Chapter 10 (by
1. Placenta Previa
It became obvious over the years that, at least statistically,
some of the second trimester procedures must have been done in the
face of an unknown and unsuspected placenta previa. This was, of
course, before ultrasound began to be used. We had never experienced
any problems that could be attributed to placenta previa in the
thousands of second trimester abortions we had done. I have spoken to
many colleagues with years of experience regarding this clinical
impression and I do not remember any one reporting a problem related
to placenta previa. More recently we have had a few cases where
patients with placenta previa, confirmed by ultrasound, were referred
for evacuation (one with a known ultrasonographically diagnosed
complete placenta previa in the second trimester with bleeding). The
procedures were completed without incident using the technique and
anesthetic described earlier for a second trimester abortion. The one
patient with the known central previa was done in the hospital
operating room. It may be helpful to know of, and to consider, this
operative technique in the treatment of placenta previa.
Thomas, et al, did a
retrospective analysis of women who had undergone a D&E and who
had had an ultrasound before the surgery. Comparing those who had
evidence of a placenta previa on ultrasound with those who did not,
he came to the conclusion that there was no significant increase in
the complication rate among those who had a placenta previa, although
there was a small increase in estimated blood loss.
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2. Fetal Death
I have no statistics regarding the number of uterine evacuations
involving a fetal demise in the second and early third trimester I
have done, but since 1978, our office was the referral site for many
of these cases from the medical community and I had done others
betore. What I am reporting, then, is purely my clinical impression.
I would estimate that I have evacuated well over 100 cases
involving an intrauterine fetal demise utilizing the second trimester
technique described above. The major complication seen was the
occurrence of coagulation coagulopathy, initially as high as 15-20%.
(The literature supports this level and even more. I have some very
specific suggestions if you decide to empty the uterus before
spontaneous expulsion occurs, or if there has been a failed attempt
to empty the uterus with oxytocin uterine stimulation (often the
reason for a referral to our office).
1. In counseling, be sensitive to the fact that this was a wanted
2. All necessary lab studies, e.g. CBC, fibrinogen levels, etc.,
should be current and on hand.1)
3. Allow time tor the size of the uterus to shrink until it is
less than that of a 16 week gestation, preferable 15 weeks or less.
At that size the entire pregnancy can be evacuated completely through
a 16 cannula. No other instrumentation is needed. (A gestation of
28-30 weeks can shrink down to this size in as little as 2 weeks,
although some take longer.)
4. Do not crush any fetal parts if at all possible. Get adequate
cervical dilation with the laminaria and dilators. If it is necessary
to crush fetal tissue, do as little as possible. Remove all tissue
gently, with minimal force. This is to avoid increasing the level of
maternal thromboplastin by adding fetal thromboplastin from the
crushed fetal tissue. (This is the reason for trying to remove the
uterine contents using the cannula alone.)
5. Avoid manual stimulation of the uterus prior to evacuation.
Any bimanual exam should be done extremely gently. Here is a case
where I would not use the hand on the fundus
6. Be sure to use the Vasopressin and Oxytocin in the local
anesthetic as described earlier for a second trimester abortion, and
be prepared to inject the uterus with another 5 to 10 units of
Vasopressin at the first sign of any increased dilation bleeding.
7. Be prepared to treat tor a consumptive coagulopathy. As stated
above, it can be stopped early, if therapy is started quickly.
8. All the above potential complications and treatment should be
thoroughly explained to the patient and significant other(s) before
starting. If referred by other physicians, be sure they are aware of
the potential problems. Try to have them available on the day of
surgery. Have them accept responsibility for any hospital treatment,
if possible, or at least, agree to be involved.
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Specific Instruments and Medications
Though these are intrequently needed they can be of immense value
in occasional cases. The list is essentially the same as those
recommended when doing a first trimester abortion with the following
1. Hern forcep -
The longer handle is invaluable in selected cases. Cheshire
2. Ringed Forcep - Having three available is very helpful in
cases where there is a concern that there may be a cervical tear.
They can be used to grasp and "walk" the cervix, looking for a tear.
They also help in those cases where the cervix needs to be held and
sutured and they can also be used for hemostasis. Passing one blade
up inside the cervix, even as high up as the internal os, while the
other blade is outside the cervix, high up in the vagina, then
closing the forcep about the bleeding site, can be very effective in
controlling bleeding. The forceps can be left in place until the area
can be sutured, even during transfer to the hospital.
3. Auxiliary power - The large I.P.A.S Manual Vacuum or a
generator that can be attached to your electrical supply may rarely
be needed but electrical failures have occurred all over this
country. The I.P.A.S system is invaluable in third world countries.
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A hospital that has the capability of stabilizing the patient,
providing rapid fluid and blood replacement, should be accessible
within 20 minutes. That hospital should also be capable of getting a
patient into surgery rapidly. In some areas this may not be possible
within any reasonable time. In that case you may have to reconsider
the services you supply. It might be advisable not to provide
abortions for the later gestations and to refer those cases to a
provider who is better prepared to handle the emergency.
A means of transporting the patient to the hospital must be
available and the time it takes to transport calculated into the 20
minutes. (How long, for example, does it take for the Paramedics in
your area to respond, get to your office, stabilize and then
transport the patient to the hospital?)
If a transfer is necessary, call the hospital emergency room
yourself and speak to the physician who will be seeing the
patient. Communicate personally and directly whenever possible.
A physician capable of providing emergency surgery should be
available and have hospital privileges at that hospital. Some sort of
relationship, formal or informal, should be established with that
physician. (Agreeing to pay the fees in cases of emergency surgery
may be an approach.) Communicate directly with the surgeon in order
to give as much information as possible and to show your concern.
It is always best if you are the surgeon. If this is not
possible, at least try to follow the patient in the hospital. The
expression of concern on your part is extremely important especially
if the case gets legal review. Spend time with the family whenever
possible. Explain and discuss the problem completely and honestly.
Someone on your staff should be assigned to stay in contact with the
patient especially after she goes home. This may not stop legal
action but it will always put you in a better light. Remember to
record everything as discussed before under "charting."
The major complications that will require immediate
hospitalization are post-operative uterine
atony2) with bleeding, perforations
of the uterus, lacerations of the uterus, cervix and/or vagina and
consumptive coagulopathy. The diagnosis of an ectopic pregnancy or an
amniotic fluid embolism will also require hospitalization. Acute
infections requiring hospitalization usually occur about two to five
days post-operatively, although a rare sub-acute and/or chronic
tubo-ovarian abscess may show up a few weeks later. A transitory
bacteremia can cause an alarming temperature spike in the immediate
post-operative period. This should be treated with I.V. antibiotics
and measures that will lower temperature (ice, Tylenol, etc.).
Hospitalization for observation may be necessary.
1. Have the ability to admit that you and your patient may be in
2. Have a well defined plan to transfer the patient to the
hospital for care by a designated individual.
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The recommendations in these papers are are not meant to be
absolutes, but rather suggestions to be explored. Many points may
seem trivial and unimportant; others may affect your practice in
dramatic ways. I urge you to approach these suggestions with an open
mind. Not everything in these papers will apply to your particular
situation. But even those of you who are using general anesthesia may
find particular suggestions useful. Patient care needs to be
reevaluated constantly in order to provide the best abortion services
possible. We all know it is hard to change old ways and established
routines, and we fall back on the old adage that says, "If it ain't
broke, don't fix it." This may be true, but what may also be true is
that "it is broke, you just don't know it," and unless you're willing
to look critically at what you do and try something new, you'll never
1) Here my Dutch colleagues do not agree,
and call this defensive medicine
2) They also do not believe in post abortion
atony, unless there are rests in the uterus
Thomas G A, Alvarez M, Friedman F, Brodman M,
Kim J, Lockwood C. The Effect of Placenta Previa on Blood Loss in
Second-Trimester Pregnancy Termination. Obstet Gynecol 1 994;84:58-60
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