Postabortion Hemorrhage Research Articles

Clinical outcomes and future fertility after uterine artery embolization for postpartum and post-abortion hemorrhage.

Postpartum hemorrhage (PPH) and post-abortion hemorrhage (PAH) are life-threatening conditions. To evaluate the efficacy and safety of uterine arterial embolization (UAE) for PPH and PAH and to investigate future fertility after UAE. This study included 57 consecutive patients (mean age = 34 years) who underwent UAE for PPH (n = 46) and PAH (n = 11) at our institution between January 2011 and December 2022. Technical success, non-visualization of the peripheral portion of bilateral uterine arteries on angiography, and clinical success, complete hemostasis after UAE, were assessed. UAE-associated complications and factors related to clinical success were analyzed. Pregnancy outcomes after UAE and complications during subsequent pregnancy were investigated in 16 patients who desired fertility and were followed up for >1 year. The technical and clinical success rates were 100% and 84.2%, respectively. Sepsis (n = 1) and uterine empyema (n = 1) were observed as severe complications. Placental disorder, bleeding within 24 h after delivery or abortion, ≥1.5 shock index, ≥6 units of transfusion erythrocytes, and ≥8 obstetrical disseminated intravascular coagulation score were significantly associated with unfavorable clinical outcomes. In total, 16 pregnancies were observed in 12 patients after UAE, three of which were miscarriages and 13 were successful live births. During pregnancy, uterine rupture (n = 1) and accreta (n = 1) were observed. UAE is an effective treatment for PPH and PAH. Although UAE could preserve future fertility, careful attention should be paid to perinatal management for unusual complications.

Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.

Retracted: Image Analysis Application of Motherwort Total Alkaloid Injection in the Treatment of Postabortion Hemorrhage.

[This retracts the article DOI: 10.1155/2022/8725030.].

The effectiveness of motherwort injection in preventing postabortion hemorrhage after induced abortion: A protocol for systematic review and meta-analysis.

Unintended pregnancy is a problem that women encounter throughout their reproductive age. Excessive and prolonged uterine bleeding is one of the most common and critical adverse reactions of induced abortion, for it increases the risk of anemia and intrauterine infection. To provide reliable clinical evidence, we performed a protocol for systematic review and meta-analysis to evaluate the hemostatic effect of motherwort in postabortion. This review protocol has been registered in the international prospective register of systematic reviews. The statement of Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols will be used as guidelines for reporting present review protocol. Original clinical randomized controlled trials assessing the beneficial effects and safety of motherwort on induced abortion will be included. Databases searched include China National Knowledge Infrastructure, Chinese Scientific Journals Database, Wanfang Database, China Biological Medicine Database, PubMed, and EMBASE Database and Cochrane Central Register of Controlled Trials. Cochrane collaboration tool is used to assess the risk of bias of included randomized controlled trials. All calculations are carried out with Stata 11.0 (The Cochrane Collaboration, Oxford, United Kingdom). This systematic review and meta-analysis will provide a detailed summary of the current evidence related to the efficacy of motherwort injection preventing postabortion hemorrhage after induced abortion. This evidence will be useful to practitioners, patients, and health policy-makers regarding the use of motherwort injection in induced abortion.

The effect of induction duration on postabortal hemorrhage in second-trimester pregnancy termination with misoprostol

Objective: The aim was to investigate how the duration of induction affects postabortion hemorrhage in second-trimester pregnancy terminations using misoprostol. Methods: This single-center retrospective cohort study was conducted between April 2020 and April 2021 at a university hospital. Singleton pregnant women having gestational age of 13–26 weeks and being hospitalized for termination were included in the study. The misoprostol was administered 200 µg every 4 hours intravaginally to patients already diagnosed with miscarriage, and 400 µg every 3 hours to all remaining patients. Estimated blood loss volume (EBLV) was calculated using a formula previously defined by Stafford et al. A total of 117 singleton pregnant women having gestational age of 13–26 weeks and being hospitalized for pregnancy termination were included in the study. Of these, 78 patients aborted within 0–24 hours (Group 2). The remaining 39 patients aborted in more than 24 hours (Group 1). Results: The EBLV was higher in the study group (p=0.003). In addition, the rate of patients with ≥500 cc and ≥1000 cc blood loss was also significantly higher in the study group (p values 0.049 and 0.016, respectively). After adjusting for potential confounder factors, the probability of blood loss of ≥500 cc and ≥1000 cc was found to be higher in the study group (adjusted OR: 2.720, 95% CI: 1.12–6.58 and adjusted OR: 6.987, 95% CI: 1.25–38.98, respectively). Conclusion: Postabortion hemorrhage risk was found to be higher in patients whose induction period lasted longer than 24 hours in second-trimester terminations with misoprostol. However, there was no deterioration in the patient’s clinical status and no increase in transfusion rates. Care should be taken with regard to vaginal bleeding in misoprostol applications lasting longer than 24 hours.

Image Analysis Application of Motherwort Total Alkaloid Injection in the Treatment of Postabortion Hemorrhage.

In order to reduce the possibility of postabortion hemorrhage leading to maternal death, the author studied the image analysis of postpartum hemorrhage based on Leonurus total alkaloid injection, combining research results, in order to explore the curative effect of Leonurus injection in treating postpartum hemorrhage. After treatment, the time and volume of vaginal bleeding were significantly lower than those in the control group (P < 0.05); it is suggested that the combination of oxytocin and motherwort can effectively reduce the time and volume of vaginal bleeding after medical abortion, conducive to postoperative recovery. The results show that motherwort injection can effectively reduce the amount of bleeding and reduce the risk of postpartum hemorrhage; in addition, adverse reactions have been reduced, and an image analysis consensus has been formed, which is worthy of promotion.

Large Uterine, Subserosal Hematoma as a Complication of Dilation and Evacuation Leading to Necrotic Uterine Defect and Delayed Postabortion Hemorrhage

A 23-year-old G2P0020 presented with a large anterior subserosal hematoma after dilation and evacuation at 19 weeks in the setting of anterior cervical laceration during dilator placement. Owing to...

First-Trimester Abortion Complications: Simulation Cases for OB/GYN Residents in Sepsis and Hemorrhage

IntroductionSerious complications associated with first-trimester abortions are rare. The US mortality rate for these procedures is 0.7 per 100,000, primarily due to infection and hemorrhage. While complications are unlikely to arise during training, residents must be prepared to manage them in practice. To address this, we developed a 2-hour simulation-based abortion complication curriculum for OB/GYN resident learners.MethodsOB/GYN residents participated in three sessions: a case-based didactic reviewing institutional aspiration abortion practice and preop preparation; an in-vivo aspiration abortion hemorrhage simulation; and an interdepartmental postabortal sepsis simulation. Participants completed surveys before and after their participation that evaluated clinical knowledge, and self-rated competence in, and preparedness for, managing first-trimester abortion complications.ResultsResident learners (N = 26) represented all four classes of OB/GYN residents. Residents initially showed stronger clinical knowledge in managing postabortal hemorrhage than sepsis (90% vs. 62%, p < .001). Clinical knowledge improved following the sepsis simulation (62% to 91%, p < .001), and remained strong but unchanged after the hemorrhage simulation (90% to 87%, p = .3). Resident self-assessments of competence and preparedness were significantly improved after both the hemorrhage (p = .006) and sepsis (p = .002) simulations. Learners reported that the simulation increased their level of comfort in managing these complications in their future practice.DiscussionPostabortal hemorrhage and sepsis simulations increased OB/GYN residents' knowledge, comfort, and preparedness for managing rare complications of first-trimester abortions. In-vivo simulation and interdepartmental collaboration were novel aspects of these simulations that may facilitate increased preparedness and management skills.

Hysteroscopic removal of retained products of conception withenhanced vascularity: a study of reliability

Purpose of Investigation: Retained products of conception (RPOC) is the leading cause of postpartum or post-abortion hemorrhage. RPOC showing high vascularity at ultrasound assessment (HV-RPOC) showed an enhanced hemorrhagic risk following blind surgical uterine emptying. The authors describe the clinical outcome of patients suffering from HV-RPOC undergoing hysteroscopic removal. Material and Methods: Cohort of symptomatic patients suffering from HV-RPOC following miscarriages, pregnancy terminations, and term deliveries. After ultrasound selection based on color-Doppler showing HV-RPOC, all patients underwent hysteroscopic resection. Results: Twenty-seven patients met the selection criteria. HV-RPOC were found in 14 and six women after first and second trimester pregnancy termination, respectively. In seven women RPOC were found after term delivery. In 18 women (66.6%) RPOC were found firmly adherent to myometrium. Neither intra- nor postoperative complications were recorded. Hysteroscopy follow-up was carried-out in 16 patients. Normal findings were found in 15 women, in one case a mild adhesion was observed. Conclusion: HV-RPOC are often characterized by abnormally adherent placenta, suggesting that an accreta can be an underlying etiology. A reliable management can be accomplished by hysteroscopic resection.

Uterine artery embolization for postpartum and postabortion hemorrhage: a retrospective analysis of complications, subsequent fertility and pregnancy outcomes.

To evaluate the impact of UAE for postpartum and postabortion hemorrhage on future infertility, especially in patients undergoing infertility treatment, along with angiographic endpoints. Sixty-two sessions performed emergent or prophylactic UAE for postpartum or postabortion hemorrhage between 2008 and 2017 were selected. Subsequent pregnancy outcomes and complications were investigated as primary outcomes. The cases were divided into two groups based on the presence of massive hemorrhage. The relationships between angiographic endpoints and complications were also evaluated as secondary outcomes. The mean patient age was 34.1 ± 6.5years. Fourteen of the 23 patients (60.9%) with desired fertility achieved pregnancy and 10 patients achieved live births (43.5%). In the patients during infertility treatment, three of the four patients had complications of severe adhesion after caesarean section or placenta accreta. In the group of patients with massive hemorrhage, the occurrence of uterine infection was significantly high (p = 0.014), but the angiographic endpoints were not significant, regardless of the occurrence of uterine infection. It was unnecessary to modify embolic endpoint according to seriousness of the hemorrhage. The pregnancy and live birth rates were acceptable, although patients undergoing infertility treatment had a higher rate of delivery complications.

Motherwort injection in preventing post-abortion hemorrhage after induced abortion: A multi-center, prospective, randomized controlled trial

ObjectiveThe aim of this study was to evaluate the efficacy and safety of motherwort injection (MI, Yi mu cao) in preventing post-abortion hemorrhage and promoting uterine retraction after induced abortion surgery. MethodsIn this multi-center randomized controlled trial undertaken between September 2014 and August 2016, 408 child-bearing age women who underwent induced abortion surgery and randomly assigned to two groups: MI group who received intramuscular MI treatment (n = 207) and no-treatment group (n = 201). The volume of vaginal bleeding and its duration were used as primary end points; and uterine size and dimension were measured as secondary end points. Blood coagulation indices, routine blood and adverse events were recorded to evaluate the safety. ResultsThe efficacy analysis was based on 366 patients. No significant difference were found in baseline characteristics between the two groups (P > 0.05). The amount of vaginal bleeding and duration of bleeding were significantly reduced in MI group compared with on-treatment group in Full Analysis Set (FAS) and Per Protocol Set (PPS) populations (P < 0.001). The volume and perimeter of the uterine dimensions in MI group were smaller than no-treatment group (P < 0.001). No significant abnormal vital signs were observed. Only 1 case of mild, transient erythema was found in MI group. ConclusionsMI could reduce post-abortion hemorrhage and improve uterine retraction in women undergoing surgical induced abortion, without serious adverse events. It was a safe and effective treatment in preventing post-abortion hemorrhage after induced abortion.

Laparoscopic Ligation of Uterine Vasculature for Fertility-Sparing Management of Postabortal Hemorrhage

Laparoscopic Ligation of Uterine Vasculature for Fertility-Sparing Management of Postabortal Hemorrhage

Laparoscopic Ligation of Uterine Vasculature for Fertility-Sparing Management of Postabortal Hemorrhage

Study ObjectiveTo present a surgical video in which bilateral uterine vasculature was ligated laparoscopically in order to preserve the uterus in a patient with postabortal hemorrhage. DesignA case report (Canadian Task Force classification III). SettingA tertiary referral center in New Haven, CT. InterventionsThis is a step-by-step demonstration of laparoscopic ligation of the uterine vasculature in a patient with postabortal hemorrhage. The patient was a 33-year-old Para 4014 woman who presented with postabortal hemorrhage after she underwent an urgent dilation and evacuation for the management of symptomatic placenta accreta at 19 weeks of pregnancy. The patient underwent a physical examination when she presented to the emergency department with postabortal hemorrhage. She was hemodynamically stable, and the examination was negative for cervical or vaginal lacerations. Coagulation studies were negative for any coagulopathy. A pelvic ultrasound did not show any retained products of conception. As per the Society of Family Planning guidelines, uterine massage was performed, and uterotonics (i.e., methylergonovine maleate 0.2 mg intramuscularly and misoprostol 1000 mg per rectum) were given [1]. The postabortal hemorrhage persisted despite medical therapy with an approximate blood loss of 600 mL over 2 hours. An intrauterine tamponade balloon was placed, and the patient then underwent a uterine angiogram and bilateral uterine artery embolization secondary to continued vaginal bleeding despite medical management. She was closely monitored and noted to have another 500 mL of blood loss over 2 hours after completion of uterine artery embolization. At this point, she was resuscitated with 2 U red blood cells because she developed symptoms of hemodynamic instability. Her hematocrit was increased suboptimally after transfusion with stabilization of her vitals. The patient was then counseled on her surgical options because she had failed medical management, intrauterine balloon tamponade, and uterine artery embolization. She stated a strong desire to preserve her uterus. Given her overall hemodynamic stability, laparoscopic ligation of the uterine vessels was proposed, which she agreed on [2]. Risks of the laparoscopic approach were explained to the patient, which included injury to the uterus, ureters, blood vessels, and nerves as well as the possibility of conversion to laparotomy. The surgery started with exploration of the peritoneal cavity. Her uterus was noted to be significantly enlarged with many engorged vessels. In order to decrease the risk of uterine perforation in this bulky and highly vascular uterus, the surgeon decided not to place a uterine manipulator. The retroperitoneum was entered at the right pelvic sidewall. Pararectal and paravesical spaces were then developed. Ureterolysis was performed in order to free its peritoneal and uterine artery attachments. The uterine artery was skeletonized cephalad to the hypogastric bifurcation and was ligated with 5-mm vascular clips. The attention was then turned to the ovarian vessels at the cornu of the uterus. Peritoneal avascular windows were created inferior and superior to the vessels. The blood supply was then ligated with an absorbable suture, and the ligature was secured using the extracorporeal knot tying technique. The same steps were repeated on the left pelvic sidewall. The procedure was completed once excellent hemostasis was assured. Besides the technical steps of the procedure, pelvic anatomic landmarks have also been emphasized in this video for educational purposes. Measurements and Main ResultsLaparoscopic ligation of the uterine vasculature was performed without any complications. The operative time was 65 minutes, and blood loss was minimal. The patient had an uneventful postoperative course and was discharged home the day after her laparoscopic surgery. ConclusionThe uterus was preserved with this minimally invasive approach for the management of postabortal hemorrhage. Laparoscopic ligation of the uterine vessels should be considered in hemodynamically stable patients who desire future fertility when managing postabortal hemorrhage.

Effects of gestational age and the mode of surgical abortion on postabortion hemorrhage and fever: evidence from population-based reproductive health survey in Georgia

BackgroundEvery year around 50 million unintended pregnancies worldwide are terminated by induced abortion. Even in countries, where it is legalized and performed in a safe environment, abortion carries some risk of complications for women. Findings of researchers on the factors that influence the sequelae of abortion are controversial and inconsistent. This study evaluates the effects of gestational age and the method of surgical abortion (i.e., dilatation and curettage and vacuum aspiration) on the most common abortion complications: postabortion hemorrhage and fever.MethodsWe performed a secondary analysis of the data from the population-based Georgian Reproductive Health Survey 2010. Information on 1974 surgical abortions performed >30 days prior to the survey interview were analyzed during the study. Logistic regression statistical analysis was applied to compare the abortion sequelae that followed vacuum aspiration and dilatation and curettage at different gestational ages (<10 weeks and ≥10 weeks). We examined two major early abortion-related complications: postabortion hemorrhage and febrile morbidity (fever ≥38 °C).ResultsPostabortion hemorrhage was reported in 43 cases (1.9%), and febrile morbidity occurred in 44 cases (2%) among all of the surgical abortions. The abortions performed by dilatation and curettage were associated with an estimated fourfold increased risk of developing hemorrhage (OR 4.4, 95% CI 2.2–8.6) and a twofold increased risk of developing fever (OR 2.37, 95% CI 1.17–4.79) compared with the abortions that were performed via vacuum aspiration. The risk of postabortion hemorrhage (OR 1.9, 95% CI 0.8–4.4) or fever (OR 0.9, 95% CI 0.4–2.1) did not significantly differ at gestational age < 10 weeks and ≥10 weeks.ConclusionVacuum aspiration was associated with reduced risks of postabortion hemorrhage and fever compared to dilatation and curettage. Gestational age ≥ 10 weeks was not found to be a predictive factor of immediate postabortion complications: hemorrhage and fever.

Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions.

Secondary postpartum hemorrhage (PPH) and postabortion hemorrhage are rare complications. Retained products of conception (RPOC) is among the most common causes of both secondary PPH and postabortion hemorrhage. Other less common causes of secondary PPH are uterine vascular abnormalities such as arteriovenous malformations and pseudoaneurysms. These are usually related to a history of a procedure such as dilation and curettage or cesarean delivery. Subinvolution of the placental site is an idiopathic cause of secondary PPH; this condition may be underrecognized and therefore could have a higher incidence than currently reported. Gestational trophoblastic disease is rare but commonly presents as secondary PPH and resembles RPOC in radiologic appearance. The first-line imaging modality for secondary PPH is ultrasound, but computed tomography and magnetic resonance imaging may be used if the ultrasound findings are indeterminate. Angiography is an important tool for the definitive diagnosis of uterine vascular abnormalities. Appropriate management requires radiologists to be familiar with the multimodality imaging features of secondary PPH or postabortion hemorrhage.

The Role of the Nonpneumatic Antishock Garment in Reducing Blood Loss and Mortality Associated with Post-Abortion Hemorrhage.

Maternal mortality attributable to post-abortion hemorrhage is often associated with delays in reaching or receiving definitive care. The nonpneumatic antishock garment (NASG), a low-technology first-aid device, has been shown to decrease blood loss and mortality among women experiencing hypovolemic shock secondary to obstetric hemorrhage etiologies. Women experiencing post-abortion hemorrhage face longer delays in receiving definitive treatment as a result of abortion-related stigma and lack of access to quality abortion care; thus the NASG has the potential to make an even greater impact within this population. We conducted a secondary analysis of data collected in Egypt, Nigeria, Zambia, and Zimbabwe in NASG trials, limiting our analytic sample to women who experienced post-abortion hemorrhage (n = 953). Blood loss significantly decreased when the NASG was added to standard hemorrhage management during the intervention phase, and there was a large, although not statistically significant, 52 percent decrease in mortality during the NASG phase. The results indicate that adding the NASG to post-abortion care among women experiencing severe hemorrhage and hypovolemic shock would decrease blood loss and mortality.

Successful management of a second-trimester post-abortion hemorrhage with the Bakri balloon tamponade

Hemorrhage after abortion is rare but it is a significant cause of abortion-related mortality and morbidity. Conservative managementof hemorrhage is gaining popularity. The authors describe a case which a uterine tamponade balloon which was successfully used tocontrol second-trimester post-abortion hemorrhage.

Uterine Arteriovenous Malformation: Case Series and Literature Review.

Uterine AV malformation is a rare cause of torrential post-abortal hemorrhage, which can present with varying grades of severity. Diagnosis requires a high degree of suspicion and is done with ultrasound and Doppler. In our institution, during the period 2008-2013, five cases of symptomatic uterine AVMs have been reported. All of them were in the reproductive age group (22-36years), presenting with a history of miscarriage or termination of pregnancy for which curettage was done. The presentation was with recurrent bouts of torrential bleeding, some triggered by second curettage, and not controllable with regular measures. Diagnosis was by ultrasound-gray scale, color Doppler, and spectral Doppler. The time interval between the onset of symptoms and the primary curettage was 8-89days; four patients underwent selective arterial embolization, and one patient opted for hysterectomy. On follow-up, all the four patients are presently free of symptoms; two of them conceived within 2years of the procedure and carried the pregnancy to term-one resulting in a live-birth and the other intrauterine death. Uterine AV malformation should be thought of as a differential diagnosis in all cases presenting with bleeding after miscarriage or curettage, since diagnosis is simple and treatment by selective arterial embolization saves morbidity of surgery and anesthesia, and more importantly reduces hospital stay and the absence from work.

Reproductive and gynecologic health after uterine artery embolization for postabortion hemorrhage

Reproductive and gynecologic health after uterine artery embolization for postabortion hemorrhage

P30.20: Doppler US in pre and post treatment of uterine AVM malformation: a case series

AVM of the myometrium considered a rare entity. It is believed that acquired uterine AVM is fed from a solitary vessel while congenital lesions have many feeding vessels. We show by Doppler that some acquired uterine AVM alsow can be fed by multiple feeding vessel. Case presentations: A 32 years old patient, G1P1, 2nd infertility.History of laparoscopic endometrioma cystectomy followed by IVF treatment, pregnancy and NSVD.repeated laparoscopic cystectomy for repeated giant endometrioma followed by two IVF reatment. Referred for routine Ultrasound evaluation 8 weeks post IVF treatment. The US revealed posterior wall hypo-echogenic mass with two jets flow. Color Doppler Ultrasound established the diagnosis of posterior wall AVM. The patient was treated with one selective embolization evaluated post treatment by Doppler Ultrasound. A 37 years old patient, G3P2CS2A1, with delayed post abortion hemorrhage. Six weeks post D&C she presented to the emergency room with vaginal hemorrhage. Doppler ultrasound imaging established the diagnosis of an anterior wall uterine AVM. The patient was treated with two consecutive selective embolization evaluated by Doppler US. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.