Immediate Physical Complications

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Sub-Index
Physical Effects
Abortion Technique Risks
Short Term Complications
Immediate Complications
Pain in Women
Organ or System Failure
Infections Related Complications
Impact on Later Pregnancies
Cancer Risks

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Immediate Physical Complications

Note: There is no specific definition for abortion complications. The authors of a particular study basically define the term for themselves. The Center for Disease Control has reported that they found about 100 complications from abortion, but the CDC has not ever published a complete list. Some would be rare, others not life-threatening. As high as 30 different immediate complications have been ascertained from various studies.

General Studies

Incidence of Emergency Department Visits and Complications After Abortion. U Ushma et al. Obstetrics & Gynecology: December 5, 2014 doi: 10.1097/AOG.0000000000000603

OBJECTIVE: To conduct a retrospective observational cohort study to estimate the abortion complication rate, including those diagnosed or treated at emergency departments (EDs).

METHODS: Using 2009-2010 abortion data among women covered by the fee-for-service California Medicaid program and all subsequent health care for 6 weeks after having an abortion, we analyzed reasons for ED visits and estimated the abortion-related complication rate and the adjusted relative risk. Complications were defined as receiving an abortion-related diagnosis or treatment at any source of care within 6 weeks after an abortion. Major complications were defined as requiring hospital admission, surgery, or blood transfusion.

RESULTS: A total of 54,911 abortions among 50,273 fee-for-service Medi-Cal beneficiaries were identified. Among all abortions, 1 of 16 (6.4%, n=3,531) was followed by an ED visit within 6 weeks but only 1 of 115 (0.87%, n=478) resulted in an ED visit for an abortion-related complication. Approximately 1 of 5,491 (0.03%, n=15) involved ambulance transfers to EDs on the day of the abortion. The major complication rate was 0.23% (n=126, 1/436): 0.31% (n=35) for medication abortion, 0.16% (n=57) for first-trimester aspiration abortion, and 0.41% (n=34) for second-trimester or later procedures. The total abortion-related complication rate including all sources of care including EDs and the original abortion facility was 2.1% (n=1,156): 5.2% (n=588) for medication abortion, 1.3% (n=438) for first-trimester aspiration abortion, and 1.5% (n=130) for second-trimester or later procedures.

CONCLUSION: Abortion complication rates are comparable to previously published rates even when ED visits are included and there is no loss to follow-up.

"Factors Associated with Immediate Abortion Complications," LE Ferris et al, Can Med Assoc J 154:1677, June 1, 1996.

A retrospective study of induced abortion at Ontario general hospitals in 1992-1993 reported 0.7% immediate complications. Immediate complications were defined as retained product of conception, hemorrhage, laceration of the cervix, perforation of the uterus and other or unspecified complications along with a small number of infections.

"Elective Abortion: Complications Seen in a Free-Standing Clinic," G.J. L. Wuiff, Jr. and S. M. Freiman, Obstetric and Gynecology 49(3): 351-357, March, 1977.

A study at Reproductive Health Services in St. Louis, Missouri during 1973-76 found an incidence of 1.54% of immediate complications following elective first trimester abortion.

"Complications of First-Trimester Abortion: A Report of 170.000 Cases," E Hakim- Elahi, H.M. Tovell, M.S. Burnhill, Obstet Gynecol 76:129, 1990.

Planned Parenthood of New York City reported an immediate complication rate from induced abortion of 0.905% on 170,000 women from 1971-1987.

"Joint Program for the Study of Abortion, (JPSA): Early medical complications of legal abortion," C. Tietze and Lewis, Studies in Family Planning, 3:97(1971).

Among immediate complications, hemorrhage, laceration of the cervix and perforation totaled 1.2 percent at eight weeks gestation and 3.6 percent at 15 weeks or longer.

"The risk of serious complications from induced abortion: Do personal characteristics make a difference," ? JW Buehler et al, Am J Obstet Gynecol 153:14-20, 1985.

Serious complications were significantly higher where there were previous induced abortions, 12 weeks or greater gestation, advancing gestational age, and one or more previous delivery.

Cervical Injuries

"Measures to Prevent Cervical Injuries During Suction Curettage Abortion," K. Schulz, D. Grimes and W. Cates, The Lancet, May 28,1983, pp. 1182-1184.

In a study of 15/438 women who had suction curettage abortions at about 12 weeks gestation or less from 1975 to 1978, cervical injuries requiring suturing occurred in approximately one out of 100 abortions. Cervical injury is one of the most frequent complications of suction curettage abortion, yet little is known about its risk factors or prevention. Most published reports lack an objective case definition of cervical injury. Reported rate of cervical injury ranges from 0.01 to 1.6 per 100 abortions. In addition to overt injury to the cervix during suction curettage, covert trauma is also important. Micro fractures of the cervix may occur during forceful dilation of the cervix, which may lead to persistent structural changes, cervical incompetence, premature delivery, and pregnancy complications.

"The Risks Associated with Teenage Abortion," W. Cates, K. Schultz, D. Grimes, New England Journal of Medicine, 309(11):612-624, September 15,1983.

There is increased risk of cervical injury during suction curettage abortions obtained by teenagers. These findings cause concern because cervical injury in initial unplanned pregnancies may predispose young women to adverse outcomes in future planned pregnancies.

"Pregnancy Termination: Techniques. Risks, and Complications and Their Management," Robert Castadot, Fertility and Sterility, 45(1): 5-16(1986).

The use of laminaria tents reduces the risk of cervical laceration of trauma, mostly in the nulliparous patient [citing various studies.] Uterine perforation and cervical laceration are best prevented by adequate training of the operator, avoidance of excessive force and recognition of the direction of the cervical canal by prior sounding. Laparoscopy is very helpful in assessing the perforation, the bleeding involved, and other possible lesions such as bladder perforation, but it cannot rule out bowel perforation. Cervical lacerations should be sutured even if bleeding is minimal.

"Delayed Reproductive Complications After Induced Abortion," K. Dalaker, S.M. Lichtenberg and G. Okland, Acta Obstet. Gynaecol. Scand. 58:491-494(1979).

A Norwegian study of 619 women by questionnaire in 1976 found that, among those not pregnant previously, 25.5% of the post-abortion women compared to 13.2% of post- delivery women (matched for age and parity) had post-abortion complications. Complications were cervical incompetence, pre-term delivery, ectopic pregnancy and sterility. Among all groups regardless of parity, total complications in the abortion group was 24.3% vs. 20.2% in the post-delivery women.

Perforated Uterus

"Management of Uterine Perforations in Connection with Legal Abortions," G. Lindell, F. Flam, Acta Obstet. Gynecol. Scand. 74: 373-375,1995.

A Swedish study found that about one-third of uterine perforations occurred at the end of a first trimester suction abortion when using a blunt curette or polyp forceps. It was stated that it was probably wise to refrain from this "security check" in many instances.

"Management of Uterine Perforation Complicating First-Trimester Termination of Pregnancy," R. Goldchmit et. al, Israel J. Med. Sci. 31: 232-234, 1995.

Recommended the use of laparoscopic surgical equipment in the management of uterine perforations.

"Uterine Perforation During Elective First Trimester Abortions: A 13-year Review," L.H. Chen et. al, Singapore Med. J. 36: 63-67,1995.

A careful assessment of uterine size and position, vigilance in the use of uterine sound and dilators, greater care in the use of suction cannula and experience in vacuum aspiration will decrease the incidence of uterine perforations during elective abortions.

"Facts About Early Abortion," Planned Parenthood, July 1985,11-2

"Perforation: Rarely, an instrument may go through the wall of the uterus. The frequency of this event is about 2 per 1,000 cases."

"A Cluster of Uterine Perforations Related to Suction Curettage," S.B. Conger, C.W. Tyler Jr. and J. Pakter, Obstetrics and Gynecology, 40(4): 551-555, October 1972.

The low incidence of uterine perforation reported for suction curettage is one of the major reasons for its widespread use. Twelve menstrual weeks of gestation has been traditionally accepted as the upper limit for performing abortions either by suction or sharp curettage. Higher rates of perforation could possibly be explained by the supplemental use of forceps and surgical curette to complete the abortion in cases of advance gestation. This study of 1,668 abortions performed by a single doctor had no perforations at 10 weeks gestation or less, but 96.8 per 1/000 abortions at 15 weeks gestation or more using suction curettage. The doctor appeared to be underestimating the length of gestation in women over 10 weeks from their last menstrual period.

"Uterine Perforation Following Medical Termination of Pregnancy by Vacuum Aspiration," S. Mittal and S.L. Misra, International J. Gynecol. Obstet. 23:45-50 (1985)

Thirty-seven cases of uterine perforation were observed out of 9,344 first-trimester elective abortions by vacuum aspiration. Cases with a retroverted uterus had a higher incidence of perforation. Studies were reviewed and were noted to be in the range of 0.2 to 7.0 perforations per 1,000 cases. Present study was 3.7 per 1/000 cases. All cases were multiparous and one-third of the cases had a history of child birth within the last six months -no laparoscopy was employed to observe possible perforation incidence.

"A case-control study of uterine perforations documented at laparoscopy," M. White, H. Ory and L. Goldenberg, Am. J. Obstet. Gynecol. 129: 623 (1977).

A case-control analysis of 19 uterine perforations which occured during laparoscopic sterilization had an overall perforation rate of 30.4 per 1,000 procedures. Case women were more likely to combine two of the three characteristics: age over 34, parity (one or more children) and obesity (20% above the ideal body weight for height).

"Uterine Perforation in Connection with Vacuum Aspiration for Legal Abortion," Peter J. Moberg, International J. Gynaecol. Obstet. 14:77-80(1976).

Statistically, 0.64 uterine perforations per 1,000 procedures were observed. It concluded that the correct judgment of uterine position and size immediately prior to the operation appears to be of the utmost importance in reducing perforations - no laparoscopy observation of incidence.

"The frequency and management of uterine perforations during first-trimester abortions," S. Kaali, I. Szigetvari and G. Bartfai, Am. J. Obstet. Gynecol 161:406-408, August 1989

The rate of uterine perforations was 8 cases in 6,408 women undergoing first-trimester abortions (1.3 per 1,000). Some 706 abortions were also performed at the time of laparoscopic sterilization; 2.8 per 1/000 were reported before laparoscopy. Some 15.6 per 1,000 unsuspected perforations were discovered during direct laparoscopic visualization. This represents a 19.8 per 1,000 rate of uterine perforation. Our data suggests that the true rate of uterine perforations is significantly underestimated.

"Joint Program for the Study of Abortion," C. Tietze and S. Lewit, Studies in Family Planning 3:97(1972).

The rate of unrecognized perforations may be three-to-thirty-fold higher than reported.

"Laparoscopy as a diagnostic and therapeutic technique in uterine perforations during first-trimester abortions," N.H. Lauresen and S. Birnbaum, Am. J. Obstet. Gynecol. 117:522(1973).

First report of laparoscopy as a diagnostic tool in uterine perforations. The article concluded that in order to prevent uterine perforation it is of extreme importance to perform a pelvic examination prior to the abortion to determine the position of the uterus since a majority of the perforations occur [to] extremely anteflexed or retroflexed uteri.

"Uterine perforations during sterilization by laparoscopy and minilaparotomy," I.C. Chi and P. Feldblum, Am. J. Obstet. Gynecol. 139(6): 735, March 15,1981.

Patients with an interval of less than one year between termination of pregnancy and sterilization were 4.8 times more likely to incur a uterine perforation than those with a longer interval.

"Prevention of uterine perforation during curettage abortion," D. Grimes, K. Schuiz and W. Cates, JAMA 251:2108-2111(1984).

No mention of laparoscopy.Reported an incidence of 1 per 1,000 cases. (A previous childbirth increases the risk of perforated uterus by 3.4.) (The level of physician training was the strongest single factor identified with incidence of uterine perforation.

"Elective Abortion: Complications Seen in a Free-Standing Clinic," G. Wulff, George Wulff Jr. and S. Michael Freiman, Obstetrics and Gynecology 49(3):351, March 1977.

Reported an incidence of 26 documented and 8 suspected cases of perforated uterus in 16/410 cases (approximately 2 per 1,000 cases.) Reported that laparoscopy was very valuable in ascertaining the exact nature of the perforation. (Laparoscopy not used to determine incidence of perforation.)