Most complications are caused by inexperience or negligence of the doctor who does the termination, some are caused by some particular condition which makes the procedure difficult, few arise under normal conditions with an observant and experienced doctor. We distinguish direct complications arising during or immediately following the procedure, delayed complications arising some time after the procedure, mostly when the patient has left the clinic, and late complications which are realised much later. Some direct complications may not be noticed but become manifest later. It is recommended to keep a record of complications. This is the best way to prevent future complications and it gives the details for a proper statistical study.

The following complications are discussed. Items 1 till 6 are direct complications, 7 and 8 delayed. Items 9 and 10 are direct, but generally become manifest later.

(You could click these subtitles to find your way)

1. Burst Ovarian Cyst.

2. Damage to the Cervix.

3. Perforation of the Uterus.

4. Retention of Soft Tissue.

5. Retention of Fetal Parts.

6. Intrauterine Bleeding.

7. Direct Blood Loss.

8. Delayed Blood Loss.

9. Infections.

10.Ectopic Pregnancy.

11.Retention of Pregnancy.

12.Late Complications.


1. BURST OVARIAN CYST - Smaller cysts never cause any problem. Occasionally an ovarian cyst bursts during bimanual examination. A resistance is felt which suddenly disappears. The patient reports a sudden sharp pain which gradually disappears. This may happen during termination.

Occasionally the course is more alarming:

This patient has an amenorrhoea of six weeks. An abdominal scan (a vaginal transducer was not available) shows a blurred shadow on the place of the uterus. The picture is not typical for an amniotic sac, it looks like a cyst but the colour is not smoothly black but blurred. On bimanual examination a soft tender bulge is felt. The patient reports that the examination causes similar pains like during coitus. Suddenly the bulge disappears and the woman feels a sharp pain. The scan now shows the normal picture of a young pregnancy. The pains increase so much that the patients tends to collapse. She is sent to a hospital. Laparoscopy reveals a burst ovarian cyst with a bleeding vessel inside. The rests of the cyst are removed and in the same session the uterus is emptied. Here we have the combination an ovarian cyst at an unusual place (in front of the uterus) with a bleeding vessel inside. The blurred aspect on the ultrasound scan picture was caused by blood inside the cyst. After bursting increasing pain is caused by blood in the peritoneal cavity.

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2. DAMAGE TO THE CERVIX - Dilating the cervix requires some force, depending on the resistance of the cervix. The commonest, rather trivial, complication is that the cervix is torn out of the tenaculum forceps. This seldom leads to more than a minor injury. A real cervix tear caused by forcing a dilator into a narrow cervix may bleed abundantly if agreat vessel is reached. A late effect may be cervical incompetence leading to future spontaneous abortions. A tear must be stitched properly or even a cervical cerclage (Shirodkar) must be applied.

Perforation of the cervix is possible while probing the uterus or dilating the cervix. The sides of the cervical canal are perforated if the probe or dilator is directed side wards into the cervical wall (fausse route). Prevent this by carefully feeling your way into the cervix. There is a definite difference in resistance between following a fausse route and following the canal in a stiff unyielding cervix. A particular risk of damage to the cervix is found in duplication of the uterus where two uteri share one cervix. This condition is described in [Chapter 11] Perforation near the internal ostium happens if the cervical canal is wide so that the internal ostium hangs somewhat in the canal, forming a recess as if the ostium is partly closed by a membrane ('hymen cervicale'). The instrument enters this recess rather than the ostium. Again, search carefully for the ostium rather than using more force.

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This is possible in almost every stage of the procedure. The main cause of perforation is inexperience or inaccurate examination and diagnosis. There are however certain uterine conditions in which there is an increased risk of perforation. Perforation may go unnoticed and may give rise to delayed symptoms.

Perforating the walls or fundus can be done with the uterine probe, the suction canula, a uterine forceps or a curette. Particularly in the case of a canula and forceps bowel damage is possible. Perforation is facilitated by the following conditions:

The soft uterine wall in advanced pregnancy is easily penetrated. Avoid this by injecting ergometrine in all cases of advanced pregnancy. In a pregnancy shortly after childbirth and if the patient had many pregnancies the uterine wall also tends to be softer than normal.

Fibromatous uterus. Because of the irregular internal lining of the uterus perforation is possible particularly on the sites where the fibroma emerges from the uterine wall. A more disastrous perforation is caused if a fibroma is mistaken for a fetal part and removed with a forceps.

Uterine surgery causing a scar inside the uterus. Instruments may penetrate the wall next to the scar. If the scar is taken for fixed placental tissue one may try to remove it with a forceps. Scars of the uterine wall may lead to placenta accreta or increta or even percreta. Trying to remove the placenta in such cases may tear a hole in the uterine wall. This could be the cause of some "spontaneous" (= unnoticed while operating) perforations.

Asherman's syndrome. Here the walls of the uterus are fused mainly as a result of a D&C in which the endometrium has been removed. This often makes pregnancy impossible, but in mild cases a pregnancy may be found. Perforation may occur if one tries to separate the fused uterine walls.

The non-pregnant uterus may be perforated if desperately is searched for tissue. Avoid this by making sure that a pregnancy exists before trying to terminate is. The same happens if one is convinced that there is a retention, for instance if some irregular echo's in ultrasound scan are mistaken for retention.

The effects of perforation are dependent on the size and place of the perforation, whether other organs are damaged, and whether the uterus is empty. A small uncomplicated perforation, not causing bleeding, needs no treatment. Big perforations may bleed intraperitoneally. Since there is little or no vaginal blood loss such bleeding may go unnoticed till the patient collapses. This happened in the only fatal case which occurred in a Dutch Abortion Clinic:

A patient with a 16 weeks pregnancy bled slightly after the procedure. She remained in bed for observation. After some two hours her condition deteriorated and she was sent to hospital. Since this was in the time that abortion was highly controversial, the hospital staff spent much time in rebuking the fact rather than treating the patient. The gynaecologist on duty quietly finished her clinic before arriving. When at last she was hurried to attend the patient , she had collapsed. A hurried venous drip with a plasma expander was installed. To speed up the drip the bottle was filled with compressed air. In the elevator on the way to the theatre the drip run out and the compressed air caused an air embolism followed by the patients death. Postmortem a two centimetre defect was seen and two litres of blood was found in the abdomen. Although the fatal mistake was made in the hospital, the clinic was closed by the authorities.

Perforation of an anteflexed uterus may cause limited bleeding in the cavum Douglasi and subsequent infection. Bowel damage will cause peritonitis. In all cases where a perforation is expected the patient should be observed. If bowel damage is suspected or if signs of shock develop the patient must be operated. If the perforation is small but the termination is not finished it is possible to empty the uterus under US control. This is rather an expert job. Repeatedly the canula is brought in the uterus till the fundus is felt. If it is certain that the canula did not enter the perforation, vacuum may be applied. Retention in a perforated uterus may cause blood loss and infection. The patient must be told of the condition and advised to come back or seek medical help if any of the following develop: abdominal pain, fever, bleeding, nausea.

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This is found in the very young pregnancy especially if narrow canula is used and/or insufficient vacuum is applied. If after aspiration the uterus is empty a characteristic scraping is felt when the canula is moved. Soft tissue retention is suspected if the canula can be moved smoothly without resistance. In most cases a part the placenta is fixed on the uterine wall while part of it blocks the canula. Retract the canula and remove the piece that blocks it. Do not adopt the disgusting habit of beating the canula on the sterile field splattering blood all over the theatre. The proper way to clean a canula is by carefully removing the tissue with a forceps. If some tissue is visible in the cervical canal fix it with a slender forceps and carefully pull it out with short jerky movements to disengage the placenta from the uterine wall.

Retention of soft tissue in the advanced pregnancy is rare. It may be caused by such rare conditions of accrete or increte or, very rare, percrete placenta. The danger here is blood loss and, if too much force is applied, perforation of the uterine wall by tearing a piece out of it.

If a patient is allowed to go home with retained soft tissue the course is dependent on the duration of pregnancy. In the advanced pregnancy blood loss may be the dominant feature. In the young pregnancy there may be a prolonged course of little blood loss until eventually the products are expelled. Since infection is a real danger it is better not to wait for the natural course. If on checkup visit retention is expected the uterus must be evacuated again by means of aspiration.

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This happens of course only in the advanced pregnancy. If in a Finks' procedure the soft tissues are removed the uterus will contract. If retention of fetal parts is not discovered there may be blood loss when the uterus relaxes. Eventually the fetal parts may be expelled spontaneously or removed by D&C. Since both courses are undesirable, the first causing much embarrassment for the patient and her family, the second leading to spiteful sneers from the established gynaecologists, this complication should never occur. After evacuation the uterus must be checked by ultrasound scan and if retained products are found they must be removed. If fetal parts are trapped in a maximally contracted uterus the patient must be allowed to stay in bed for about an hour. After this bed rest, or earlier if bleeding starts, the procedure can be resumed. Evacuation of the now relaxed uterus is much easier.

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After evacuation there may be a little blood loss. If the uterus is firmly contracted this is practically nil. Sometimes the cervix closes either spontaneously or it is blocked by a blood clot or some retained tissue. In this case blood is trapped in the uterus. Even if the uterus is fully contracted the bleeding may continue until the intrauterine pressure equals the bloodpressure in the damaged vessels. This causes the uterus to swell. This condition causes much pain. The situation may even seem alarming. By ultrasound scan the condition can be evaluated, but generally it can be diagnosed by feeling the uterus on external (abdominal) examination. Treatment is very simple. Bring the patient back to the theatre. Introduce a narrow canula which allows the blood to flow off which gives instant relief. Repeat a short aspiration to remove all blood and possible retained fragments of tissue.

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Bleeding from the injection sites after injecting the local anaesthetic occurs frequently but invariably ceases within a few minutes. So we are only concerned with uterine bleeding

7.1. Damaged or torn placenta.

7.2. Implantation site of placenta.

7.3. Cervical implantation of the cervix.

7.4. Damaged or torn uterine wall.

7.5. Damaged or torn cervix.

7.6. Failure of the uterus to contract, even if it is empty.

7.7. Defective clotting mechanism.

When trying to remove the contents of the uterus by classical D&C in an advanced pregnancy blood loss may be abundant, first from the partly removed placenta, later from the exposed implantation site of the uterine wall. The latter will finish if the uterus is empty, because then the uterus contracts and thereby closes its vessels. Termination with prostaglandins too is generally accompanied with much blood loss probably due to early separation of the placenta from the uterine wall.

7.1 If the placenta is not fully removed in advanced pregnancy it will bleed. Therefore in D&E we try to wait with the complete removal of the placenta until the fetal parts are removed.

7.2 If the uterus does not contract the site of implantation of the placenta will bleed. In the case of an advanced pregnancy this may be abundant. For this reason in advanced pregnancy a premedication with ergometrine and a local anaesthetic with a vasoconstrictor (nor-adrenaline) is recommended.

7.3 In case of a cervical implantation of the cervix (very rare, about one in a hundred thousand pregnancies) bleeding may be alarming and eventually fatal. We encountered two cases in twenty years. In both cases the patient was rapidly sent to a hospital where an emergency hysterectomy had to be done. Don't waste time with tamponade of the vagina. It only helps to keep the bed clean but bleeding continues filling up the uterus. In an emergency you may do Bekkering's Twist. This manoeuvre, described by the abortion pioneer Bekkering in the Netherlands, is done by grabbing the cervix with two tenacula or forceps and forcefully turning the uterus about ninety degrees thus closing the great uterine arteries.

Case 1: During a normal aspiration procedure the patient starts bleeding profusely. The aspiration is hurried through and ergometrine is administered to allow the uterus to contract. Bleeding becomes somewhat less but does not stop. By ambulance she is brought to hospital. The gynaecologist assumes incomplete evacuation of an advanced pregnancy. When he starts a D&C bleeding becomes abundant and a hysterectomy is done. Pathologic examination confirms the diagnosis cervical implantation of the placenta.


Case 2: A few months later exactly the same happens. The patient is sent to the same hospital this time with the suggested diagnosis cervical implantation. This is ridiculed by the (same) gynaecologist, who makes a big fuss about abortion clinics attacking advanced pregnancies. Again bleeding is profuse after the start of a an emergency hysterectomy is done. The gynaecologist maintains his objections about abortion clinics and sticks to his opinion that we attacked an eighteen weeks pregnancy. Later the pathological diagnosis reads: 'uterus containing blood but no products of pregnancy with evidence of cervical implantation of the placenta'.

7.4 In case of perforation of the uterine wall blood loss may occur if a vessel is severed. Bleeding may not be evident if the blood disappears in the abdominal cavity. Big perforations may bleed intraperitoneally. Since there is little or no vaginal blood loss such bleeding may go unnoticed till the patient collapses. This happened in the only fatal case which occurred in a Dutch Abortion Clinic:

A patient with a 16 weeks pregnancy bled slightly after the procedure. She remained in bed for observation After some two hours her condition deteriorated and she was sent to hospital. Since this was in the time that abortion was highly controversial, the hospital staff spent much time in rebuking the fact rather than treating the patient. The gynaecologist on duty quietly finished her clinic before arriving. When at last she was amended she had collapsed. A hurried venous drip with a plasma expander was installed. To speed up the drip the bottle was filled with compressed air. On the way to the theatre the drip run out and the compressed air caused an air embolism followed by the patients death. Postmortem a two centimetre defect was seen and two litres of blood was found in the abdomen. A legal procedure was eagerly started but later dismissed because death was a direct result of the hospital procedure.

7.5 Bleeding from a damaged cervix is generally not alarming. If a cervical tear involves the great vessels bleeding may be considerable. A rapid closure of the tear by stitching is necessary.

7.6 A not contracting uterus is very rare or even impossible. An empty uterus always contracts. So if a uterus seems not responding it is more likely one of the other cases. Ergometrine may be give but a thorough ultrasound scan check must be done to exclude the other possibilities.

7.7 A defective clotting mechanism may exist in the case of DIC. This situation may be present in the case of dead fetus or after instillation of hypertone saline into the amnion. In case of a dead fetus the patient should be referred to a hospital where a blood transfusion can be given, especially if the death of the fetus was caused by some earlier trial to obtain an abortion. It is a clear medical indication anyway. The diagnosis without the use of ultrasound scan may be difficult. The uterus may be quite small, so that a 25 weeks pregnancy with a dead fetus can easily be mistaken for a 12 to 14 weeks normal pregnancy. See case history elswhere

An ISAD internet survey in 1998 among 33 abortion facilities worldwide revieled the posible onset of bleeding caused by DIC from during the intervention until 10 hours after it. The best therapy is the administration of fresh frozen plasma. Testing the blood on coagulation factors ante operationem makes no sense as the fibirinogen is "consumed" during the operation.

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In the above mentioned cases blood loss starts during the procedure or shortly afterwards. But in all cases of retention bleeding may start several hours later. In case of a well contracted uterus containing retained products bleeding may be evident after relaxation of the uterus. The patient should be warned that in all cases of blood loss which is more abundant than a 'strong period' must be reported. Ideally she should come back to the clinic, or she may go to the nearest hospital.

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9. INFECTIONS - Signs of infection are fever, abdominal pain, vaginal secretion. Best treatment is a repeated aspiration procedure or D&C to empty the uterus in case of retention and to remove the infected endometrium, combined with an antibiotic course. Salpingitis may lead to sterility.

Infections are caused by

9.1 Existing infection in the vagina which is brought up with the instruments.

9.2 Negligence in maintaining sterility.

9.3 Negligence of the patient after the procedure.

9.4 Retention of placental tissue or fetal products.

9.5 Perforation.


9.1 Obviously an existent infection of the vagina can be brought up into the uterus. Ideally every patient should be screened and, if an infection is found, treated before the termination is done. This is, of course, impossible. An antibiotic course for every patient has been done in the beginning of the abortion era in the Netherlands. Every patient received a course of an broad spectre antibiotic to take at home. Soon, however, this practise has been abandoned. The incidence of infections have remained very low. Clearly the uterus is able to defend itself against infections if not too many bacteria are brought in, except in the case of retention. Cleaning the vagina is not an absolute prevention. It is impossible to sterilise the vagina, germicides like Cidex® are to toxic. A compromise is cleaning the vagina as described in Chapter 9 where also an antibiotic prophylaxis is recommended.

9.2 It is during a termination procedure practically inevitable to touch unsterile objects. Therefore a strict no-touch technique should be maintained as is described in Chapter 9

9.3 The patient should observe the recommendations to prevent infections as described in Chapter 4.

9.4 Retained products are not reached by antibiotics and form an huge load of bacteria which may infect the uterus and oviducts. Retention is discussed later [click here].

9.5 A perforation of the uterine wall may lead to infection and peritonitis, especially if there is retention of products or some other condition which favours infection. Perforation of the strongly anteflexed uterus may lead to limited bleeding in the cavum Douglasi which may go unnoticed but the haematoma may get infected, which is illustrated in the following case:

This was in pre-ultrasound days. A Spanish woman made an appointment. On examination a very tender swollen uterus was found. A pregnancy test was negative. She denied any prior intervention. An inflammation was suspected and she was sent to a hospital for examination and treatment. With a laparoscope a mass in the cavum of Douglas was found. On operation a perforation on that site was found, which started bleeding rather heavily. The uterus appeared to be of normal size. The gynaecologist managed to stitch the perforation site and arrest the bleeding. Later the patient told that a midwife in Portugal did a termination. On later examination the mass in the cavum Douglasi was interpreted as a pregnancy.

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In over 90% of cases an ectopic pregnancy is situated in one of the tubes. If the embryo does not die the tube may burst during the eighth to tenth pregnancy week. Shortly before bursting the woman may feel continuous abdominal pain, and the diagnosis may be made by ultrasound scan. In that case it is, of course, contraindicated to do an abortion, the patient must be referred for surgical treatment. Also by US before the eighth week diagnosis may be impossible.

On bimanual vaginal examination one finds an enlarged soft uterus, very much like a normal pregnant uterus. If the diagnosis is not made and the abortion procedure is started the feeling of the uterus is somewhat different than usual in a pregnant uterus, more like an empty flabby sac. The uterus contains decidua only, rather much white homogeneous material. On examination no membranes or placental tissue are found. This makes the diagnosis ectopic pregnancy certain. (The only other possibility is aspiration of a non-pregnant hemiuterus). This is one of the reasons why the necessity of macroscopic examination of the removes tissues is stressed.

That the diagnosis may be difficult is demonstrated in the following case:

A patient travelled some 1500 km for termination of her pregnancy. On bimanual examination (before we had a scanner) I found a swollen uterus and a tender adnexa. During aspiration the uterus felt like a flabby empty sac. Only some homogeneous tissue was taken. She was told that an ectopic pregnancy was expected and she was advised to go to a nearby hospital. She preferred to travel home to be seen by her own gynaecologist. I gave her a letter with concerning the case. One day later she came back. Her gynaecologist was convinced that she had a normal pregnancy. Again an aspiration was done and the little mass of tissue sent for immediate pathological examination. Again the diagnosis ectopic pregnancy was reached and again the patient refused admission. Later her gynaecologist reported that she arrived at home in great pain and that she was operated immediately for a burst tubal pregnancy.

The following case shows that a gynaecologist can not always be relied on:

A Greek woman came for abortion. The ultrasound scan showed the typical picture of a uterus with a homogeneous filling, suspect for ectopic pregnancy. When sent to a hospital the gynaecologist declared that he saw nothing abnormal. When she returned an aspiration was done, the tissue was sent for pathologic examination. The diagnosis was 'endometrium with deciduous changes'. The gynaecologist was not prepared to change his opinion. The woman decided to travel back. She collapsed in the aircraft and after landing in Athens she was rushed to a hospital where she was operated for a burst ectopic pregnancy. When the gynaecologist was confronted with this fact his lame excuse was that the pathological diagnosis was 'deciduous changes of endometrium', which he considered different from 'decidua'. About six months later she came back to the clinic This time with a normal pregnancy.

Ultrasound scan, preferably using a vaginal probe, may reveal the diagnosis. The uterus is seen filled with a homogeneous mass which shows white on the screen, lacking the typical picture of a gestational sac. No amniotic fluid (black) is seen. Only in more advanced pregnancy it may be possible to see a fetus outside the uterus. Occasionally it is possible to see a gestational sac is a young pregnancy.

It is very well possible to disrupt the ectopic by doing a bimanual vaginal examination. Typically the patient complains of a sudden sharp pain after which she collapses. That this phenomenon may occasionally occur after accidentally disrupting an ovarian cyst is shown [above].

Theoretically a patient may have a combined intra- and extrauterine pregnancy. A few cases have been reported in USA, two in the Netherlands only. Since aspiration in case of an ectopic yields rather much tissue we suspect that at least in some of the reported cases this tissue was mistaken for the products of a normal pregnancy and that the diagnosis ectopic was simply not considered.

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ll. RETENTION OF PREGNANCY - This is liable to happen in very young pregnancies or in certain uterine conditions. See Chapter 13 for further discussion.

12. LATE COMPLICATIONS - Late complications are the secondary results of complications during or after a termination and such complications which develop slowly without initial symptoms:

12.1 Sterility following salpingitis caused by infection during or after termination.

12.2 Cervical incompetence following too wide dilation or damage to the cervix. This leads to repeated spontaneous abortions because the cervix opens before term.

12.3 Asherman's syndrome if the basal layer of the uterine mucosa has been damaged by excessive curettage or by sharp bony fetal parts (notably the razor sharp bones of the skull). The bare parts of the uterine wall may form adhesions which cause dysmenorrhoea and infertility.

12.4 Placenta accreta (or increta) in successive pregnancies on the basis of such defects of the basal layer. The mechanism is described in Chapter 10

12.5 Rhesus antagonism if a Rhesus negative woman is pregnant and the fetus is Rhesus positive.To prevent this it is recommended that every Rhesus Negative patients gets an injection of Rhesus anti D-immunoglobulin after treatment.

12.6 The Post Abortion Syndrome. Not one woman has a termination for fun and every woman has an emotional crisis afterwards, the intensity is individually very different. Most women regain their balance soon, and prolonged stress is rare. But if we may believe the anti-abortion-activists almost every other woman tries to commit suicide.

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