Abortion Services in New Zealand

Risks of abortion

Possible complications and risks of surgical abortion
Possible side effects and complications of medical abortion
Second trimester medical abortion risks

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Possible complications and risks of surgical abortion

Early abortion (under 12 weeks from the time of the last normal menstrual period) is one of the safest procedures carried out in hospitals and clinics throughout the world. There is very little risk associated with abortion, particularly in early pregnancy. In the first 20 weeks, abortion is much safer than giving birth. There is no evidence to suggest a straightforward abortion has any effect on future fertility or any other aspect of general health.

There are however a small number of possible complications:

Extra bleeding

If extra bleeding occurs during the operation or just after it may be necessary to give an injection to slow it down. Occasionally, an intravenous drip line is required and this may mean a longer stay in hospital. Very rarely a blood transfusion is required. Smokers are at an increased risk of excess bleeding [1]. Extra bleeding may also occur after the operation. If this is heavier than a period or is associated with abdominal pain a doctor should be contacted. This happens in about 4% of women after an abortion [2].

Retained tissue or clots

Occasionally, the uterus does not contract during the operation as it should do, and so some tissue or blood clot is left inside. If this happens there may be extra cramps or pain with bleeding which gets worse over 24-48 hours. If the pain increases steadily after the operation a doctor should be consulted.

Infection (endometritis)

This causes fever (feeling hot and sweaty) and pain in the lower abdomen sometimes with heavier bleeding or an offensive vaginal discharge. It may happen 2-7 days after the operation. An infection requires antibiotic treatment from a doctor to prevent more serious infection which may affect fertility (the ability to have children in the future). The risk of infection is from 3-6% after termination [2]. Diagnosis and treatment of any pre-existing infection such as Chlamydia will reduce the risk of infection. Some doctors give routine antibiotics to reduce the risk of infection.

Allergic reactions

Reactions to the local anaesthetic or other drugs used are rare. Patients must tell health professionals what medications or recreational drugs they are taking to make sure they do not react with medications given in the clinic. An allergic reaction usually shows up as a rash on the skin and settles within 12-24 hours. Very rarely the reaction may be severe and cause trouble with breathing. If this occurs it will usually happen within minutes of taking the drug. The doctor may need to delay the operation and will give an injection to relieve the symptoms. It may be that the woman will need to spend more time than expected in the clinic or transfer to another hospital on the day of operation because of this.

Perforation of the uterus (womb)

As the cervix (neck of the womb) is dilated in about 1-4 in 1000 cases the instrument used passes through the uterine wall [3]. It may be necessary to repair the uterus under a general anaesthetic. If the bladder or bowel has been damaged they will also be repaired.

Failed abortion (continuing pregnancy)

This is rare, occurring in about 0.2% of cases (1 in 1000) [4]. This can happen due to unusual conditions: there can be more than one chamber in the uterus or the pregnancy may not be in the uterus.

Psychological complications

Abortion rarely causes lasting negative consequences and there may be positive outcomes. However, the following factors may be associated with an adverse outcome - prior psychiatric illness, late gestation, personality traits such as low self-esteem, dependency or conflict with religious and cultural beliefs.

Severe complications

These are rare in the first trimester (up to 12 weeks). If damage to major vessels occurs, with severe haemorrhage, hysterectomy may be required. Pulmonary embolus (a clot on the lung) is a rare complication. Death occurs in approximately 0.7 per 100,000 but again this is more likely to follow a late abortion. In New Zealand, since accurate statistics have been collected in 1980 there have been no deaths dierctly attributable to the abortion procedure. Total number of abortions from 1980 to 2011 are 354,824.

Possible side effects and complications of medical abortion

Side effects are an expected part of medical abortion [5]. Some arise from the abortion process itself and some from the medication. Complications of medical abortion usually represent an extreme or severe side effect.

Pain

90% of women experience abdominal cramps [6], [7] but the severity varies from patient to patient. Many women do not request any form of pain relief, but some require medication.

Pain is modified by factors such as fear and anxiety. Full preliminary information and support during the procedure can modify pain.

Women can be offered pre-misoprostol pain relief, oral paracetamol, codeine or an NSAID (Non-steroidal anti-inflammatory drug); alternatively pain relief can be offered as required. There are side effects particularly from codeine (light-headedness or dizziness, sedation, nausea and vomiting).

Oral analgesics or NSAIDs will be sufficient to control the pain most women experience, but some may require a stronger narcotic such as Pethidine or Fentanyl given as an intramuscular or intravenous infection. Many women are happy to stay in a clinic during the medical abortion so that stronger pain relief is available. In the US most women are at home for this part of the procedure and manage with only oral medication.

For severe persistent pain it is important to exclude other causes such as ectopic pregnancy (see below).

Bleeding

This is a normal consequence of the abortion process but may exceed the woman's previous experience of bleeding. [8] As with pain management, informing women in advance what to expect is essential.

Surgical intervention for excessive bleeding is required in less than 1% of first trimester medical abortions. About 0.4% (4 in 1000) require an emergency surgical procedure because of bleeding and 0.2% (2 in 1000) require a blood transfusion [9] [7].

Practical considerations

The heaviest bleeding usually occurs at the time of expulsion of the sac/fetus. In a small proportion of women (2-5%) [9] this will be within the 48 hours following the "abortion pill" known as mifepristone or by the trade name in New Zealand Mifegyne®. About 50% of women will experience some bleeding during this time.

On Day 2 of the procedure the abortion may take place within 30 minutes of the administration of another drug or it may be delayed for 4-6 hours. This second drug is a prostaglandin, usually misoprostol, known also by the trade name Cytotec®. Most women are able to recognise the passage of the fetal sac.

Excessive bleeding at this time may need an injection of an oxytocic drug such as Syntocinon® (about 1.5% [9]). If bleeding soaks through two thick full-size sanitary pads per hour for two consecutive hours the woman will need to be assessed further by a doctor.

Bleeding at home post-abortion

Bleeding after medical abortion is commonly more prolonged than after surgical abortion [8] and lasts up to 3 weeks. Despite this, women seldom become anaemic [10].

The woman should contact her on-call nurse/doctor if bleeding is heavy enough to soak through two thick full-size sanitary pads per hour for two consecutive hours [11]. The size of the clots and how the woman feels are also important to consider. If there is concern prompt admission to hospital is advised.

Ultrasound examination can rule out an ongoing pregnancy but does not assist at this stage in assessing whether there are other retained products which require surgery. [11] Surgical termination is therefore only needed for the reasons given below.

The sort of questions patients will be asked by the nurse/doctor on call will be:

The woman may need to have a surgical abortion if there is one or more of the following: [5]

Failed abortion (continuing pregnancy)

Medical abortion fails in 2-5% of cases. Because of the risk to the fetus of drugs taken for medical abortion it is essential to ensure that products have been passed and that the pregnancy is not ongoing.

This is assessed by:

Incomplete abortion

As with surgical suction curettage a small percentage of women will have incomplete expulsion of the pregnancy tissue after an early medical termination. If bleeding is not excessive there is no need to urgently intervene.

Symptoms can include prolonged and irregular bleeding episodes. An ultrasound examination helps to exclude a failed abortion but as with ultrasound after surgical abortion, cannot reliably tell whether there are retained products of conception [12] [13].

The indications to intervene surgically are listed above.

Gastrointestinal side effects

Nausea and vomiting are common at this stage of pregnancy. An increase in the nausea, with vomiting and diarrhoea are common after the misoprostol although less common when the drug is inserted into the vagina rather than taken by mouth [14]. These symptoms are usually self-limiting.

Drugs like Maxolon® or Buccastem® are useful to manage severe nausea and vomiting. Diarrhoea can be a problem for some women and a recent study showed a drug called loperamide can help this [15].

Headache, dizziness and fever

Headache and dizziness are usually mild and self-limiting. Dizziness may be a side effect of any of the medications or a response to the abortion process. Unless associated with excessive bleeding this symptom is best managed with rest, drinking plenty, slow position changes and assistance with moving around [5].

Hot flushes and sensations of warmth or fever are also fairly common side effects of medical abortion. They can be a reaction to either mifepristone or misoprostol. These symptoms are usually short-lived and resolve spontaneously. A temperature exceeding 38℃ that persists for several hours warrants evaluation for infection.

Infection

Endometritis is a rare complication of medical abortion, especially if patients are screened and treated for STIs. If there is persistent lower abdominal pain, with or without irregular bleeding or fever, in the days after the pregnancy tissue is passed, a doctor should be consulted as these are symptoms of possible infection or incomplete abortion [5]. Antibiotics may be needed if there is infection. In the USA there have been rare fatal infections due to toxic shock syndrome.

Ectopic (tubal) pregnancy

An undiagnosed ectopic pregnancy is a most dangerous complication of early pregnancy. Every effort must be made before the TOP to exclude an ectopic pregnancy. However, some will be missed. If no products are seen either with medical abortion or on suction curettage then follow-up to exclude ectopic must be done.

If severe, prolonged pain is experienced with a medical abortion a doctor must be consulted.

Teratogenicity (risk of fetal damage by the drugs)

This is an issue if a woman changes her mind after either Mifegyne® or Mifegyne® and misoprostol.

Evidence suggests that misoprostol may result in congenital anomalies when used during the first trimester of pregnancy (both limb abnormalities and a syndrome called Moebius sequence [16]).

Second trimester medical abortion risks

Risk of complications are similar to those listed above for early medical abortion except for ongoing pregnancy.

Most risks are greater with a later pregnancy and more like the risks associated with childbirth.

References:

  1. Heisterberg, L. and M. Kringelbach, Early complications after induced first-trimester abortion. Acta Obstet Gynecol Scand, 1987. 66(3): p. 201-4.
  2. Sawaya, G.F., et al., Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta-analysis. Obstet Gynecol, 1996. 87(5 Pt 2): p. 884-90.
  3. Induced abortion operations and their early sequelae. Joint study of the Royal College of General Practitioners and the Royal College of Obstetricians and Gynaecologists. J R Coll Gen Pract, 1985. 35(273): p. 175-80.
  4. Kaunitz, A.M., et al., Abortions that fail. Obstet Gynecol, 1985. 66(4): p. 533-7.
  5. Kruse, B., et al., Management of side effects and complications in medical abortion. Am J Obstet Gynecol, 2000. 183(2 Suppl): p. S65-75.
  6. Spitz, I.M., et al., Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med, 1998. 338(18): p. 1241-7.
  7. Schaff, E.A., et al., Low-dose mifepristone 200 mg and vaginal misoprostol for abortion. Contraception, 1999. 59(1): p. 1-6.
  8. Harper, C., et al., Blood loss with mifepristone--misoprostol abortion: measures from a trial in China, Cuba and India. Int J Gynaecol Obstet, 1998. 63(1): p. 39-49.
  9. Ashok, P.W., et al., An effective regimen for early medical abortion: a report of 2000 consecutive cases. Hum Reprod, 1998. 13(1O): p. 2962-5.
  10. Harper, C., et al., Provision of hormonal contraceptives without a mandatory pelvic examination: the first stop demonstration project. Fam Plann Perspect, 2001. 33(1): p. 13-8.
  11. Creinin, M. and E. Aubeny, Medical Abortion in early pregnancy, in A Clinician's guide to medical and surgical abortion, P. Stubblefield, Editor. 1999, Churchill Livingstone: New York. p. 91-106.
  12. Wolman, I., et al., Transvaginal sonohysterography: a new aid in the diagnosis of residual trophoblastic tissue. J Clin Ultrasound, 1996. 24(5): p. 257-61.
  13. Dillon, E.H., et al., Endovaginal US and Doppler findings after first-trimester abortion. Radiology, 1993. 186(1): p. 87-91.
  14. el-Refaey, H., et al., Induction of abortion with mifepristone (RU 486) and oral or vaginal misoprostol. N Engl J Med, 1995. 332(15): p. 983-7.
  15. Jain, J.K., et al., Early pregnancy termination with vaginal misoprostol combined with loperamide and acetaminophen prophylaxis. Contraception, 2001. 63(4): p. 217-21.
  16. Gonzalez, C.H., et al., Limb deficiency with or without Moebius sequence in seven Brazilian children associated with misoprostol use in the first trimester of pregnancy. Am J Med Genet, 1993. 47(1): p. 59-64.

Last Updated: 9 February 2013