chapter10.htm

Chapter 10 (by Eugene Glick)

Complicated Pregnancies

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.

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 pregnancy.

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 (Hanson Maneuver) during evacuation.

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.

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 additions:

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.

Back-up Hospitalization

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.

Note:

1. Have the ability to admit that you and your patient may be in trouble.

2. Have a well defined plan to transfer the patient to the hospital for care by a designated individual.

Conclusion

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 know.

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

REFERENCES

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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