Management of Individuals with Bleeding or Thrombotic Disorders Undergoing Abortion

For first-trimester abortion, surgical management is generally preferred over medical management for individuals with bleeding disorders or who are on anticoagulation. For second-trimester abortion, surgical management may be recommended to limit bleeding though this has not been studied in these populations. Providers should individualize the mode of abortion with the approach of shared decision making, interdisciplinary collaboration, and accounting for the availability of procedural abortion and resources if complications.

In an individual who presents for second-trimester procedural abortion with a suspected bleeding disorder, prompt referral to a hematologist should be initiated.

Decision on the ideal setting for individuals undergoing procedural abortion with bleeding disorders or who are on anticoagulation should be individualized. Given the low bleeding risk of first-trimester procedures, it is possible to manage individuals without additional risk factors for bleeding in a hospital outpatient clinic or free-standing clinic setting. In general, second-trimester abortions in these individuals should be preferably done in a hospital-based setting given increased access to resources should complications or hemorrhage occur.

Although data concerning bleeding risk is limited, for a first-trimester procedural abortion in an individual on anticoagulation who has no additional risk factors for bleeding and is to undergo a procedure that is anticipated to be uncomplicated, anticoagulation can generally continue uninterrupted.

All individuals should undergo an individualized risk assessment for VTE when they present for abortion. If they have multiple risk factors and are determined to be high risk for VTE (individuals with an unprovoked or hormonally provoked VTE, individuals with a family history of VTE and antithrombin deficiency, individuals with homozygosity for factor V Leiden or combined factor V Leiden/prothrombin gene mutation regardless of family history ) and are not currently on VTE prophylaxis, they can be offered anticoagulation prior to the abortion if there is a delay until the procedure, or can forego pre-procedure anticoagulation. High risk individuals can be offered 4-6 weeks of anticoagulation post procedure.

The decision to interrupt anticoagulation in an individual currently on anticoagulation desiring a second-trimester procedural abortion must be done after an individualized risk assessment including absolute risk of VTE if anticoagulation is to be interrupted and bleeding risks with anticoagulation if it is continued.

Use of NSAIDs for post-abortion pain management is generally recommended. However, NSAID use should be tailored to the risks and benefits for the specific individual with a bleeding disorder or on anticoagulation, with specific attention paid to the possible interaction of NSAIDs with anticoagulants.

Surgical management of incomplete abortion in individuals with bleeding disorders or on anticoagulation is generally recommended over medical management.