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Surgical Abortion
ChristyM.Boraas andJessikaA.Ralph
29
Introduction
Induced abortion and early pregnancy loss in the
United States are common. One in four pregnant
people will have an induced abortion in their lifetime and roughly one tenth of clinically recognized
pregnancies end in miscarriage [1, 2]. Though not
all cases are managed surgically, induced abortion
remains the second most common procedure for
people of reproductive age after cesarean section
[1, 3]. Surgical uterine evacuation for induced
abortion or pregnancy loss in the United States is
safe, and complications are infrequent. Abortion by
any method is safer than childbirth; major complication (transfusion, unplanned hospitalization, further surgical procedures) rates for surgical uterine
evacuation are less than 1% in the rst trimester
and less than 5% in the second trimester [4]. Other
potential complications include hemorrhage, uterine and cervical injury, infection, and incomplete
abortion. Because of the rarity of such events,
many clinicians do not have direct experience managing complications of surgical abortion. This
chapter details their management so all surgeons,
regardless of training, can understand evidencebased procedural abortion care.
C. M. Boraas (*) · J. A. Ralph
Department of Obstetrics, Gynecology and Women’s
Health, University of Minnesota Medical School,
Minneapolis, MN, USA
e-mail: bora0021@umn.edu; ralph044@umn.edu
Hemorrhage
Hemorrhage after dilation and curettage (D&C)
or dilation and evacuation (D&E) is rare, occurring less than 1% of the time and generally considered to be clinically relevant when requiring
intervention (such as transfusion or hospital
admission) and/or greater than 500 mL total
blood loss [5]. Despite its low incidence, postabortion hemorrhage is one of the most common
causes of abortion-related morbidity and mortality, particularly in the second trimester [5].
Etiologies of hemorrhage are similar to those at
the time of childbirth, including uterine atony,
cervical laceration, retained products of conception, abnormal placentation, uterine perforation,
and coagulopathy.
Uterine Atony
Background
Research suggests that atony, or hypercontractility of the uterus, is the most frequent cause of
hemorrhage after abortion, identied in approximately 50% of cases [5]. Older patient age and
increasing gestational duration were independent
risk factors for hemorrhage due to atony, specically in the second trimester [5]. Other risk factors include prior cesarean section, history of
obstetric hemorrhage, underlying bleeding disorders, uterine leiomyomata, and obesity [5].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_29
309
310
C. M. Boraas and J. A. Ralph
Prevention
Hemorrhage prevention measures include the
use of vasopressin or epinephrine in the paracervical block, which has been shown to decrease
blood loss with dilation and evacuation procedures, especially in the second trimester [6].
Prophylactic use of methylergonovine does not
reduce blood loss at the time of surgical abortion, but the use of prophylactic oxytocin has
been shown to reduce hemorrhage frequency for
second-trimester procedures [4, 7]. The use of
halogenated anesthetic gas is also associated
with atony and thus is not recommended in the
setting of surgical abortion [8].
Recognition
If hemorrhage after surgical abortion does occur,
a general approach should start with a physical
exam, including inspection of the cervix and
vagina to look for lacerations, a bimanual exam
to assess uterine tone, and bedside ultrasonography to help identify hematometra, free uid in
the pelvis, or retained tissue.
Management
In the absence of other identiable causes, poor
uterine tone should be considered the primary etiology and bimanual massage should be initiated.
Concurrent administration of uterotonic medications should occur if the tone does not rapidly
improve and can successfully treat bleeding much
of the time. Most used medications for uterine
atony are listed in Table 29.1 [9]. There is little
evidence to recommend one agent over another.
However, due to its rapid onset, administration of
methylergonovine maleate is frequently used rst
unless contraindicated. If heavy bleeding persists,
multiple medications and/or doses should be
administered, while also reassessing for other
potential causes (Figs.29.1, 29.2, and 29.3).
When bleeding is refractory, additional immediate interventions include placement of additional intravenous access, uid resuscitation,
laboratory evaluation, and consideration of
potential transfusion. Intrauterine tamponade
with a Foley catheter or intrauterine balloon is
often a logical next step; balloons are left in place
for up to 24hours while ensuring hemodynamic
stability. Intrauterine tamponade may be similarly achieved with the packing of plain or
medication- soaked (vasopressin or thrombin)
gauze. If all the above-listed interventions are
insufcient, more intensive and invasive procedures may be required, such as uterine artery
embolization (UAE), laparoscopy, laparotomy,
and rarely, hysterectomy.
Table 29.1 Commonly used medications for surgical abortion hemorrhage
Dose and route of
Medication
Methylergonovine maleate 0.2mg PO, IM, IV Every 2–4hours Hypertension
Misoprostol (PGE1
analog)
Carboprost (15-methyl
PGF2alpha)
Oxytocin
Tranexamic acid 1g in 10mL IV given over
Vasopressin
PO per os, IM Intramuscular, IV Intravenous, PGF prostaglandin F, PGE prostaglandin E
a
Adapted from [9, 15]
b
In addition to known hypersensitivity to any of the medications
c
For prevention and treatment
d
Primarily for prevention, no clear role in acute treatment of hemorrhage
c
d
administration Dosing frequency Contraindications
800 mcg buccal or
sublingual
0.25mg IM Every 15–90minutes, not to
10units IM 10–40units
per 500–1000mL IV bolus
then as continuous infusion
10minutes
2–8units per 10–30mL of
saline or local anesthetic
Every 4hours Rare
execeed eight doses
Once Rare
Second dose after
30minutes if ongoing
bleeding
Once Rare
a
Asthma
Caution with concurrent
antibrinolytic therapy
b
Retained products
Uterine perforation
Ascending branch
29 Surgical Abortion
of conception
Placenta accreta
Placenta previa
Serosa
Myometrium
Endometrium
spectrum
311
Uterine atony
Cervical laceration
Normal
placenta
Uterine cavity
Placenta accreta
spectrum
Internal os
of uterus
Cervix
Fig. 29.1 Etiologies of surgical abortion hemorrhage
of uterine artery
Uterine artery
Descending
branch of
uterine artery
Lateral low
cervical
perforation
Internal iliac
artery
Abnormal placentation
Ovarian
artery
Fundal
perforation
Uterus
Perforation in the posterior
lower uterine segment
Lateral perforation at
junction of cervix and
lower uterine segment
Vagina
Vaginal artery
Fig. 29.2 Sites of uterine perforation during surgical abortion
312
Sigmoid
Tenaculum
Fig. 29.3 Mechanism
of uterine perforation
during surgical abortion
C. M. Boraas and J. A. Ralph
Uterus
on cervix
Suction
cannula
Speculum
Abnormal Placentation
Background
Abnormal placentation, formerly called placenta accreta, increta, and percreta, is now
known as placenta accreta spectrum (PAS) disorder and is associated with potentially massive
and life- threatening hemorrhage. With a rising
incidence, surgeons should maintain a high
index of suspicion for PAS, particularly for
patients with prior cesarean section or other
uterine surgery that involves the full thickness
of the myometrium [10].
Prevention
Preoperative identication of PAS is associated
with signicantly less blood loss and should be
evaluated with ultrasonography and/or magnetic
resonance imaging in patients presenting with a
complete placenta previa and a history of prior
uterine surgery or any other concerning ndings
on ultrasonography. Second-trimester placenta
previa is diagnosed in about 2–6% of pregnancies, however, previa alone (without PAS) does
not complicate surgical uterine evacuation,
including D&E [8].
Patients with suspected PAS have an increased
risk of hemorrhage at the time of surgical uterine
colon
evacuation and may be best served in a hospital
setting with experienced surgeons and the capacity for large-volume blood product transfusion.
Access to hospital-based care for induced abortion varies greatly across the United States given
the political landscape and restrictive abortion
care policy. For those patients desiring future fertility, D&E may be considered depending upon
patient and team level factors, operative setting,
preoperative imaging, etc. Given the ability of the
placenta to invade the uterine myometrium,
serosa, parametrium, bladder, and rarely other
organs such as the ureters, rectum, and vagina,
multidisciplinary care planning, including
anesthesia, maternal-fetal medicine, gynecologic
oncology, urology, and interventional radiology
may help preoperatively in these cases.
Recognition andManagement
Hemorrhage during surgical abortion in the setting of PAS should prompt a quick escalation of
intervention. Occasionally, UAE alone may be
successful in controlling bleeding, but laparoscopy or laparotomy with hysterectomy may be
required. Alternatively, for patients that do not
desire future fertility, hemorrhage may be reduced
or avoided by offering gravid hysterectomy, with
or without preoperative UAE, rather than D&E.
29 Surgical Abortion
313
Acute Coagulopathy
Background
Disseminated intravascular coagulation (DIC),
the extreme activation of the coagulation cascade
that leads to depletion of clotting factors and
platelets is a rare but serious complication of
D&E and is rarely seen after D&C. DIC at the
time of surgical abortion tends to be consumptive,
in response to massive hemorrhage. DIC associated with late rst or second-trimester uterine
evacuation is more likely to occur in the setting of
an intrauterine fetal demise, especially if the
demise occurred at a more advanced gestational
duration and when there has been a longer interval
between demise and uterine evacuation [11–13].
Amniotic uid embolism is an even more rare etiology of post-abortion DIC that is not preventable,
is characterized by hemodynamic and respiratory
collapse, and requires emergent resuscitation
[14]. The overall incidence of DIC is roughly 2%
for D&E cases performed for fetal demise and
0.2% for other indications, and onset typically
occurs within 2hours of the procedure [12, 13].
primary cause of bleeding is paramount.
Concurrently, preparing for blood product
replacement therapy is critical. Many D&E procedures take place in outpatient settings without
access to blood banking and thus, the next steps
are stabilizing the patient with intravenous uid
resuscitation and initiating emergent transfer to a
higher acuity setting. In the hospital setting, surgeons should maintain ongoing communication
with anesthesia and support teams in the operating room and consider activating the massive
transfusion protocol. Recommendations for optimal timing of transfusion for pregnant patients
are limited but generally recommended to be a
1:1:1 ratio of red blood cells:fresh frozen
plasma:platelets and in the setting of DIC, consideration of early use of cryoprecipitate [15].
Surgeons should be aware of specic protocols at
their institutions. Continued clinical and lab
assessments are recommended to assess response
to blood components.
Cervical Injury
Prevention
No known preoperative measures alter the risk of
DIC at the time of D&E but surgeons should
consider preoperative laboratory evaluation
including blood typing, complete blood count,
coagulation studies including prothrombin time,
brinogen level, and consideration of blood
crossmatching.
Recognition
No universally recognized diagnostic criteria or
single laboratory test can diagnose DIC and clinical recognition remains the mainstay. Laboratory
evaluation of platelets, brinogen, and D-dimer
are useful for diagnosis and evaluation of resuscitation efforts. DIC should be suspected with persistent bleeding from uterine atony or cervical
laceration or other etiology, especially when it is
failing to clot, and with any signs of cardiovascular compromise.
Management
Given most DIC occurs secondary to another etiology of bleeding, identifying and addressing the
Background
Cervical injury occurs in fewer than 1% of D&Cs
and roughly 2% of D&Es [16, 17]. The risk of
cervical laceration is increased in individuals
without a prior vaginal birth, as well as in cases
of more advanced gestation [16].
Prevention
During D&C, the diameter of the required
instruments is small and pregnancy tissue is pliable; thus, the cervix may be opened safely with
mechanical dilation alone. However, during
D&E, the dilation needed to accommodate forceps and fetal tissue is greater, and mechanical
dilation alone frequently results in laceration.
Preparation of the cervix, either with osmotic
dilators, medications, or both reduces the likelihood of cervical laceration [18]. Protocols for
cervical preparation vary widely and may occur
over hours or days; no one method has been
demonstrated to be superior. While a review of
314
C. M. Boraas and J. A. Ralph
potential methods of preparation is beyond the
scope of this chapter, they may include mifepristone and/or misoprostol to produce cervical
softening and effacement; dilation may be
achieved mechanically with a foley balloon or
via osmotic dilators such as Dilapan-S or laminaria tents [19, 20].
Recognition
Distal cervical lacerations near the external os are
directly visible on an exam. Lacerations of the
proximal cervix, near the internal os, can be more
difcult to diagnose, both because the internal os
is likely not directly visible, and because its
injury can create continuity with the abdominal
cavity or the retroperitoneal space. Lacerations of
the proximal cervix should be suspected if bleeding continues from the endocervical canal in the
presence of a rm uterus [8].
Management
Small distal cervical lacerations can often be
treated with direct pressure, sometimes combined
with the application of silver nitrate or ferric subsulfate solution. Larger lacerations may require
re-approximation with absorbable suture [8].
Proximal cervical lacerations can be managed
with cervical stay sutures at 3 and 9 o’clock combined with tamponade, which can be achieved
with packing or a Foley catheter. If these measures are not sufcient, uterine artery embolization should be considered [8].
Uterine Injury
Background
Uterine perforation is an uncommon complication during surgical abortion. The rate of occurrence ranges from 0.09 to 15 per 1000 cases [16].
Risk factors for perforation are advanced parity,
increasing gestational duration, and the use of a
uterine sound [8, 16, 17].
Prevention
Like cervical lacerations, appropriate preparation
of the cervix helps prevent uterine perforation
from occurring. Ultrasound guidance for D&E
procedures is reasonable but has not been denitively shown to reduce rates of perforation given
the rarity of this complication [8, 19, 20].
Recognition
A surgeon may have increased suspicion for perforation when an instrument passes further than
expected without resistance or the gritty sensation is no longer appreciated with the aspiration
curette. Patients may develop hypotension,
bowel/omentum may be visualized in the instrument, and patients who are awake may express
sudden onset pain. The small bowel is the most
common viscera injury and can occur through
anterior or fundal uterine perforations, while the
large bowel is primarily injured through posterior
perforations [8].
Management
Low-risk perforation patients (blunt instruments
without suction, typically in the rst or early second
trimesters) can be discharged home after extended
observation to ensure no hemodynamic instability;
the perforations will resolve without further treatment or sequelae. Higher- risk perforations tend to
be: lateral; 1 to 2cm in diameter; occurring after the
rst trimester; and associated with acute abdominal
pain, symptomatic blood loss, or bowel injury.
Ultrasound can be used to observe if there is free
uid in the pelvis, however, laparoscopy or laparotomy may be required if injury to the adnexa or
bowel is suspected or if blood loss leads to hemodynamic instability [8, 16, 17].
29 Surgical Abortion
315
Infection
Background
Postabortal infection is rare in safe abortion settings, occurring after less than 1% of induced
abortions at any gestation in the United States.
Most commonly, patients present with endometritis due to translocation of skin, vaginal, and/or
gastrointestinal ora into the endometrial cavity;
rarely, patients present with sepsis. Risk factors
for postabortal infection include an active,
untreated sexually transmitted infection or bacterial vaginosis at the time of the procedure [21].
Prevention
Routine antibiotic prophylaxis is the mainstay of
prevention and reduces the rate of postoperative
infection signicantly [8]. The Society of Family
Planning recommends a single dose of doxycycline 200 mg pre-operatively; other potential
choices are listed in Table 29.2 [22]. Vaginal
preparation with either povodine-iodine or
chlorhexidine solution does not reduce infection
rates. Preoperative screening for N. gonorrhea
and C. trachomatis should be recommended for
those with risk factors such as younger age [21].
infertility and sepsis, a low threshold for treatment is acceptable. Rarely do patients present
with toxic shock; these patients may not have specic pelvic complaints but instead manifest general malaise and refractory hypotension [8, 21].
Management
Treatment of postoperative uterine infection typically follows treatment for pelvic inammatory
disease (PID) as it is usually polymicrobial in
nature; coverage for C. trachomatis should be
included. A frequently prescribed combination is
ceftriaxone and doxycycline (see the Centers for
Disease Control and Prevention PID guidelines
for others). Imaging should be considered to rule
out retained products of conception as well as
pelvic abscess. If identied, retained tissue in the
endometrial cavity should be promptly evacuated; an abscess may require percutaneous drainage. Patients who present with sepsis or toxic
shock should be given supportive care with
aggressive uid resuscitation, and/or vasopressors, as needed [8, 21].
Retained Products ofConception
Background
Recognition
Typically, patients present within a few days of
the procedure with some combination of pelvic
pain, uterine tenderness, fever, and leukocytosis.
These criteria are subjective and likely cause
overdiagnosis, but as potential sequelae include
abortion infection prophylaxis
Medication Dose and route of administration
Doxycycline 200mg PO or IV
Metronidazole 500mg PO or IV
Tinidazole 2g PO or IV
Azithromycin 1g PO or IV
PO per os, IM Intramuscular, IV Intravenous
a
Adapted from [8, 21]
a
Residual pregnancy tissue (incomplete abortion)
and/or blood products (hematometra) retained
within the uterus following surgical abortion,
while uncommon, may cause patients discomfort
and predispose them to further complications of
ongoing bleeding and infection. The incidence of
re-aspiration is low, 0.29–1.96% of patients in the
rst trimester and 0.40–2.70% in the second trimester, most commonly for hematometra [8].
Prevention
Immediate postoperative inspection of tissue
removed from the uterus is standard practice and
conrms abortion procedure completion in most
cases7. Formal pathology evaluation of evacuated
316
C. M. Boraas and J. A. Ralph
tissue is not routinely indicated. It is also crucial
for surgeons to note a “gritty” texture with the
suction cannula on all intrauterine surfaces and
the resolution of any brisk bleeding from the cervical os prior to terminating the procedure.
Ultrasound guidance, while not routinely necessary, may be helpful to conrm procedure completion, particularly in anatomically variant or
logistically challenging cases, as well as those
performed at more advanced gestational
durations.
Recognition andManagement
Diagnosis and treatment are typically guided by
clinical presentation, as it can be normal to
observe heterogeneous endometrial tissue and/or
small collections of clotted blood on ultrasound
examination following clinically complete surgical abortion. Patients presenting with persistent
pelvic pain, fever, or ongoing heavy bleeding
should undergo prompt imaging and consideration of re-aspiration or treatment with misoprostol to empty uterine contents and avoid further
complications.
Conclusions
Overall, surgical evacuation of pregnancy in the
rst and second trimesters either with dilation
and curettage or dilation and evacuation is safe,
and complications are rare. Risk generally
increases with advancing gestational duration of
pregnancy. Understanding risk factors, steps to
minimize risk, and overall management of more
common potential complications can help
decrease surgical morbidity.
References
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Obstet Gynecol. 2018;132(5):e197–207.
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surveillance—United States, 2019. MMWR Surveill
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4. National Academies of Sciences, Engineering, and
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#20131. Contraception. 2013;87(3):331–42.
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Cesarean Hysterectomy
BrettD.Einerson andAndrewP.Soisson
30
Introduction
The incidence of cesarean hysterectomy, dened
as hysterectomy associated with cesarean delivery, is reported to occur in approximately 71–82
cases per 100,00 deliveries worldwide. The prevalence of cesarean hysterectomy is directly
related to the increasing incidence of cesarean
delivery which is now performed in at least 30%
of all births [1]. The most common indication for
cesarean hysterectomy is maternal hemorrhage
associated with uterine atony (35.3% of cases),
placental accreta spectrum (34.8% of cases), and
uterine rupture/trauma [2, 3]. Uterine atony is the
most common cause of hemorrhage although
abnormal placentation is increasingly recognized
as a key contributor.
Placenta accreta spectrum (PAS) is dened as
abnormal adherence of the placenta to the uterine
myometrium. Abnormal attachment of the placenta directly to the myometrium prevents its
B. D. Einerson
Department of Obstetrics & Gynecology, University
of Utah, Salt Lake City, UT, USA
e-mail: brett.einerson@hsc.utah.edu
A. P. Soisson (*)
Division of Gynecologic Oncology, Department of
Obstetrics & Gynecology, University of Utah,
Salt Lake City, UT, USA
e-mail: andrew.soisson@hci.utah.edu
complete removal leading to almost immediate
hemorrhage [4]. This condition develops due to
disruption of decidualized endometrium in areas
of the uterus that have undergone surgical trauma
such as prior dilation and curettage, prior myomectomy, endometrial ablation, and especially
cesarean section. The incidence of placenta
accreta has now risen to almost 1in 500 births
[5].
Uterine scar rupture is another cause of cesar-
ean hysterectomy and occurs in approximately
0.7–1.6% of those with prior cesarean deliveries
undergoing labor. In patients undergoing a trial of
labor after cesarean (TOLAC), hysterectomy for
uterine rupture is required in 0.19–0.56% [6].
This is a review of the common complications
of cesarean hysterectomy, both in those with and
those without placenta accreta spectrum.
Complications ofSimple Cesarean
Hysterectomy
The most common complications associated with
simple cesarean hysterectomy, which we will
dene as hysterectomy due to uterine atony or
rupture and not PAS, are hemorrhage and surgical site infection (SSI). Injury to the urologic
tract is also common and will be discussed in the
section on the placenta accreta spectrum.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_30
319