Management of Hemorrhage at the Time of Abortion

Publication Date: September 18, 2023
Last Updated: January 19, 2024

Clinical Recommendations

While clinical practices vary, we recommend checking a preoperative hemoglobin or hematocrit level for individuals undergoing later abortion to appropriately assess and manage blood loss (GRADE 1B). We suggest consideration of preoperative hemoglobin for first-trimester medication or procedural abortion in individuals with a history of anemia. (2, B)
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We recommend referral to a higher-acuity site for people with a diagnosis of or concern for PAS or cesarean scar ectopic pregnancy. (1, B)
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We recommend the decision to undergo medication or procedural abortion be patient driven. (1, A)
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We suggest using a lower threshold to intervene for bleeding in the setting of procedural abortion for spontaneous fetal demise as the risk of hemorrhage is increased. (2, C)
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We recommend clinicians identify placental location in all people with a uterine scar who are presenting for second-trimester abortion and, if a complete previa is seen, perform a detailed evaluation with ultrasound. (1, A)
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We recommend ultrasound as the imaging modality for the evaluation of placenta accreta, but the absence of ultrasound findings does not preclude a diagnosis of PAS. Clinical risk factors are equally important as predictors of PAS. (1, A)
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Preoperative UAE may be more useful in settings where emergent UAE is not readily available; therefore, we suggest that the decision to use preoperative UAE be made on a case-by-case basis by the clinician. (2, B)
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We recommend avoiding the use of methylergonovine as a prophylactic agent for procedural abortion at 20 to 24 weeks. (1, A)
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We recommend the use of prophylactic oxytocin in settings where increased bleeding is of concern. (1, A)
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We recommend the routine use of vasopressin during procedural abortion but recognize that the cost may be prohibitive. (1, B)
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While there are insufficient data to recommend the routine use of ultrasound in second-trimester abortion, we suggest that clinicians consider its use when anticipating multiple passes with forceps (standard procedural abortion) and in training settings. (2, B)
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We recommend immediate administration of uterotonics if massage alone fails, with methylergonovine maleate and misoprostol as appropriate first-line treatments. (1, B)
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Given data supporting tranexamic acid’s use in postpartum hemorrhage, we suggest it as a safe and effective agent for prophylaxis and treatment for hemorrhage at the time of abortion. (2, C)
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We recommend that clinicians place a Foley or Bakri balloon to tamponade the endometrium if retained tissue or hematometra is not suspected and the etiology is thought to be atony or lower uterine segment bleeding. (1, B)
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Because UAE is associated with less morbidity and mortality than laparotomy and hysterectomy, we recommend attempting it prior to more invasive measures in settings where available. (1, B)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Management of Hemorrhage at the Time of Abortion

Authoring Organization

Society of Family Planning

Publication Month/Year

September 18, 2023

Last Updated Month/Year

April 1, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

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.

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D006470 - Hemorrhage, D000028 - Abortion, Induced

Keywords

hemorrhage, abortion, induced abortion

Supplemental Methodology Resources

Data Supplement