Complications

Cervical Shock.  This is a vasovagal reaction that usually occurs when the paracervical block is being performed but may also occur after this. A tonic-clonic reaction may be confused with a seizure but is distinguished by the presence of bradycardia, rapid patient recovery, and the absence of a postictal state. The reaction is usually limited to a few minutes. Preoperative cervical dilatation with osmotic dilators or misoprostol, or the routine use of atropine with cervical anaesthesia, can prevent cervical shock.

Perforation. The clinical presentation of perforation depends on the location of the injury. Perforation at the isthmic portion of the uterus can lacerate the ascending branch of the uterine artery in the broad ligament, leading to a hematoma or intra-abdominal bleeding and severe pain.  Immediate management is laparotomy and ligation of the severed vessel(s) as well as repair of the uterine injury. Rarely, hysterectomy may be required to manage the bleeding.

Low cervical perforation may injure the descending branch of the uterine artery in the cardinal ligament. This injury is usually the result of forceful dilatation of the cervix. Preoperative cervical dilatation reduces this complication.

The bleeding is usually external in this situation rather than intra-abdominal. The bleeding can temporarily subside as the arteries go into spasm. Deaths due to bleeding have occurred several hours or even days after an unrecognized low cervical perforation. Arteriography and selective embolization of the hypogastric arteries should be considered prior to hysterectomy.

If a fundal perforation occurs at the end of the procedure, expectant management is usually all that is necessary.

If perforation occurs before or during evacuation of the uterus, the procedure should be completed under direct laparoscopic observation or using ultrasonic guidance.  It is important to turn the suction off once perforation is recognized to reduce the risk of pulling bowel or omentum into the uterine cavity. If the bowel or omentum is brought into the uterine cavity or through the cervix, laparoscopy or laparotomy will be necessary to complete the procedure and examine the intra-abdominal contents for injury.  The omentum or bowel should be left within the uterine fenestration to facilitate the identification and repair of lesions in these structures as well as the uterus.

Hemorrhage. Excess bleeding may indicate uterine atony, a low-lying implantation, a more advanced gestational age, or perforation. Misoprostol (1000 ìg rectally or buccally) or intravenous oxytocin, alone or in combination, should be administered, and the abortion completed. The uterus is then massaged bimanually to ensure contraction. If this is unsuccessful,  the   administration   of   intramuscular/ intramyometrial 15-methylated prostaglandin F2α may be effective. Persistent   post-abortal   bleeding   suggests retained tissue, hematometra, or perforation. Prompt surgical intervention by repeat curettage and possibly laparoscopy should be performed.  Uterine artery embolization and, rarely, hysterectomy may be necessary.

Hematometra  (Post-Abortal   Syndrome).  Increasing   lower abdominal pain within a half-hour of the procedure suggests the formation of a hematometra (accumulation of blood and clots in the uterine cavity). The uterus is large, globular,  and   tense   with   associated   hypotension   or vasovagal response. This condition could be mistaken for a broad ligament hematoma, but the mass is midline and arises from the cervix. The uterus needs to be re-evacuated immediately.

 

Summary of Recommendations

REFERENCES

Victoria Jane Davis, MD
These guidelines were reviewed by the Clinical
Practice - Gynaecology Committee and the Social and Sexual
Issues Committee and approved by the Executive and Council of
the Society of Obstetricians and Gynaecologists of Canada.