CHAPTER 12 - COMPLICATIONS
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.
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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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3. PERFORATIONS OF THE
UTERUS -
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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4. RETENTION OF TISSUE
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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5.RETENTION OF FETAL PARTS
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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6.INTRA UTERINE BLOOD
LOSS
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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7. DIRECT BLOOD LOSS
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
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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8. DELAYED BLOOD LOSS
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.
9.1 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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10.ECTOPIC PREGNANCY
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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last revision spring 2010