Module 3: Early surgical abortion theory
6. Management of complications and aftercare
Management of complications
Complications of an early surgical abortion using vacuum aspiration are uncommon. They include: anaphylaxis, cervical shock, haemorrhage (< 1%), incomplete evacuation (often not diagnosed at the time), ongoing pregnancy and perforation of the uterus.
All facilities providing early surgical abortion care must have a management plan for these complications prior to commencing provision of services.
Click here for examples of emergency plans that can be used as templates.
Clinics should have hospital transfer plans outlining the means of communication and transport and the protocol for emergency transfer of care.
Anaphylaxis: follow the Australian and New Zealand Committee on Resuscitation (ANZCOR) guideline.
Cervical shock: stimulation of the vagal nerve with cervical dilatation/stimulation can result in a significant reduction in heart rate leading to bradycardia and thus low blood pressure presenting as loss of consciousness and if there is inadequate cerebral perfusion a self-limiting seizure as the bradycardia resolves.
Symptoms and signs of vasovagal syncope include complaints of feeling faint/dizzy/lightheaded, a slow pulse rate < 60 bpm, low blood pressure, pale appearance with sweating, nausea and less commonly vomiting followed by a loss of consciousness.
Use a resuscitation approach ABCDE – and STOP any instrumentation of the cervix.
Bradycardia associated with cervical shock is managed with atropine administered intravenously 500 – 600 micrograms (comes in 600 microgram 1 mL vials in New Zealand) repeated as necessary every 3 – 5 minutes up to a total dose of 3 micrograms. Call for emergency assistance after two doses.
Haemorrhage: excessive bleeding during an early surgical abortion should be managed by emptying the products of conception from the uterus to enable the uterus to contract.
Ecbolics can be used to make the uterus contract once the uterus is empty if bleeding continues. As oxytocin receptors do not develop early in pregnancy ergometrine intramuscular (IM) is more effective than oxytocin IM/IV however ergometrine can precipitate vomiting and hypertension. Misoprostol sub-lingual (SL)/rectal (PR) administration and Carboprost IM are also effective. You must be familiar with the doses (Table 6) and contraindications to all medicines you are prescribing. If bleeding does not resolve then consider if the cause is an injury to the uterus or cervix; these require surgical management. For patients who have contraindications to ecbolics (N.B. These cases should be performed in a hospital with an experienced anaesthetist present), bimanual compression and insertion of a foley catheter with 20 – 30mL of saline in the balloon to tamponade the internal walls of the uterus can be an alternative. Timing of removal should be based on clinical environment and resolution of haemorrhage.
Incomplete evacuation: if the uterus is not feeling empty and you have point of care ultrasound then complete the procedure under ultrasound. Always consider perforation as a possible cause. Sometimes procedures take longer than expected and as long as you are in the cavity and there are products of conception being evacuated continue.
Perforation of the uterus is important to diagnose. Do not put suction on until you are at the fundus. If you do not feel the fundus, STOP and follow your pathway for perforation management. If you have a point of care ultrasound keep the canula in place and assess where the canula is and take an image. Perforation of the uterus is an emergency; you must follow your preprepared emergency pathway for management.
Tables 6, 7 and 8 provide an overview of the medicines and management approaches used in emergency situations relating to early surgical abortion.
Table 6. Uterotonics for haemorrhage following early surgical abortion.
*Some medicines are available on PSO. Medicines marked with an asterisk are recommended but not available on PSO.
Table 7. Emergency medicines used for managing complications associated with early surgical abortion.
Medicine |
Dose |
Used for: |
Atropine sulfate |
600 micrograms/mL IV every 3 – 5 minutes. Maximum dose 3 mg |
For prolonged symptomatic bradycardia with vasovagal CALL FOR EMERGENCY HELP if it persists after the second dose |
Tranexamic acid* |
1 g IV |
For control of haemorrhage whilst transferring to emergency care. Not available on PSO. |
Adrenalin 1:1000 |
0.5 mg (1 mg/mL) IM. Repeat doses at 5 – 15 minute intervals as necessary. |
For anaphylaxis. Preferable to inject in mid-anterolateral thigh |
Naloxone |
0.1 mg – 0.2 mg (0.25 – 0.50 mL) IV/IM every 2 – 3 minutes. Maximum dose 0.4 mg. |
Opiate antidote |
Flumazenil* |
0.2 mg (2 mL) IV every minute.
Maximum dose 1 mg |
Benzodiazepine antidote. Not available on PSO. |
*Some medicines are available on PSO. Medicines marked with an asterisk are recommended but not available on PSO.
Table 8. Emergency management chart for complications associated with early surgical abortion.
MAINTAIN CLIENT SAFETY ● CALL FOR HELP ● ASSESS PATIENT CONDITION |
- Recent exposure
- Hives
- Coughing/ sneezing
- Low pulse
- Flushed / agitated
- More severe: shortness of breath
|
- High pulse
- Cool, clammy skin
- Low blood pressure
- Perioral cyanosis
- Onset over minutes or hours
- Rare syncope
|
- Low pulse
- Low blood pressure
- Pale, sweaty
- Cool, clammy skin
- Nausea, vomiting
- May lose consciousness
- Sudden onset
|
- Unresponsive
- No pulse
- Absent respirations
|
- Rhythmic limbs, jaw movements
- Pulse > 60 bpm
- Possible incontinence
|
- Anxious
- Rapid, shallow breathing
- Normal pulse
- Numbness
- Carpal-pedal spasm
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ANAPHYLAXIS |
HYPOVOLEMIC SHOCK |
VASOVAGAL REACTION (Neurogenic Shock) |
CARDIO-PULMONARY ARREST |
SEIZURE |
HYPER-VENTILATION |
- Adrenaline mg 1:1000 0.5 mL IM
- Oxygen
- Instigate your emergency plan
|
- Instigate your emergency plan
- Elevate legs
- Place large bore IV, infuse NS rapidly
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- Keep supine
- Elevate legs
- Cool cloth/ice pack
- Oxygen
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- Prevent injury
- Lateral position to protect airway
- Let seizure run its course
- Oxygen
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- Reassure patient
- Slow-count breathing
- Place paper bag over mouth to rebreathe CO2
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If low BP:
- Start IV, lactated ringers solution or normal saline
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Evaluate cause and manage
Start 2nd IV line |
If persistent symptomatic bradycardia:
- Give Atropine 600 micrograms IV
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If continues > 2 minutes, Instigate emergency plan
Give Midazolam 10 mg IM |
Ensure patient is stable before leaving the clinic |
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Instigate your emergency plan |
Repeat once within 5 minutes, if needed |
After care/Poroaki
New Zealand Aotearoa Abortion Clinical Guideline 2021:
- Recommendation 5.2.1: “Following abortion, give verbal and written information on what to expect. See Table 1: Information for people considering an abortion in Appendix B.”
- Recommendation 5.4.1: “Consider selective follow-up with their health practitioner for people who:
- are at risk of (or develop) complications
- still need contraception
- may need ongoing mental health support
- are living with complexities
- are young, or
- request follow-up.”
Ensuring the person has all the support structures they need is important in abortion care. This includes informing them of the availability of counselling support services.
Provide a letter detailing their care to the person and what to expect and when and how to seek further advice. Many systems automatically upload electronic discharge letters to general practitioners. You must have consent from the person to share their health information with other health providers and many people will choose not to share their abortion information, and this must be facilitated.
The majority of people will not need any further intervention after an early surgical abortion, but they must be provided with information on what to expect and when to seek further advice or emergency care. For a patient information leaflet, click here.
Advise the person that they:
- Can expect to bleed off and on for up to two weeks
- May have cramps and can pass blood clots for up to two weeks; ibuprofen can help
- There is no evidence that it is harmful to use a menstrual cup or tampon after an abortion, but pads make it much easier to see how heavy the bleeding is
- Should consult a health practitioner if they soak more than two pads in 20 minutes for more than two hours, if they have increasing heavy bleeding or pain, or if they develop a fever.
Table 9 lists potential post-procedural medicines that can be considered for analgesia for patients.
Table 9. Post-procedure medicines following early surgical abortion.
Medication |
Dose |
Comments |
Codeine* |
30 – 60 mg, every four hours. Maximum dose 240 mg every 24 hours. |
Equivalent medicines can also be used. Not available on PSO. Give < 5 day supply. |
Tramadol* |
50 – 100 mg (IR), every four hours. Maximum dose 400mg every 24 hours. |
Equivalent medications can also be used. Not available on PSO. Give < 5 day supply. |
Paracetamol |
1 g, four times daily, as needed. Maximum 4 g every 24 hours. |
Give 2 weeks supply |
Ibuprofen* |
400 mg, four times daily, as needed. Maximum dose 2.4 g every 24 hours. |
Equivalent medicines can also be used. Not available on PSO. Give 2 weeks supply. |
*Some medicines are available on PSO. Medicines marked with an asterisk are recommended but not available on PSO.
Some people having an abortion may request or require follow-up and this must be facilitated. Depending on who and where the abortion care is being provided the follow up may be with the abortion provider or arranged with a more appropriate health practitioner, for example their general practitioner if they are not the provider.
