Approach to Medical Abortion Complications in the ED – A Medical Student Clinical Pearl

Victoria Mercer

MD Candidate | Class of 2023
Dalhousie Medicine New Brunswick

Case:

A 28 year old female presents to the ED with cramping abdominal pain and heavy vaginal bleeding ongoing for 4 days. She has soaked through 4 regular pads in the last 2 hours, an increase from her ongoing bleeding. She also describes an increase in lower abdominal pain and some lightheadedness. Taking her medical history you discover she was 9 weeks pregnant and had a medical abortion approximately 4 days ago.

Vitals: HR 101, BP 101/65, RR 19, SpO2 98%, T 37.5°C

Brief Review of Medical Abortion

Medical abortions account for approximately 40% of abortions and is both an effective and safe method of terminating pregnancies that are <11 weeks(1). Serious complications are rare but must be recognized by the emergency physician to prevent morbidity and mortality.

Standard regimen of medical abortions includes administration of 200mg oral Mifepristone, a progesterone receptor antagonist, followed by 800mg of Misoprostol, a synthetic prostaglandin, 24-48 hours later (1). Mifepristone disrupts pregnancy growth and misoprostol induces uterine contractions to aid in the expulsion of the pregnancy contents (2).

Expectations vs complications

Bleeding

Bleeding and cramping generally begin 1-4 hours after ingestion of misoprostol however the heaviest bleeding generally occurs 3-8 hours post ingestion as the pregnancy tissue is expelled from the uterus (2). Duration of bleeding is generally 11 to 17 days (1,2). Heavy bleeding is defined as soaking through 2 pads per hour for at least 2 hours, upon which patients should be counselled to seek medical assistance (1,2).

Differential diagnosis of post medical abortion hemorrhage: Uterine atony (40-50%), retained products of conception (POC), placenta previa or accreta, coagulopathies

Cramping & Pain

Over 90% of patients following mifepristone-misoprostol will experience cramping (3). This may be moderate pain that responds to oral analgesics such as acetaminophen, ibuprofen or in some cases, an opioid (3). When pain is not improving or controlled by oral medication, this could be concerning (2,3).

Differential of refractory pain: incomplete abortion, ectopic pregnancy, infection

Fever

Temperatures above 38.0 °C for several hours despite antipyretics is abnormal and should warrant investigation for infection. Most cases of postabortion infections are due to endogenous flora or pre-existing infections. If retained POC is identified via ultrasound, broad spectrum antibiotics should be administered and obstetric and gynecology should be consulted for surgical management (2).

Pearl:

Post-abortion triad includes pain, low-grade fever and bleeding. Most often caused by RPOC(4).

Approach to Patient in ED After a Medical Abortion

Case Continued:

Pelvic examination findings include a soft and enlarged uterus. No cervical lacerations are identified. On ultrasound you notice increase heterogenicity within the endometrial cavity and a thickened endometrial wall. You suspect the cause for her post-abortion hemorrhage is due to RPOC.

You begin a bimanual uterine massage and initiate methylergonovine administration. After 3 repeat doses, the bleeding begins to subside. Vital signs remain stable and OB/GYN is consulted for further management.

References

1. First-trimester pregnancy termination: Medication abortion – UpToDate [Internet]. [cited 2021 Nov 8]. Available from: https://www.uptodate.com/contents/first-trimester-pregnancy-termination-medication-abortion?search=medical%20abortion&source=search_result&selectedTitle=1~72&usage_type=default&display_rank=1#H2018734958
2. Orlowski MH, Soares WE, Kerrigan KL, Zerden ML. Management of Postabortion Complications for the Emergency Medicine Clinician. Annals of Emergency Medicine. 2021. 77(2):221-232. doi.org/10.1016/j.annemergmed.2020.09.008
3. Kruse B, Poppema S, Creinin MD, Paul M. Management of side effects and complications in medical abortion. American Journal of Obstetrics and Gynecology. 2001. 183(2):S65–75.
4. Abortion Complications Clinical Presentation: History, Physical, Causes [Internet]. [cited 2021 Nov 9]. Available from: https://emedicine.medscape.com/article/795001-clinical#b4
5. Yahya B. Retained products of conception [Internet]. [cited 2021 Nov 9]. Available from: https://radiopaedia.org/articles/retained-products-of-conception
6. Kerns J, Steinauer, J. Management of postabortion hemorrhage. Contraception (Stoneham). 2013. 87(3): 331-342. 10.1016/j.contraception.2012.10.024