Diseases information. Disorders. Treatment.

Complications

The most common postabortal complication is a triad of pain, bleeding, and low-grade fever. Often, this complication
can be managed initially by administration of oral antibiotics and ergot preparations. However, most cases are caused
by retained gestational tissue or a clot in the uterine cavity. These symptoms are best managed by a repeat uterine
evacuation, performed under local anesthesia in an ambulatory setting.

Anesthesia

Local anesthesia is preferred because general anesthesia increases the risk of uterine perforation, visceral injury,
hemorrhage, and death. However, when local anesthesia is used, complications include convulsions, syncope, and
fever. The addition of epinephrine to the local anesthetic is contraindicated. Rarely, fatal anaphylaxis as a result of the
metabisulfite preservative in epinephrine solutions has occurred in women with asthma.

Cervical Shock

Vasovagal syncope produced by stimulation of the cervical canal can be seen after paracervical block. Brief tonic-clonic
activity rarely may be observed and is often confused with seizure. It is distinguished by the presence of a very slow
pulse, rapid patient recovery, and the absence of a postictal state. The routine use of atropine with paracervical anesthe-
sia or the use of conscious sedation prevents cervical shock.

Beyond 7 menstrual weeks of gestation, larger cannulas and vacuum sources are required to evacuate a pregnancy.
This procedure, standard vacuum curettage, is the most common method of abortion in the United States. By recent
convention, procedures performed before 13 menstrual weeks are called suction or vacuum curettage, whereas similar
procedures carried out after 13 weeks to perform mid-trimester abortion are termed D&E. Equipment, facilities, and
trained personnel to handle emergencies should be available when these procedures are performed.
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Technique

Uterine size and position should be noted during a pelvic examination performed before the procedure. Ultrasonography
is advised if there is a discrepancy of more than 2 weeks between the uterine size and menstrual dating. If not already
performed, tests for gonorrhea and chlamydia should be obtained, and the cervix and vagina should be prepared with
a germicide. Paracervical block is established with 20 mL or less of 1% lidocaine injected deep into the cervix at the
3, 5, 7, and 9 o’clock positions to form a ring of anesthetic at the junction of the cervix and lower uterine segment.
Conscious sedation can be added by using a variety of drugs. However, if conscious sedation is used, a pulse oximeter
is advised and oxygen should be available. The cervix should be grasped with a single-toothed tenaculum placed
vertically with one branch inside the canal. The uterine depth can be measured with a sound. Dilation then should be
carefully performed with a tapered dilator.
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Alternatively, hygroscopic dilators (laminaria) can be used before evacuation for a few hours or overnight. Although
these dilators require several hours to achieve cervical dilation, there is a fivefold reduction in cervical lacerations and
a threefold reduction in uterine perforations when laminaria are used instead of forcible dilation. Laminaria do not
increase postabortal infection. Synthetic dilators work faster, either by producing both dilatation and cervical softening
or only producing softening. One trial comparing a prostaglandin analogue with the synthetic hygroscopic dilators found
that the hygroscopic dilators were more effective for preparation of the cervix before first-trimester vacuum curettage.
A single rod of laminaria or a synthetic hygroscopic dilator can become entrapped by a resistant cervix and fragment
upon attempted removal. Therefore, for first-trimester procedures, two or more laminaria or a synthetic hygroscopic
dilator plus a small rod of laminaria should be used.
A vacuum cannula with a diameter in millimeters that is one less than the estimated gestational age (eg, 9-mm size
for an estimated 10-week gestation) should be used to evacuate the cavity. After the tissue is removed, there should
be a quick check with a sharp curette, followed by a brief reintroduction of the vacuum cannula. The aspirated tissue
should be examined as described previously.
The risk of infectious morbidity is lowered when antibiotics are used prophylactically with induced abortion.
Tetracycline or its analogues, doxycycline and minocycline, are probably the best of the current agents for this purpose
because of their broad spectrum of antimicrobial effect and oral absorption. D-negative patients should receive D
(Rho[D]) immune globulin before leaving the facility.
Endometrial Cancer

In the United States, about 1.5 million legal abortions are performed each year; 90% of these procedures are performedin the first trimester of pregnancy. Teenagers and women older than age 40 years have the highest abortion rates.Before 16 weeks of gestation, legal abortion as practiced in the United States may be performed safely in an office setting with simple instruments. Adequate preoperative and postoperative counseling is essential, and options to pregnancy termination should be presented.

The risk of death from first-trimester abortion is less than 1 per 100,000 abortions. The risk of death increases with
gestational age and by type of procedure. Dilation and evacuation (D&E) is safer than other options for the early mid-trimester.
Hysterotomy and hysterectomy, two procedures rarely indicated for abortion, are the least safe. General
anesthesia increases the risk of death from vacuum curettage abortion.
Maternal conditions for which termination of a desired pregnancy should be considered include cyanotic heart disease
with pulmonary hypertension, severe hypertension, previous myocardial infarction, and other comparable major
illnesses. Major anomalies and mid-trimester premature rupture of membranes are recognized fetal implications for
termination. With any maternal or fetal condition that would pose a risk to the health of the mother or fetus, the decision
should be carefully weighed by the woman in consultation with the physician.
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MENSTRUAL EXTRACTION

Sensitive pregnancy tests allow early diagnosis of pregnancy, and many women seek abortion services within 1-2 weeks
of the missed period. Abortion of these early pregnancies with a small-bore vacuum cannula is called menstrual
regulation, menstrual extraction, or minisuction. The only instruments required are a speculum, a tenaculum, a Karman
cannula, and a modified 50 mL syringe. At the end of the procedure, the tissue is rinsed and examined in a clear dish
of water or saline over a light source to detect chorionic villi and the gestational sac. This examination is performed to
rule out ectopic pregnancy and to decrease the risk of incomplete abortion.
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Ovulatory Bleeding: Menorrhagia
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Menorrhagia is defined as menstrual blood loss in excess of 80 mL per menstrual period. However, objective measurement is not practical, so the diagnosis must be made indirectly. Complicating matters is the poor association between a woman’s characterization of the amount of blood loss and the amount as measured in the laboratory. Although evaluation should include assessment for anemia, many women with measured blood losses consistently in excess of 80 mL per menstrual period are able to maintain normal hemoglobin status. The presence of anemia, however, is an objective indicator of significant blood loss and indicates the need for more urgent management. The traditional method of asking women to describe their blood loss in terms of the number of tampons and pads used per day can be supplemented with pictography. In this method, which has been shown to accurately mirror measured blood loss, women are asked to indicate which of several standardized drawings of blood-stained sanitary products best compare with their own experience.
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Both endometrial histology and the status of the endome-trial cavity may require evaluation. The purpose of the endometrial cavity assessment is to identify anatomic changes that might be causing the menorrhagia, such as endometrial polyps or submucous leiomyoma. Transvagi-nal ultrasonography, transvaginal ultrasonography with saline instillation, and hysteroscopy are the office methods commonly used. The endometrium usually can be effectively sampled by office biopsy with any of the currently available techniques.
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Ovulatory Bleeding: Not Cycle Related

Ovulatory bleeding that is not cycle related comprises a heterogeneous group of disorders that causes intermenstmal bleeding, including infection, neoplasms, genital trauma, and nongynecologic sources. Usually, bleeding in this category will be of recent onset, and the history will be suggestive of the cause. Postcoital bleeding requires evaluation of the cervix for infection (eg, chlamydia, gonorrhea) and a Pap test to determine neoplasia. The physical examination is particularly important to assess possible trauma, tumors, cervical polyps, ulceration, uterine enlargement or irregularity, adnexal masses, or evidence of inflammation. Evaluation of the uterus by biopsy and either transvaginal ultrasonography or hysteroscopy may be necessary if no cause is identified.
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Some women experience vaginal spotting at the time of expected ovulation, which perhaps is related to the brief, abrupt decline in estradiol that follows its preovulatory surge. These women should undergo a general evaluation when they present with this complaint. If the evaluation is negative and the spotting is consistent in timing and amount from month to month, no further evaluation is needed.

Patient Evaluation

History of the Present Illness

The history establishes the woman’s baseline menstrual cycle pattern and characterizes in detail the changes that led to the current consultation. The latter should include when the abnormal bleeding began; the characteristics of the new bleeding pattern; and the presence of additional symptoms such as pain, fever, or other systemic complaints. Historic features that suggest pregnancy should be elicited. The medical history should focus on current medications, birth control method, past surgery, and other gynecologic diagnoses.
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Certain problems are more likely to occur in specific age groups. For example, pregnancy and infection are more common among women under age 30 years; cancer, leiomyomas, and endometrial polyps tend to cluster in women older than age 40 years. Clotting abnormalities are most common among teenage girls with heavy menstrual bleeding. However, overreliance should not be placed on risk by age because any diagnoses may occur in any menstruating woman.
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Once a pregnancy-associated problem is eliminated, the clinician should be able to use the historic information to focus on one of the categories of the differential diagnosis. The remaining evaluation should be based on this classification.

Anovulatory Bleeding

Anovulatory episodes are commonly associated with normal events in a woman’s reproductive life cycle. After menarche, girls may not establish regular ovulatory cycles for several months. At the other end of the spectrum, some women develop anovulatory cycles as their ovarian function declines with the approach of menopause. Reestablishment of ovulation after interrupting events such as use of hormonal contraception and pregnancy is usually prompt except in two situations. Women who breastfeed will resume ovulation unpredictably; the timing is probably related to the frequency of breastfeeding. Depot medroxyprogesterone acetate, now commonly used as a contraceptive method, does not clear from the system immediately after it is discontinued, and menstruation may not resume until several months after the last injection.
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Chronic anovulation is more likely attributable to an endogenous disorder like polycystic ovary syndrome or other androgen disorders. Acute anovulation can be caused by stress, intercurrent illness, medication use (eg, spironolactone), or endocrine disturbances (eg, prolactinoma, adrenal hormone excess, thyroid hormone problems).

The major focus of the patient evaluation should be to identify any underlying cause of the ovulatory dysfunction. This will involve the measurement of various hormones (eg, gonadotropins, androgens, adrenal and thyroid hormones), with the specific selection depending on the clinical presentation. In addition, women with longstanding anovulation should be assessed for endometrial hyperpla-sia and anemia.
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Pregnancy
Ectopic pregnancy
Trophoblastic disease
Abnormal intrauterine pregnancy
Anovulatory
Transient anovulation
Polycystic ovary syndrome
Androgen disorder
Ovarian tumor
Adrenal tumor
Thyroid disorder
Ovulatory: Menorrhagia
Idiopathic
Endometrial polyp
Submucous leiomyoma
Coagulopathy (yon Willebrand’s disease, iatrogenic
cause, hematologic malignancies) Intrauterine device
Ovulatory: Not Cycle Related
Injury
Intravaginal foreign body
Endometritis
Cervicitis
Cancers of endometrium, cervix, vagina, or vulva latrogenic secondary to sex steroid use (eg, oral contraceptive)
Nongenital tract: bladder, kidney, colon, or rectum

Terminology of Abnormal Vaginal Bleeding Ovulatory

Menorrhagia/hypermenorrhea–heavy flow (>80 mL), longer flow (>7 days), or both
Intermenstrual bleeding–bleeding between otherwise-normal menses
Midcycle bleeding–bleeding at time of expected ovulation
Premenstrual spotting–light bleeding preceding regular menses
Polymenorrhea–periods too close together (<21 days)
Anovulatory
Metrorrhagia–irregular bleeding at frequent intervals
Menometrorrhagia–irregular heavy bleeding
Oligomenorrhea–bleeding at intervals of >40 days
Amenorrhea–no bleeding for at least 90 days
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