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Abortion%20Complications%20Management%20Workshop

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Abortion Complications Management Workshop Summary Hemorrhage is a common cause of abortion-related mortality. 50% of women have no risk factors Critical to prepare ... – PowerPoint PPT presentation

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Title: Abortion%20Complications%20Management%20Workshop


1
Abortion Complications Management Workshop
2
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 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 gt 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
  • 4 Ts
  • Tissue Retained Clot, Tissue, Hematometra
  • Tone Uterine Atony
  • Trauma Perforation, Cervical Lacerations
  • Thrombin Rare Bleeding Disorders, DIC

ALSO 2013
10
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)
SFP Guideline 2012
11
Algorithm 7 Ts
  • 6 Ts 2 steps each
  • 4 Ts (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
  • Bleeding history?
  • Appropriate tests
  • clot test, repeat hgb, coags
  • Note Women taking anticoags did not have
    clinically significant increased VB lt 12 weeks

Kaneshiro 2011, SFP Guideline 2012
17
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

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

19
Review Hemorrhage Algorithm 7 Ts
  • Recognize heavy bleeding initiate algorithm
  • 6 Ts 2 steps each
  • 4 Ts (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 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

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, youll have comps

36
Questions Thank you
  • Please fill out evaluations!
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