Abortion Complications

Post-abortion complications present the same way in the ED whether the abortion was procedural, medication-related, or self-induced. Bleeding is most common, but retained products, polymicrobial infection, uterine trauma, and toxic exposures are the diagnoses that can rapidly become life-threatening.

Emergency Evaluation of Abortion Complications

• Nonjudgmental history first: Complication risk turns on gestational age, method used, timing, bleeding, discharge, and systemic symptoms, and patients may not initially disclose a self-induced abortion.
• Pregnancy status and dating: Pregnancy status and last menstrual period anchor the workup because ongoing pregnancy, incomplete abortion, and alternative causes of bleeding all stay on the table early.
• Pelvic exam matters: A pelvic exam is essential because brisk bleeding, tissue at the os, discharge, or visible injury can quickly separate retained products from infection or trauma.
• Ultrasound for dangerous causes: Ultrasound is the key bedside imaging test for retained products and intrauterine findings, with a few practical limits and pitfalls we get into in the episode.
• Baseline resuscitation labs: CBC, coagulation studies, and type and screen help frame hemorrhage severity and transfusion readiness while the team rules out the highest-risk complications.

Major Post-Abortion Complications

• Hemorrhage is most common: Bleeding is the leading complication, and instability or retained products should trigger urgent OB/GYN involvement rather than prolonged ED observation.
• Polymicrobial septic abortion: Infection after abortion is typically polymicrobial, including vaginal flora, anaerobes, and STI pathogens, and can progress to shock, DIC, organ failure, and future sterility.
• Source control mindset: Septic abortion is managed like any other sepsis syndrome, but retained products often make source control the decisive step. We walk through where D&C fits in the episode.
• Retained products of conception: Retained products are more common after unsafe abortion and usually declare themselves with bleeding or infection rather than a subtle exam finding.
• Genital tract and visceral trauma: Foreign body insertion can perforate the vagina, cervix, uterus, bowel, or bladder, and uterine artery injury is a recognized cause of massive hemorrhage.
• Imaging for perforation: FAST, pelvic ultrasound, and CT each have a role when intra-abdominal bleeding or perforation is suspected, with the sequencing nuances covered in the chapter.

Chemical and Medication Toxicity

• Caustic vaginal injury: Inserted caustic substances can cause chemical burns with local tissue damage to the vagina or uterus, so the exam has to look beyond bleeding alone.
• Methotrexate toxicity clues: Methotrexate exposure can produce dermatologic findings plus liver and renal toxicity, and knowing the reported dose helps guide poison-center-informed management.
• Herbal abortifacient toxicity: Pennyroyal and black cohosh are classic herbal abortifacients; they are unreliable and can cause serious hepatic or renal injury. Call Poison Control early.
• Misoprostol and mifepristone context: Medication abortion commonly uses mifepristone 200 mg followed by misoprostol, but in the ED the priority is recognizing complications rather than reconstructing the outpatient regimen.

References:

1. Upadhyay UD, et al. Abortion-related emergency department visits in the United States: An analysis of a national emergency department sample. BMC Med. 2018;16(1):88. Published 2018 Jun 14. PMID: 29898742