DISCLAIMER: This blog will be speaking about the medical care secondary to an abortion (spontaneous or medically-induced). Kindly leave your politics and religion in your back pocket for this post. I understand this may make you uncomfortable, but I encourage you to learn so we can better understand and care for our patients.
Let's start with clarifying terminology. Abortion is defined medically as loss of pregnancy. There are spontaneous abortions (miscarriages if <20 weeks or stillbirth if >20 weeks) or medically-induced abortions (sometimes termed 'elective').
Miscarriages occur in 10-15% of all pregnancies (when women know they are pregnant), and 80% of these occur in the first trimester. It is believed that if we accounted for women who did not know they were pregnant, the rate of miscarriage could be as high as 50%.
According to Guttmacher Institute, 18% of pregnancies (excluding miscarriages)ended in medically-induced abortion in 2017. It's safe to say that abortions are quite common, so let's talk about them! Let’s look at typical progesterone levels in pregnancy. The corpus luteum produces progesterone until the fetus by way of the placenta can produce enough of its own to sustain the pregnancy, at around 8-12 weeks.
Miscarriages can happen for a variety of reasons; most of the time it is impossible to know the cause. More than likely, a chromosomal abnormality is to blame, but implantation problems or maternal health conditions could also play a role.
Mifepristone is the chemical abortion agent that is FDA approved up to 10 weeks from conception. It works as a progesterone antagonist. Because progesterone is needed to build the placenta, mifepristone causes endometrial shedding and induces bleeding.
Mifepristone is a progesterone antagonist. It causes the levels of progesterone to effectively bottom out, preventing the uterus from sustaining pregnancy.
Misoprostol, a prostaglandin analog, can be used in conjunction and assists in strength and frequency of uterine contractions and dilation of the cervix. As expected, this treatment is very likely to cause severe cramping, bleeding, nausea, and diarrhea. There is a chance the medication will be unsuccessful in removing the entirety of the uterine contents. This places the patient at a large risk for infection.
Prostaglandins bind to the EP1 and EP3 receptors in the uterus to trigger contractions and dilate the cervix. This is the effect of analogous misoprostol.
The surgical abortion can be performed by vacuum aspiration or by the more invasive dilation and curettage (D&C). It is important to understand what kind of abortion your patient had. Dilation and curettage has a significantly higher risk of infection, hemorrhage, cervical injury (no C-collar needed), and uterine perforation. It is not uncommon that prophylactic antibiotics will be ordered for this patient.
This is a perfect segue into why we care pre-hospitally. What are we looking for? How can we properly assess our patients, screen for life-threats, treat respectfully?
Let's start with some common concerns…
Infection. If a standard of care is to prescribe prophylactic antibiotics, it's probably a good idea for us to be nervous about sepsis if we get a patient post-abortion. HOPEFULLY, all of these women are instructed to stick to pads to manage the bleeding after their procedures, but be sure to ask them specifically. Using tampons to control bleeding illuminates a huge neon VACANCY sign for bacteria in the female reproductive organs…and check in they will. Next, you should ask about the length and quality of bleeding. Miscarriages and medical abortions can be incomplete. This could be a source for infection as well.
Keep in mind that most of our experiences with sepsis up to this point have likely been with patients, often geriatric, with comorbidities. It's possible our lower end 100s for these patients is just as alarming as Grandpa's 130s. Be flexible in your algorithms. Don't delay a sepsis alert if she's 104 degrees can fry a dang egg on her head, is confused, but her heartrate is 102 and her pressure is 110/60. Sorry, lady, you didn't quite make the cut for an alert! Don't do that. Treat your patient. If you need a big room, go get her a big room.
Hemorrhage. Bleeding is expected with any type of abortion, of course. Again, ask about the length and quality of bleeding. Disseminated intravascular coagulation (DIC) should be considered in all severe bleeding patients. Look for your signs of shock.
Mental Health Emergencies. This is a very delicate and personal issue. Abortion and infertility are words so taboo it's as if we worry that saying them too loud will cause a contagion. For many women, this is a very challenging experience. Some could be at an increased risk of domestic violence or ostracization. Be aware of how you communicate with your patients. Try and encourage an environment where they feel they can be honest and detailed with you so you can get a proper assessment. Ensure their privacy and dignity are protected.
Pain Control. I have been on a truck with medics who have uttered "of course it hurts, what were you expecting to happen when you got an abortion?" and have withheld pain medications. Please, if you take nothing away from this blog, don't be that guy. It's like being the guy who slams the narcan "to ruin their high". It doesn't look good on you. Strangely enough, it's actually not our job to judge our patients, only to treat them and listen to them. Look, I'm not going to sit here and convince you their pain is real just as I shouldn't have to do that for someone whose arm is hanging out of the socket. All I'm saying is if someone is in misery in your bus and you are withholding medication because you disapprove of the mechanism that caused their pain, you should probably just go home.
Embolism. Don't forget there is a small risk of amniotic fluid embolism which can cause severe respiratory distress or cardiovascular collapse.
Although not often thoroughly covered in traditional education models, comprehensive post-abortion care is imperative to help prevent life-threatening complications and long-lasting psychological trauma. Miscarriages occur in 10-15% of all pregnancies, and 25% of women are expected to have an abortion before turning 45. The odds of treating a patient after the termination of a pregnancy are high; will your standards of quality of care be as high?