is, to restore the
  volume and efficiency of the circulatory system
  as measured by an increase in blood pressure and
  decrease in the pulse and respiratory rates.

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Shock (3)

• While the immediate and intensive treatment of
  shock is essential to save to the womans life,
  it is only the first step the underlying cause
  must also be treated immediately in order to
  prevent the womans condition from worsening.    

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Signs and Symptoms of Shock

• Fast, weak pulse (rate 110 per minute)
• Low blood pressure (systolic lt90)
• Pallor (especially inner eyelid, palms or around
  the mouth)
• Sweatiness or cold, clammy skin
• Rapid breathing (respirations 30 per minute)
• Anxiousness, confusion or unconsciousness
• Scanty urine output (lt30 ml per hour)

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Initial Treatment for Shock

• Call for help.
• Monitor vital signs.
• Turn the client onto her side to minimize the
  risk of aspiration if she vomits.
• Make sure her airway is open.
• Give oxygen at 68 liters per minute (mask or
  cannula).
• Keep the client warm (do not overheat).
• Elevate her legs to increase return of blood to
  her heart.

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Initial Treatment for Shock (2)

• Give IV fluids (normal saline or Ringers
  lactate), 1 liter in 1520 minutes with large
  bore needle (1618 gauge).
• Note A more rapid replacement is required in the
  management of shock resulting from bleeding.
  Replace 23 times the estimated fluid loss
• REFER if IV fluids are not available.
• Do not give fluids or medications orally.

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Initial Treatment for Shock (3)

• Monitor vital signs, IV fluids and urine output.
  
• Collect blood for hemoglobin or hematocrita
  hemoglobin of 5 g/100 ml or less or hematocrit of
  15 or less is life-threatening and will require
  blood transfusion.
• Cross-match blood perform a bedside clotting
  test.
• Give broad-spectrum IV or IM antibiotics.
• Refer if IV/IM antibiotics are not available.

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Initial Treatment for Shock (4)

• Remove any visible POC, which may help the uterus
  to contract and control bleeding. Do not do a
  complete pelvic exam at this time.
• If the womans condition improves, adjust the
  rate of the IV infusion to 1 liter in 6 hours and
  continue managing the underlying cause of shock.

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Severe Vaginal Bleeding

• Prolonged or excessive vaginal bleeding and
  symptoms of incomplete abortion are usually
  caused by retained products of conception (POC)
  or by injury to the vagina, cervix or uterus,
  including perforation of the uterus.
• Taking prompt action to stop the bleeding and
  replace fluid or blood volume can be lifesaving.
• The blood pressure and heart rate should also be
  closely monitored, as shock may develop at any
  time.
• Blood pressure, pulse rate, hematocrit or
  hemoglobin, and urine output are the primary
  measures of the amount of blood loss.

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Severe Vaginal Bleeding (2)

• Treatment includes control of bleeding,
  intravenous fluids (when available) to replace
  fluid volume, antibiotics to fight infection and
  stabilization before uterine evacuation can
  occur.
• Surgery may sometimes be required to identify and
  repair the source of bleeding
• Refer the client to a higher level of care as
  soon as she is stable.

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Signs of Severe Vaginal Bleeding

• Heavy, bright red vaginal bleeding with or
  without clots
• Blood-soaked pads, towels or clothing
• Pallor (conjunctiva and around the mouth, or
  palms)
• Dizziness, fainting

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Initial Treatment for Severe Bleeding

• Same as for shock
• Check vital signs.
• Elevate the legs or, if possible, raise the foot
  of the bed.
• Make sure that the airway is open if available,
  start oxygen at 68 liters per minute by mask or
  nasal cannula.
• Restore fluid volume
• Start IV with a large-bore needle or catheter (16
  gauge or higher).

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Initial Treatment for Severe Bleeding (2)

• Monitor amount of blood loss
• Heart rate
• Blood pressure
• Hematocrit (if lab available)
• Number of pads soaked or amount of blood on
  sheets, mattress, clothing, etc.
• Monitor vital signs, IV fluids and urine output.
  
• Collect blood for hemoglobin or hematocrit
  cross-match blood and perform a bedside clotting
  test.
• If there are signs of intra-abdominal injury or
  ectopic pregnancy, do further assessment and
  appropriate treatment immediately.

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Disseminated Intravascular Coagulation (DIC)

• If the woman is bleeding from several places and
  the bleeding is not easily stopped, quickly
  assess her for DIC, a bleeding disorder that is
  sometimes seen with severe sepsis.

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Signs of DIC

• Bleeding from inside the mouth, bladder,
  injection site or venipuncture site
• Blood in the urine
• Failure of the womans blood to clot
• If no lab is available, look at places where
  blood has pooled such as on the bed or floor to
  assess clotting
• Decreased platelet count

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Management of DIC

• Treating the underlying cause of bleeding is the
  mainstay of DIC management.
• Giving blood products, such as fresh whole blood
  or fresh frozen plasma, can help control bleeding
  while the infection is being treated.
• REFERRAL to a higher level (tertiary) facility is
  usually required.

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Infection and Sepsis

• Infection is a common complication of incomplete
  abortion.
• The presence of retained POC makes it easy for
  infection to grow, especially when they result
  from an unsafe abortion that used unsafe methods
  or contaminated instruments.
• Localized infections from induced or spontaneous
  abortion can rapidly lead to more generalized
  sepsis and septic shock, which can be fatal.

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Signs/Symptoms of Infection or Sepsis

• Chills, fever, sweats, general discomfort
• Foul-smelling vaginal discharge
• Lower abdominal pain/tenderness
• Mucopus from the cervix
• Excessive pain or cervical motion tenderness on
  bimanual examination
• Distended abdomen
• History of attempting to end the pregnancy or
  history of recent miscarriage
• Prolonged bleeding (gt8 days)

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Risk Assessment for Septic Shock
Assessment of Risk for Septic Shock Assessment of Risk for Septic Shock
Low Risk High Risk
Low fever First trimester abortion No evidence of intra-abdominal injury Stable vital signs High fever (gt40C) or subnormal temperature (lt36.5C) Second trimester abortion Any evidence of intra-abdominal injury Any evidence of shock (falling BP and rising pulse rate)
Adapted from World Health Organization (WHO).1994. Clinical Management of Abortion Complications A Practical Guide. WHO Geneva. Adapted from World Health Organization (WHO).1994. Clinical Management of Abortion Complications A Practical Guide. WHO Geneva.
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Infection/Sepsis Initial Treatment

• Check vital signs.
• Do not give anything by mouth surgery may be
  needed.
• Make sure the airway is open. If needed, give
  oxygen 68 liters/minute by cannula or mask.
• Start IV broad spectrum antibiotics immediately
  (first obtain blood culturesif available).
• If the woman has been exposed to tetanus and her
  vaccination history is uncertain, give her
  tetanus toxoid.

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Infection/Sepsis Initial Treatment (2)

• If the woman becomes unstable, give IV fluids
  (normal saline or Ringers lactate), 1 liter in
  1520 minutes or faster.
• If the woman has lost a lot of blood or appears
  anemic, check her hemoglobin or hematocrit
  cross-match and do clotting test, if available.
• All sources of infection must be identified and
  treated.
• Monitor vital signs, IV fluids and urine output.

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Intra-Abdominal Injury

• Includes uterine perforation and possible damage
  to surrounding organs, including the cervix,
  vagina or bowel.
• Risk of infection, sepsis, peritonitis and
  tetanus is very high.
• May be discovered during the initial physical
  exam or later during uterine evacuation (rare
  with MVA).
• May initially present without symptoms, and then
  progress rapidly to serious and even
  life-threatening complications.
• A ruptured ectopic pregnancy or ovarian cyst can
  present with symptoms of intra-abdominal
  hemorrhage similar to intra-abdominal injury
• History of ectopic pregnancy, pelvic infection or
  use of certain contraceptive methods has greater
  possibility of ectopic pregnancy.
• Delay in treatment is extremely dangerous and may
  lead to death unless there surgical intervention.

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Signs/Symptoms of Intra-Abdominal Injury

• Severe abdominal pain/cramping
• Distended abdomen
• Nausea/vomiting
• Fever
• Shoulder pain
• Decreased bowel sounds
• Tense, hard abdomen
• Rebound tenderness
• Any of above symptoms combined with signs of
  shock may indicate major intra-abdominal
  hemorrhage

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Initial Treatment of Intra-Abdominal Injury

• Check vital signs.
• Do not give anything by mouth as surgery may be
  needed.
• Make sure the airway is open. If the woman is
  unstable, give oxygen 68 liters/minute by
  cannulae or mask.
• If there is any indications of infection (fever,
  chills, pus) give broad-spectrum antibiotics (IV
  or IM).
• If possible exposure to tetanus and her
  vaccination history is uncertain, give tetanus
  toxoid.

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Intra-Abdominal Injury Initial Treatment (2)

• To restore fluid volume, give IV fluids (normal
  saline or Ringers lactate), 1 liter in 1520
  minutes or faster, using a large-gauge needle.
• It may take 13 liters of IV fluids to stabilize
  a woman who has lost a lot of blood or is in
  shock.
• Check her hemoglobin or hematocrit.
• Cross-match and perform a clotting test, if
  available.
• Give IV or IM analgesia for pain management.
• Monitor urine output.
• If possible, take abdominal x-rays.

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Signs of Perforation before Vacuum Aspiration

• Fast pulse (110 per minute)
• Falling blood pressure (diastolic lt60)
• Excess bleeding
• Signs and symptoms of intra-abdominal injury

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Signs of Perforation during Vacuum Aspiration

• Cannula, dilator or other instrument penetrates
  beyond expected size of the uterus.
• Syringe vacuum decreases with the cannula well
  inside the uterus.
• Excessive bleeding after the uterus is empty.
• Fat or bowel in aspirated tissue found during or
  after the procedure.

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Initial Treatment for Uterine Perforation

• If uterine evacuation not started
• Check for signs of intra-abdominal injury
• If present, treat accordingly before performing
  evacuation.
• If not present, proceed cautiously with
  evacuation.
• Treatment during uterine evacuation (evacuation
  is not complete)
• Begin IV fluids and antibiotics.
• Check hematocrit arrange for blood transfusion
  if indicated (hematocrit lt15 or hemoglobin lt5
  mg/100 ml).

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Treatment during Uterine Evacuation (2)

• Complete the evacuation under direct visual
  control (laparoscopy or laparotomy) to assess
  damage to pelvic organs and to prevent further
  damage. If laparoscope not available, REFER.
• Repair damage as necessary.
• After surgery, give uterotonic (if the uterus has
  not been removed) and observe vital signs every
  15 minutes for 2 hours.
• If the client becomes stable and bleeding slows,
  give ergometrine (0.20.5 mg IM if not
  contraindicated) and observe overnight.
• If condition worsens, transfer to a higher level
  of care.

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Treatment of Perforation If the Evacuation Is
Complete

• Begin IV and broad-spectrum antibiotics.
• Give ergometrine 0.20.5 mg IM repeat up to 3
  doses as needed.
• Observe for 2 hours, checking vital signs
  frequently.
• If client becomes stable and bleeding slows, give
  additional ergometrine (same dose) and continue
  observation overnight.
• If client condition worsens, give additional
  doses of oxytocin or ergometrine.
• If bleeding continues, a laparoscopy or
  minilaparotomy may be needed.
• Transfer the woman as soon as possible to a
  higher level of care.

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Referral Guidelines

• When a client needs to be referred or
  transferred, arrangements should be timely and
  efficient.
• The referral site must have everything possible
  to stabilize the woman and provide continued
  treatment.
• Standing arrangements for referral and transport
  should exist at all health facilities.

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Referral Guidelines (2)

• Stabilize the client.
• Prepare referral information.
• If possible, trained staff should accompany the
  client.
• If possible, continue treatments including oxygen
  and IV therapy.
• Keep client warm.
• If in shock or hemorrhage, keep feet elevated.