Postabortion hemorrhage: Prevention and management

Last reviewed: September 28, 2022

Recommendation:

• Clinicians should consider measures to prevent or prepare for increased bleeding in individuals who are at high risk for hemorrhage and are undergoing abortion.
• Hemorrhage caused by atony may be treated with uterine massage, uterotonic medications, re-aspiration, tamponade or surgery.
• Closely monitor hemorrhaging individuals for signs of shock.

Strength of recommendation: Strong

Quality of evidence: Low

Epidemiology

The Society for Family Planning defines postabortion hemorrhage as excessive bleeding that requires a clinical response such as transfusion or hospital admission, and/or bleeding in excess of 500mL (Kerns & Steinauer, 2013). Hemorrhage after induced abortion is rare, occurring in 0-3 per 1,000 cases following medical abortion up to 9 weeks gestation or vacuum aspiration before 13 weeks gestation, and 0.9-10 per 1,000 cases following uterine evacuation at or after 13 weeks gestation (Kerns & Steinauer, 2013; Kerns et al., 2019; Upadhyay et al., 2014). Causes of bleeding include placenta previa or accreta, uterine atony, retained products of conception, cervical or vaginal laceration, uterine injury, and coagulopathy (Kerns & Steinauer, 2013; Perriera, Arslan, & Masch, 2017).

Prevention

All individuals presenting for abortion care should be asked about aspects of their medical history associated with increased risk for bleeding. That includes a review of obstetric complications – especially hemorrhage, having had two or more cesarean deliveries, a bleeding disorder, gestational age of more than 20 weeks, fetal death, obesity, increased maternal age, and placenta previa or accreta (Kerns & Steinauer, 2018; Kerns et al., 2019; Whitehouse et al., 2017). Providers may consider measures to prevent or prepare for increased bleeding —such as assessing a preabortion hemoglobin or hematocrit, ensuring uterotonic medications are readily available, preparing for possible transfusion, or referral to a higher-level facility—although there is little evidence to guide practice (Kerns & Steinauer, 2018). In one randomized trial, addition of four units of vasopressin to a preprocedure paracervical block significantly decreased blood loss during dilatation and evacuation procedures and reduced the incidence of postabortion hemorrhage when compared to placebo (Schulz, Grimes, & Christensen, 1985). This effect was larger at later gestational ages. Administration of prophylactic oxytocin or syntocinon (five or 10 units) has not been shown to decrease postprocedure bleeding following first-trimester vacuum aspiration in a clinically meaningful way (Nygaard et al., 2010; Ali & Smith, 1996). When administered prior to dilatation and evacuation (D&E) procedures performed between 18-24 weeks, 30 units of oxytocin decreased blood loss and the incidence of hemorrhage compared to placebo (Whitehouse et al., 2019). Methylergonovine, a medicine commonly administered prophylactically to prevent excessive bleeding after D&E, was found to increase, rather than decrease, bleeding when administered prophylactically immediately after D&E at 20-24 weeks (Kerns, et al., 2021).

Diagnosis

When postabortion hemorrhage is suspected, clinicians should take a rapid, systematic approach to assessment and treatment. Initial assessment includes inspection of the cervix for laceration, bimanual examination to assess for uterine atony and tenderness, and uterine aspiration or ultrasound examination to evaluate for retained products of conception or blood.

Management

Cervical lacerations may be treated with direct pressure with gauze or ring forceps, application of topical clotting agents (silver nitrate or ferric subsulfate solution), or by placing absorbable sutures.

Uterine atony requires a rapid, sequential response starting with uterine massage, followed by uterotonics, re-aspiration, uterine tamponade and finally surgical measures. Clinicians should move quickly to the next step if bleeding is not controlled. When uterotonic medications are used, additional or repeat doses may be used if bleeding does not improve after the first dose.

Uterotonic medications and dosages:*

*Extrapolated from postpartum data (American College of Obstetricians and Gynecologists, 2017; Kerns & Steinauer, 2013; Mavrides et al., 2016; Morris et al., 2017; Prata & Weidert, 2016; World Health Organization, 2020).

If tamponade is used to stop bleeding, the Foley balloon, obstetric balloon, gauze or inflated condom catheter should be left in place for several hours while the patient is observed. If the patient remains stable after the balloon or gauze is removed, they may be discharged.

When bleeding continues after assurance of complete uterine evacuation and no visible lacerations, providers must consider other complications, such as perforation, coagulopathy or placenta accreta (National Abortion Federation, 2022). If coagulopathy, such as disseminated intravascular coagulation, is present, blood products may be required. Surgical measures including hysterectomy, uterine compression sutures, uterine artery ligation or uterine artery embolization can be performed for severe bleeding that cannot be controlled by other measures. Providers at health centers without available operating theaters or expertise should have clear protocols for resuscitation and transfer to a higher level of care. Individuals at risk of shock require intravenous line placement, supplemental oxygen, fluid resuscitation and replacement of blood products as indicated.

Methylergonovine, a medicine commonly administered prophylactically to prevent excessive bleeding after D&E, was found to increase, rather than decrease, bleeding when administered prophylactically immediately after D&E at 20-24 weeks (Kerns, et al., 2021).

References

Ali, P.B. & Smith, G. (1996). The effect of syntocinon on blood loss during first trimester suction curettage. Anesthesia, 51, 483-485.

American College of Obstetricians and Gynecologists. (2017). ACOG Practice Bulletin Number 183: Postpartum hemorrhage. Obstetrics & Gynecology, 130(4), e168-e186.

Kerns, J.L., Pearlson, G., Mengesha, B., Harter, K., Jackson, R.A. & Drey, E.A. (2021). A randomized controlled trial of methylergonovine prophylaxis after dilation and evacuation abortion. Contraception, 103(2), 116-120.

Kerns, J. & Steinauer, J. (2013). Society of Family Planning Clinical Guideline 20131: Management of postabortion hemorrhage. Contraception, 87(3), 331-42.

Kerns, J., Ti, A., Askel, S., Lederle, L., Sokoloff, A., & Steinauer, J. (2019). Disseminated intravascular coagulation and hemorrhage after dilation and evacuation abortion for fetal death. Obstetrics & Gynecology, 134(4), 708-713.

Lauerson, N. H., & Conrad, P. (1974). Effect of oxytocic agents on blood loss during first trimester suction curettage. Obstetrics & Gynecology, 44(3), 428-433.

Mavrides, E., Allard, S., Chandraharan, E., Collins, P., Green, L., Hunt, B. J., … on behalf of the Royal College of Obstetricians and Gynaecologists. (2016). Prevention and management of postpartum hemorrhage. BJOG: An International Journal of Obstetrics & Gynaecology 124, e106-e149.

Morris, J. L., Winikoff, B., Dabash, R., Weeks, A., Faundes, A., Gemzell-Danielsson, … Visser, G. H. A. (2017). FIGO’s updated recommendations for misoprostol used alone in gynecology and obstetrics. International Journal of Gynecology & Obstetrics, 138(3), 363-366.

National Abortion Federation. (2022). Clinical Policy Guidelines. Washington DC: National Abortion Federation.

Nygaard, I. H. H., Valbo, A., Heide, H. C., & Kresovic, M. (2010). Is oxytocin given during surgical termination of first trimester pregnancy useful? A randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica, 90, 174-178.

Perriera, L. K., Arslan, A. A., & Masch, R. (2017). Placenta previa and the risk of adverse outcomes during second trimester abortion: A retrospective cohort study. Australian and New Zealand Journal of Obstetrics and Gynaecology, 57(1), 99-104.

Prata, N., & Weidert, K. (2016). Efficacy of misoprostol for the treatment of postpartum hemorrhage: Current knowledge and implications for health care planning. International Journal of Women’s Health, 8, 341-349.

Schulz, K. F., Grimes, D. A., & Christensen, D. D. (1985). Vasopressin reduces blood loss from second-trimester dilatation and evacuation abortion. The Lancet, 2, 353-356.

Upadhyay, U., Desai, S., Zlidar, V., Weitz, T. A., Grossman, D., Anderson, P., & Taylor, D. (2014). Incidence of emergency department visits and complications after abortion. Obstetrics & Gynecology, 125, 175-183.

Whitehouse, K., Tschann, M., Davis, J., Soon, R., Salcedo, J., Friedlander, E., & Kaneshiro, B. (2017). Association between prophylactic oxytocin use during dilation and evacuation and estimated blood loss. Contraception, 96, 19-24.

Whitehouse, K., Tschann, M., Soon, R., Davis, J., Micks, E., Salcedo, J., … & Kaneshiro, B. (2019). Effects of prophylactic oxytocin on bleeding outcomes in women undergoing dilation and evacuation. Obstetrics & Gynecology, 133(3), 484-491.

World Health Organization. (2020). WHO recommendation on routes of oxytocin administration for the prevention of postpartum haemorrhage after vaginal birth. Geneva: World Health Organization.