Other Medications

1.   Medication-Induced Fetal Demise (also known as “Feticide” or “Fetocide”): Generally used to refer to the use of medications, most commonly digoxin or concentrated potassium chloride (KCl) that are used to stop the fetal heart before doing an induction or surgical abortion.   Fetal demise results in softening of fetal tissues and possibly facilitates extraction of the fetus. It is used before induction abortion to avoid the delivery of a live fetus.  Potassium chloride injection can be used to reduce the number of fetuses in multiple gestations, such as reducing triplets to twins.  In doing this to terminate an anomalous fetus, it is call “selective reduction” (SR) (see “multifetal pregnancy reduction” above).

2.   Digoxin:  Digoxin is a heart medication that sometimes is injected into the amniotic fluid or fetus to cause fetal demise before surgical or induction abortion (see Feticide).  For both intra-amniotic and intra-fetal digoxin injection, a dose of 1 mg is common.  Higher doses, up to 3 mg in the third trimester, are used by some clinicians, but the safety of larger doses has not been established in studies.  Demise is less immediate than with KCl, but usually occurs within 24 hours.

3.   Potassium Chloride (KCl):  Potassium chloride (KCl) is a pharmacologic agent that is used to cause fetal demise before abortion.  It also is used for multifetal pregnancy reduction (abortion of one or more fetuses while one or more are left viable in the uterus).  KCl requires direct fetal intra-cardiac or intra-umbilical injection and is done under ultrasound guidance by specially trained physicians.  KCl will not cause fetal demise when injected into the amniotic fluid, unlike digoxin.  Injection of KCl into the fetal heart or umbilical cord typically stops fetal cardiac activity immediately.

4.   Mifepristone:  Mifepristone, a steroid related to progestin, works by blocking the activity of the body’s progesterone, a substance needed to continue pregnancy.  (See Medical Abortion.)

5.   Misoprostol:  Misoprostol is a synthetic prostaglandin (PG E1) developed and manufactured in the U.S. for the treatment and prevention of stomach ulcers.  Thousands of studies have evaluated its use in gynecology because it causes uterine contractions and cervical softening, or “ripening.”  In the U.S., misoprostol is not FDA-approved for induction termination, but it is approved as part of the early medical abortion regimen with mifepristone.  Misoprostol also is given to women before a surgical abortion or labor induction to achieve cervical ripening[1] and for treatment of excessive bleeding after an abortion or other uterine procedure.  Misoprostol tablets are produced for oral use in doses of 100mcg and 200mcg, but have also been studied for various indications to be used vaginally, buccally (in the cheeks), sublingually (under the tongue) or rectally.

6. Vasopressin and Epinephrine:  These medications cause constriction of blood vessels in the areas where injected.  They sometimes are added to the cervical numbing medications.  Vasopressin has been shown to reduce blood loss significantly from second-trimester dilation and evacuation abortions and decrease the need for reaspiration.

7.   Oxytocin (Pitocin) and Methylergonovine Maleate (Methergine): These medications are uterotonic drugs that frequently are administered following second-trimester procedures to cause uterine contraction and decrease blood loss.  They may be used either to prevent or to treat heavier bleeding.

 

G.  Complications and Interventions

1.   Post-Abortion Hemorrhage:  A blood loss of 500 mL or bleeding requiring transfusion are commonly used definitions of post-abortion hemorrhage.  Causes include incomplete abortion, uterine atony, placental abnormalities, perforation or uterine injury, cervical laceration, and bleeding disorders. Post-abortion hemorrhage occurs in approximately 0.8 per 100,000 abortions, with increased risk at more advanced gestations.  Treatment depends upon the underlying cause of the hemorrhage, and may include uterine massage; re-aspiration; medications (such as prostaglandin F2a, oxytocin, misoprostol, methylergonovine, or vasopressin); a pressure balloon inside the uterus; surgery, including laparotomy for repair of perforation or hysterectomy; or uterine artery embolization by Interventional Radiology.

2.   Cervical Laceration:  A cervical tear most commonly resulting from the tenaculum, mechanical dilation or pressure on the cervix. Tears of the external cervix are the most common, are usually easy to repair and have little impact on the patient. Treatment options include observation alone; direct compression for 5-10 minutes; the application of silver nitrate, ferric subsulfate or other procoagulants (medications that cause blood clotting); or surgical repair using an absorbable suture.  For higher cervical tears that extend inside the internal cervical os, or opening to the uterus, pressure with a balloon, uterine artery embolization or surgery may be needed.   Although not entirely preventable, the risk of a cervical laceration can be lessened especially in later gestations by the use of osmotic dilators or cervical priming agents.  The rate of occurrence is 0-1%.

3.   Uterine Atony (or Uterine Hypotonous):  Failure of the uterine musculature to contract normally after an abortion. This complication also is common after childbirth. The blood vessels supplying the pregnancy are severed when the placenta separates from the wall of the uterus.   The bleeding that results from these severed vessels normally stops when the uterus contracts, compressing the vessels.  However, if the uterus does not contract enough, bleeding can continue.  Significant blood loss can result from a floppy, uncontracted uterus.  Greater gestational age increases the risk of uterine atony.  Treatment may include uterine massage, medications (uterotonics), placement of a pressure balloon or Foley catheter in the uterus, uterine artery embolization (temporary blockage of the uterine arteries by Interventional Radiologists) and surgery (most commonly hysterectomy).

4.   Lower Uterine Segment Atony:  The lower uterine segment is the inferior portion of the uterus that joins with the cervical canal and expands during pregnancy to become the lower part of the uterine cavity.   This part of the uterus has less muscle tissue and is affected by scar tissue after a cesarean section.  Even when the top of the uterus contracts well, atony of the lower segment can result in significant bleeding.  Treatment is similar to that for all causes of uterine atony.

5.   Placenta Accreta/Increta/Percreta

Placenta Accreta:  Refers to the abnormally deep attachment of the placenta through the endometrium (inside lining of the uterus) and into the myometrium (the muscle layer of the uterus). It is present in 1-2 per 10,000 second-trimester abortions and usually produces hemorrhage during or after the procedure.  It is rarely an issue before the second trimester. Placenta accreta frequently is associated with prior uterine surgery such as cesarean delivery and surgery to remove fibroids (myomectomy).   When the condition is suspected before a procedure, preoperative planning helps to mobilize staff and have the proper equipment to handle treatment of hemorrhage, including uterine artery embolization or hysterectomy.  “Accreta” often is used non-specifically to refer to any degree of abnormal placentation, but more strictly refers to the least deep invasion of the placenta, with deeper invasion becoming increasingly more difficult to treat.

Type

Invasion of placenta has occurred:

Accreta

Superficially onto the myometrium (uterine muscle)

Increta

Deep into the myometrium

Percreta

Through the myometrium

6.   Endometritis/Post-Abortal Infection:  Infection after abortion is uncommon.  Studies demonstrate preventative antibiotics reduce infection risk after surgical abortion.  Treatment with antibiotics may be done as an outpatient or in the hospital depending upon the severity of the infection.  Sterile procedure is critical to prevent infection after surgical abortion but still does not completely prevent it.

 7.   Uterine Perforation:  A hole usually caused by an instrument puncturing the uterine wall.  Small holes caused by a smooth dilator may not require treatment other than observation or antibiotics.  Holes that have been penetrated by forceps or suction usually require surgery to check for damage to other organs and to repair the hole and any other damaged organs.

 8.   Broad Ligament Hematoma:  A blood clot collection (or hematoma) that results from a tear in the upper vagina, cervix, or uterus that disrupts the uterine or vaginal arteries.  Blood collects in the limited yet expandable space to the side of the uterus.

9.   Uterine Foley/Bakri Balloon:  A balloon used to create pressure inside the uterus in cases of persistent bleeding when pharmacologic therapies have failed and before resorting to more invasive procedures, such as uterine artery embolization or surgery.  An intrauterine pressure balloon also can serve to temporize before another surgical procedure or uterine artery embolization.

10. Uterine Artery Embolization:  A procedure performed by a radiologist under X-ray guidance (fluoroscopy) where a small catheter is threaded through the largest artery in the groin to the uterine arteries and a substance is placed into the uterine arteries to block blood flow to the uterus.  In the setting of post-abortion hemorrhage, the substance generally used is very temporary, so that it should be less likely to cause difficulties with future pregnancies.

11. Pregnancy Complications Seen During Abortion Care: Pregnancy complications seen during abortion care include ectopic pregnancy (pregnancy outside of the uterus, usually in the Fallopian tube) and molar pregnancy (an abnormal overgrowth of tissue that is supposed to develop into placenta, which may increase post-abortion bleeding and is associated with other medical risks).



[1]   See supra Section C.