Abortion, Complications

Last Updated: August 29, 2006

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Synonyms and related keywords: miscarriage, spontaneous abortion, therapeutic abortion, postabortion complications, post-abortion
complications, complications of anesthesia, postabortion tria, pain, bleeing, lo!-grae fe"er, hematometra, retaine proucts of conception,
uterine perforation, bo!el an blaer in#ur$, faile abortion, septic abortion, cer"ical shoc%, cer"ical laceration, isseminate intra"ascular
coagulation, &'C, complications of abortion
AUTHOR INOR!ATION Section " o# "$
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
Author, Sla%a & 'a(#ber), !*, AC+,, Assistant -rofessor of Meicine, .ar"ar Meical /chool0 Associate Chief,
Research &irector, &irector of Eucation an )raining, &epartment of Emergenc$ Meicine, )he Cambrige .ospital
/la"a 1 Gaufberg, M&, *ACE-, is a member of the follo!ing meical societies, American College of Emergenc$
-h$sicians
Eitor2s3, Roy Alson, !*, ,-*, AC+,, AA+!, Meical &irector, 4orth Carolina +aptist AirCare0 Associate
-rofessor, &epartment of Emergenc$ Meicine, (a%e *orest 5ni"ersit$ /chool of Meicine0 rancisco Tala%era,
,-arm*, ,-*, /enior -harmac$ Eitor, eMeicine0 !ark .wan)er, !*, !/A, Assistant -rofessor, &epartment of
Emergenc$ Meicine, )homas 6efferson 5ni"ersit$0 0o-n Halamka, !*, Chief 'nformation 7fficer, CareGroup
.ealthcare /$stem, Assistant -rofessor of Meicine, &epartment of Emergenc$ Meicine, +eth 'srael &eaconess
Meical Center0 Assistant -rofessor of Meicine, .ar"ar Meical /chool0 an ,amela *yne, !*
Associate -rofessor, &epartment of Meicine, &i"ision of Emergenc$ Meicine, 5ni"ersit$ of California at 8os Angeles
/chool of Meicine
&isclosure
INTRO*UCTION Section 1 o# "$
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
/ack)ro(nd: Complications of spontaneous an therapeutic abortions inclue 293 complications of anesthesia, 223
postabortion tria 2ie, pain, bleeing, lo!-grae fe"er3, 2:3 hematometra, 2;3 retaine proucts of conception, 2<3 uterine
perforation, 263 bo!el an blaer in#ur$, 2=3 faile abortion, 2>3 septic abortion, 293 cer"ical shoc%, 2903 cer"ical
laceration, an 2993 isseminate intra"ascular coagulation 2&'C3?
,at-op-ysiolo)y: -ostabortion complications e"elop as a result of : ma#or mechanisms, as follo!s, 293 incomplete
e"acuation of the uterus an uterine aton$, !hich leas to hemorrhagic complications, 223 infection, an 2:3 instrumental
in#ur$?
re2(ency:
In t-e US: *re@uenc$ epens on gestational age 2GA3 at time of abortion an metho of abortion? Complication
rates accoring to GA at time of abortion are as follo!s, 293 fe!er than 6 !ee%s, less than 9A0 223 92-9: !ee%s,
:-6A0 an 2:3 secon trimester, up to <0A, possibl$ higher?
!ortality3!orbidity: Mortalit$ an morbiit$ epen on GA at time of abortion? 'n the 5/, mortalit$ rates per 900,000
abortions are as follo!s, 293 fe!er than > !ee%s, 0?<0 223 99-92 !ee%s, 2?20 2:3 96-20 !ee%s, 9;0 an 2;3 more than 29
!ee%s, 9>?
CLINICAL Section 4 o# "$
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
History: -resentation epens on the t$pe of complication the patient e"elops?
'ntraoperati"e an earl$ postoperati"e complications rarel$ are seen in the E&, but some patients e"elop these
t$pes of complications an present to the E& for treatment? Complications inclue the follo!ing,
o 8ocal anesthesia, -aracer"ical bloc% is the most common metho of anesthesia for therapeutic abortion?
Acciental intra"ascular in#ection of anesthetic is a potentiall$ life-threatening complication of this metho
that coul lea to con"ulsion, cariopulmonar$ arrest, an eath?
o General anesthesia, Complications !ith general anesthesia ma$ lea to uterine aton$ !ith se"ere
hemorrhage?
o Cer"ical shoc%, 1aso"agal s$ncope prouce b$ stimulation of the cer"ical canal uring ilatation ma$
occur? Rapi reco"er$ usuall$ follo!s?
o -ostabortion tria, -ain, bleeing, an lo!-grae fe"ers are the most common presenting complaints?
-ostabortion tria usuall$ is cause b$ retaine proucts of conception?
o .emorrhage, EBcessi"e hemorrhage uring or after abortion ma$ signif$ uterine aton$, cer"ical laceration,
uterine perforation, cer"ical pregnanc$, a more a"ance GA than anticipate, or coagulopath$?
o .ematometra, -atients usuall$ present !ith persistent postabortion bleeing an increase lo!er miline
abominal pain?
o -erforation, -atients !ith uterine perforation misse uring the proceure usuall$ present to the E& !ith
increase abominal pain, bleeing 2possibl$ ranging from "er$ mil to absent3, an fe"er? 'f perforation
results in in#ur$ to ma#or bloo "essels, patients ma$ present in hemorrhagic shoc%?
o +o!el in#ur$, )his ma$ accompan$ uterine perforation? 'f initiall$ unrecogniCe, patients present !ith
abominal pain, fe"er, bloo in the stool, nausea, an "omiting?
o +laer in#ur$, )his occurs as a result of uterine or cer"ical perforation? -atients present !ith suprapubic
pain an hematuria?
o /eptic abortion, -atients present !ith fe"er, chills, abominal pain, an "aginal bleeing?
o *aile abortion 2continue intrauterine or ectopic pregnanc$3, *ailure to terminate pregnanc$ is relati"el$
common !ith "er$ earl$ abortions 2D6 !% GA3? /uch patients ma$ present to the E& !ith s$mptoms of
continuing pregnanc$ such as h$peremesis, increase abominal girth, an breast engorgement? 'n
aition, an unrecogniCe ectopic pregnanc$ in the postabortion perio presents in the usual manner?
o &'C, /uspect &'C in all patients !ho present !ith se"ere postabortion bleeing, especiall$ after
mitrimester abortions? 'ncience is approBimatel$ 200 cases per 900,000 abortions0 this rate is e"en
higher for saline instillation techni@ues 2660 per 900,000 abortions3?
,-ysical:
1ital signs
o Monitoring of "ital signs is essential for patients !ith postabortion complications?
o 'ncreasing fe"er coul be a sign of progressing infection?
o )ach$caria an h$potension ma$ be signs of se"ere hemorrhage or septic shoc%?
Abominal eBamination
o /uprapubic tenerness is common in the postabortion perio? /e"ere tenerness is unusual, ho!e"er, an
ma$ be a sign of hematometra, blaer perforation, or bo!el in#ur$?
o )enerness in other areas of the abomen 2eg, reboun tenerness, guaring3 strongl$ inicates
instrumental in#ur$ complications 2eg, perforation, bo!el in#ur$, blaer in#ur$3?
o A tener mass in suprapubic area suggests hematometra?
o &iminishe or absent bo!el souns are a sign of e"eloping peritonitis?
1aginal eBamination
o Assess the @uantit$ an rate of hemorrhage?
8oo% for possible "aginal or cer"ical in#ur$?
'entif$ the source of bleeing 2eg, intrauterine, cer"ical os, lesions of "ul"a, "agina, or "aginal
portion of cer"iB3?
o Cer"ical motion tenerness on bimanual eBamination ma$ be suggesti"e of pel"ic infection or ectopic
pregnanc$?
o A large tener uterus ma$ be a sign of hematometra?
o AneBal tenerness or masses ma$ suggest ectopic pregnanc$, pel"ic inflammator$ isease 2-'&3, c$st, or
hematoma?
Rectal eBamination
o Rectal eBamination must be performe if bo!el in#ur$ is suspecte?
o -resence of rectal tenerness an bloo 2or guaiac-positi"e stool3 ma%es the iagnosis of bo!el in#ur$
almost certain?
*I+R+NTIALS Section 5 o# "$
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
Abortion, Complete
Abortion, 'ncomplete
Abortion, 'ne"itable
Abortion, Misse
Abortion, /eptic
Abortion, )hreatene
Appenicitis, Acute
&$sfunctional 5terine +leeing
&$smenorrhea
7"arian C$sts
7"arian )orsion
-regnanc$, Ectopic
-regnanc$, )rauma
-regnanc$, 5rinar$ )ract 'nfections
)rauma, 8o!er Genitourinar$
5rinar$ )ract 'nfection, *emale
1aginitis
1ul"o"aginitis
Ot-er ,roblems to be Considered:
-erforate "iscus
Acute peritonitis
6OR7U,
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
Lab St(dies:
Complete bloo count, platelets
/e@uential Multiple Anal$sis-=
+eta-human chorionic gonaotropin0 re@uesting a @uantitati"e le"el ma$ pro"ie useful information an a basis for future comparison?
-rothrombin time/acti"ate partial thromboplastin time
5rinal$sis
)$pe an screen or t$pe an cross !ith antibo$ screen 2!ith se"ere hemorrhage3
*ibrinogen an fibrin split proucts if &'C is suspecte
&-imer
Ima)in) St(dies:
)o eBclue free air as a result of bo!el perforation, perform either upright chest B-ra$ or obtain %ine$, ureter, blaer 2E5+3 an upright
abominal B-ra$s?
7rer or perform ultrasoun !ith a "aginal probe to rule out ectopic pregnanc$, retaine proucts of conception, an hematometra?
7rer arteriograph$ if in#ur$ to large bloo "essels is suspecte?
TR+AT!+NT
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
,re-ospital Care: Monitor "ital signs an pro"ie flui resuscitation if the patient is hemo$namicall$ unstable?
+mer)ency *epartment Care: /creen all patients !ith postabortion complications for Rh factor? Aminister Rho2&3 immune globulin
2RhoGAM3 if results inicate that the patient is Rh-negati"e an unsensitiCe?
-atients !ith the postabortion tria 2ie, pain, bleeing, lo!-grae fe"er3 ma$ respon to treatment !ith oral antibiotics an ergot
preparations? 'mmeiatel$ initiate these agents? 'n most cases, ho!e"er, bloo clots or retaine proucts of conception must be
e"acuate from the uterus? 'n these cases, aminister meications parenterall$, as the patient !ill unergo anesthesia?
.emorrhage or hematometra
o Monitor "ital signs an rate of bleeing? Aminister fluis an bloo as neee?
o Aminister '1 oB$tocin for treatment of uterine aton$?
o Alternati"e treatments for uterine aton$ inclue intracer"ical "asopressin or carboprost tromethamine an bimanual uterine
massage?
o 'f bleeing persists, screen for coagulopath$/&'C an obtain immeiate g$necologic consultation !ith the intention of transferring
the patient to the operating room 27R3 for repeat curettage an, if necessar$, h$sterectom$?
5terine perforation, bo!el in#ur$, an blaer in#ur$, 'f one or an$ combination of these complications is suspecte or iagnose in the
E&, treat as follo!s?
o .emo$namicall$ stabiliCe the patient?
o 'nsert a *ole$ catheter?
o )ransfer to the 7R for laparoscop$/laparotom$ an further treatment?
*aile abortion, continue pregnanc$, an ectopic pregnanc$
o 'f the patient is stable, perform ultrasoun an a beta-human chorionic gonaotropin 2hCG3 test to establish iagnosis an further
treatment?
o 'f the patient is unstable, transfer to the 7R for ilation an curettage 2&FC3 an/or laparoscop$/laparotom$?
Cons(ltations:
Consult an obstetrician/g$necologist 27+/GG43 in all cases of postabortion complications?
Consult surger$ an urolog$ if bo!el or blaer in#ur$ is iagnose?
!+*ICATION
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
)he goals of pharmacotherap$ are to eraicate the infection, reuce morbiit$, an pre"ent complications?
&rug Categor$, Antibiotics -- 'mmeiatel$ aminister broa-spectrum antibiotics to patients !ith se"ere postabortion infection?
*r() Name
CefoBitin 2MefoBin3 -- 'nicate for infections cause b$ susceptible gram-positi"e cocci an
gram-negati"e bacilli? Man$ infections cause b$ gram-negati"e bacteria resistant to some
cephalosporins an penicillins respon to cefoBitin?
Ad(lt *ose
2 g '1 @6h an 900 mg '1 oB$c$cline @92h0 continue at least ; an at least ;> h after
impro"ement0 then 900 mg -7 oB$c$cline bi 90-9;
,ediatric *ose 4ot establishe
Contraindications &ocumente h$persensiti"it$
Interactions
-robeneci ma$ increase effects of cefoBitin0 coaministration !ith aminogl$cosies or
furosemie ma$ increase nephrotoBicit$ 2closel$ monitor renal function3
,re)nancy + - 5suall$ safe but benefits must out!eigh the ris%s?
,reca(tions
+acterial or fungal o"ergro!th of nonsusceptible organisms ma$ occur !ith prolonge use or
repeate treatment0 caution in patients !ith pre"iousl$ iagnose colitis
*r() Name
&oB$c$cline 2+io-)ab, &or$B, 1ibram$cin3 -- )reats infections cause b$ susceptible gram-
negati"e an gram-positi"e organisms, in aition to infections cause b$ susceptible
Rickettsia, Chlamydia, an Mycoplasma species?
Ad(lt *ose 900 mg '1 @92h an 2 g '1 cefoBitin @6h0 continue at least ; an at least ;> h after patient
impro"es0 then 900 mg -7 oB$c$cline bi 90-9;
,ediatric *ose
D92 $ears, 4ot establishe
H92 $ears, Aminister as in aults
Contraindications &ocumente h$persensiti"it$, se"ere hepatic $sfunction
Interactions
+ioa"ailabilit$ ecreases !ith antacis containing Al, Ca, Mg, *e, or +i subsalic$late0
tetrac$clines can increase h$poprothrombinemic effects of anticoagulants0 tetrac$clines can
ecrease effects of -7 contracepti"es, causing brea%through bleeing an increase ris% of
pregnanc$
,re)nancy & - 5nsafe in pregnanc$
,reca(tions
-hotosensiti"it$ ma$ occur !ith prolonge eBposure to sunlight or tanning e@uipment0 reuce
ose in renal impairment0 consier rug serum le"el eterminations in prolonge therap$0
tetrac$cline use uring tooth e"elopment 2last half of pregnanc$ through age > $3 can cause
permanent iscoloration of teeth0 *anconili%e s$nrome ma$ occur !ith outate
tetrac$clines
*r() Name
Gentamicin sulfate 2Garam$cin, Gentaciin3 -- Aminogl$cosie antibiotic for gram-negati"e
co"erage? 5se in combination !ith both an agent against gram-positi"e organisms an an
agent that co"ers anaerobes? 4ot the &7C? Consier if penicillins 2see note abo"e3 or other
less toBic rugs are contrainicate, !hen clinicall$ inicate, an in miBe infections cause
b$ susceptible staph$lococci an gram-negati"e organisms? &osing regimens are numerous0
a#ust ose base on CrCl an changes in "olume of istribution? Ma$ be aministere
'1/'M?
Ad(lt *ose
/erious infections an normal renal function, : mg/%g/ '1 @>h0 monitor renal le"els
8ife-threatening infections, < mg/%g/ '1 @6->h0 monitor renal le"els
Maintenance ose, 9-2?< mg/%g '1 an 9-9?< mg/%g '1, respecti"el$, @>h0 monitor renal le"els
,ediatric *ose
H92 $ears, 9?<-2?< mg/%g/ose '1 @>h or 6-=?< mg/%g/ '1 i"ie @>h0 not to eBcee :00
mg/0 monitor renal le"els, a#ust for renal function as neee0 monitor renal le"els as in
aults
Contraindications &ocumente h$persensiti"it$, nonIial$sis-epenent renal insufficienc$
Interactions
Coaministration !ith other aminogl$cosies, cephalosporins, penicillins, an amphotericin +
ma$ increase nephrotoBicit$0 aminogl$cosies enhance effects of neuromuscular bloc%ing
agents0 thus, prolonge respirator$ epression ma$ occur0 coaministration !ith loop
iuretics ma$ increase auitor$ toBicit$ of aminogl$cosies0 possible irre"ersible hearing loss
of "ar$ing egrees ma$ occur 2monitor regularl$3
,re)nancy C - /afet$ for use uring pregnanc$ has not been establishe?
,reca(tions
4arro! therapeutic ineB 2not intene for long-term therap$30 caution in renal failure 2not on
ial$sis3, m$asthenia gra"is, h$pocalcemia, an conitions that epress neuromuscular
transmission0 a#ust ose in renal impairment
*r() Name
)icarcillin an cla"ulanate potassium 2)imentin3 -- -resumpti"e therap$ prior to ientification
of organism? 'nhibits bios$nthesis of cell !all mucopeptie0 effecti"e uring stage of acti"e
gro!th?
Ad(lt *ose
D60 %g, 200-:00 mg/%g/ '1 i"ie @;-6h
H60 %g, :?9 g '1 @;-6h or 200-:00 mg/%g/ in e@uall$ i"ie oses @;-6h0 not to eBcee 9>-
2; g/
,ediatric *ose Aminister as in aults
Contraindications
&ocumente h$persensiti"it$0 se"ere pneumonia, bacteremia, pericaritis, emph$sema,
meningitis, an purulent or septic arthritis shoul not be treate !ith -7 penicillins uring
acute stage
Interactions
)etrac$clines ma$ ecrease effects0 high concentrations of ticarcillin ma$ ph$sicall$
inacti"ate aminogl$cosies if aministere in same '1 line0 effects !hen aministere
concurrentl$ !ith aminogl$cosies are s$nergistic0 probeneci ma$ increase penicillin le"els
,re)nancy + - 5suall$ safe but benefits must out!eigh the ris%s?
,reca(tions
-erform C+Cs prior to initiation of therap$ an at least !ee%l$ uring therap$0 monitor for
li"er function abnormalities b$ measuring A/) an A8) uring therap$0 eBercise caution in
patients iagnose !ith hepatic insufficiencies0 perform 5A an +54 an creatinine
eterminations uring therap$ an a#ust ose if "alues become ele"ate0 monitor bloo
le"els to a"oi possible neurotoBic reactions
*r() Name
Ampicillin an sulbactam soium 25nas$n3 -- &rug combination of beta-lactamase inhibitor
!ith ampicillin? Co"ers s%in, enteric flora, an anaerobes? 4ot ieal for nosocomial
pathogens?
Ad(lt *ose
9?< 29 g ampicillin J 0?< g sulbactam3 to : g 22 g ampicillin J 9 g sulbactam3 '1/'M @6->h0 not
to eBcee ; g/ sulbactam
,ediatric *ose
4ot establishe for peiatric patients !ith intra-abominal infections
H;0 %g, Aminister as in aults
Contraindications &ocumente h$persensiti"it$
Interactions
-robeneci an isulfiram ele"ate ampicillin le"els0 allopurinol ecreases ampicillin effects
an has aiti"e effects on ampicillin rash0 ma$ ecrease effects of -7 contracepti"es
,re)nancy + - 5suall$ safe but benefits must out!eigh the ris%s?
,reca(tions A#ust ose in renal failure0 e"aluate rash an ifferentiate from h$persensiti"it$ reaction
*r() Name
'mipenem an cilastatin soium 2-rimaBin3 -- )reats multiple-organism infections for !hich
other agents lac% !ie-spectrum co"erage or are contrainicate ue to potential toBicit$?
Ad(lt *ose
2<0-<00 mg '1 i"ie @6h0 not to eBcee :-; g/, base on se"erit$ of infection
Alternati"el$, aminister <00-=<0 mg 'M or intra-abominall$ @92h
,ediatric *ose
9<-2< mg/%g/ose '1 @6h0 maBimum ail$ ose for full$ susceptible organisms is 2 g/0 for
infections !ith moeratel$ susceptible organisms, maBimum ose is ; g/
Contraindications &ocumente h$persensiti"it$
Interactions
Coaministration !ith c$closporine ma$ increase C4/ a"erse effects of both agents0
coaministration !ith ganciclo"ir ma$ result in generaliCe seiCures
,re)nancy C - /afet$ for use uring pregnanc$ has not been establishe?
,reca(tions A#ust ose in renal insufficienc$
*r() Name
-iperacillin an taCobactam soium 2Kos$n3 -- )reats septicemia cause b$ susceptible
organisms?
Ad(lt *ose 92 g piperacillin J 9?< g taCobactam '1 in e@uall$ i"ie oses of : g @6h for =-90
,ediatric *ose
D92 $ears, 4ot establishe
H92 $ears, Aminister as in aults
Contraindications &ocumente h$persensiti"it$
Interactions )etrac$clines ma$ ecrease effects of ticarcillin0 high concentrations of ticarcillin ma$
ph$sicall$ inacti"ate aminogl$cosies if aministere in same '1 line0 effects !hen
aministere concurrentl$ !ith aminogl$cosies are s$nergistic0 probeneci ma$ increase
penicillin le"els
,re)nancy + - 5suall$ safe but benefits must out!eigh the ris%s?
,reca(tions
-erform C+Cs prior to initiation of therap$ an at least !ee%l$ uring therap$0 monitor for
li"er function abnormalities b$ measuring A/) an A8) uring therap$0 eBercise caution in
patients iagnose !ith hepatic insufficiencies0 perform 5A an +54 an creatinine
eterminations uring therap$ an a#ust ose if "alues become ele"ate0 monitor bloo
le"els to a"oi possible neurotoBic reactions
*r() Name
Clinam$cin 2Cleocin3 -- 5seful as treatment against aerobic streptococci an most
staph$lococci? 'nhibits bacterial gro!th, possibl$ b$ bloc%ing issociation of pepti$l t-R4A
from ribosomes, causing R4A-epenent protein s$nthesis to arrest?
Ad(lt *ose /erious infections ue to aerobic an anaerobic organisms, 600-9200 mg/ '1 i"ie @6->h
,ediatric *ose
>-96 mg/%g/ '1 i"ie ti/@i
/e"ere infections, 96-20 mg/%g/ i"ie ti/@i
Contraindications &ocumente h$persensiti"it$0 pseuomembranous colitis0 hepatic impairment
Interactions
'ncreases uration of neuromuscular bloc%ae, inuce b$ tubocurarine an pancuronium0
er$throm$cin ma$ antagoniCe effects0 antiiarrheals ma$ ela$ absorption
,re)nancy + - 5suall$ safe but benefits must out!eigh the ris%s?
,reca(tions
A#ust ose in se"ere hepatic $sfunction0 no a#ustment necessar$ in renal insufficienc$0
associate !ith se"ere an possibl$ fatal colitis
*r() Name
CefotaBime 2Claforan3 -- )reats septicemia an g$necologic infections cause b$ susceptible
organisms? Arrests bacterial cell !all s$nthesis, !hich in turn inhibits bacterial gro!th?
Ad(lt *ose
Moerate-to-se"ere infections, 9-2 g '1/'M @6->h
8ife-threatening infections, 9-2 g '1/'M @;h
,ediatric *ose
D92 $ears, 4ot establishe
H92 $ears, Aminister as in aults
Contraindications &ocumente h$persensiti"it$
Interactions
-robeneci ma$ increase cefotaBime le"els0 coaministration !ith furosemie an
aminogl$cosies ma$ increase nephrotoBicit$
,re)nancy + - 5suall$ safe but benefits must out!eigh the ris%s?
,reca(tions A#ust ose in se"ere renal impairment0 has been associate !ith se"ere colitis
*r() Name
1ancom$cin .C8 21ancocin, 1ancole3 -- -otent antibiotic irecte against gram-positi"e
organisms an acti"e against enterococcal species? 5seful in the treatment of septicemia
an s%in structure infections? 'nicate for patients !ho cannot recei"e or ha"e faile to
respon to penicillins an cephalosporins or !ho ha"e infections !ith resistant
staph$lococci? )o a"oi toBicit$, current recommenation is to assa$ onl$ "ancom$cin trough
le"els after the thir ose, ra!n 0?< h before neBt osing? &oses an osing inter"als ma$
be a#uste base on CrCl?
Ad(lt *ose <00 mg/ to 2 g/ '1 ti/@i for =-90
,ediatric *ose ;0 mg/%g/ '1 i"ie ti/@i for =-90
Contraindications &ocumente h$persensiti"it$
Interactions
Er$thema, histamineli%e flushing an anaph$lactic reactions ma$ occur !hen aministere
!ith anesthetic agents0 ta%en concurrentl$ !ith aminogl$cosies, ris% of nephrotoBicit$ ma$
increase abo"e that !ith aminogl$cosie monotherap$0 effects in neuromuscular bloc%ae
ma$ be enhance !hen coaministere !ith nonepolariCing muscle relaBants
,re)nancy C - /afet$ for use uring pregnanc$ has not been establishe?
,reca(tions
Caution in renal failure, neutropenia0 Lre manM s$nrome is cause b$ too rapi '1 infusion
2ose aministere o"er a fe! min3 but rarel$ happens !hen ose gi"en as 2-h
aministration or as -7 or '- aministration0 re man s$nrome is not an allergic reaction
&rug Categor$, Ergot alkaloids -- Ergot eri"ati"es are use for oB$tocic effects on uterine muscle? )hese agents pre"ent postabortion
uterine aton$ an hemorrhage?
*r() Name
Ergono"ine maleate 2Ergotrate Maleate3 -- -re"ents an treats postabortal hemorrhage ue
to uterine aton$ b$ proucing a firm contraction of the uterus !ithin minutes? Although
intene primaril$ for 'M aministration, faster response can be achie"e through '1
aministration? .o!e"er, because '1 route prouces higher incience of a"erse effects,
reser"e for emergencies such as eBcessi"e uterine bleeing? /e"ere uterine bleeing ma$
re@uire repeate oses but selom re@uires more than 9 in#ection @2-;h?
Ad(lt *ose 0?2 mg 'M/'1 repeat @2-;h if neee
,ediatric *ose 4ot establishe
Contraindications &ocumente h$persensiti"it$, not to be use in cases of threatene spontaneous abortion
Interactions
Concurrent aministration of meth$lergono"ine !ith "asoconstrictors or other ergot al%alois
ma$ prouce aiti"e effect
,re)nancy N - Contrainicate in pregnanc$
,reca(tions
&iscontinue if ergotism e"elops0 caution in heart isease, h$pertension, mitral-"al"e
stenosis, "enoatrial shunts, sepsis, obliterati"e "ascular isease, or hepatic or renal
impairment
*r() Name
Meth$lergono"ine 2Methergine3 -- Acts irectl$ on the smooth muscle of the uterus0 inuces a
rapi an sustaine tetanic uterotonic effect that reuces bleeing?
Ad(lt *ose
0?2 mg 'M
/e"ere uterine bleeing, Repeat oses @2-;h0 same ose ma$ be aministere '1 to
prouce @uic%er response0 ho!e"er, because '1 route prouces higher incience of a"erse
effects, reser"e for emergencies such as eBcessi"e uterine bleeing
,ediatric *ose 4ot establishe
Contraindications &ocumente h$persensiti"it$, glaucoma, )ourette s$nrome, anBiet$
Interactions
Concurrent aministration of meth$lergono"ine !ith "asoconstrictors or other ergot al%alois
ma$ prouce aiti"e effect
,re)nancy C - /afet$ for use uring pregnanc$ has not been establishe?
,reca(tions Caution in sepsis, obliterati"e "ascular isease, or hepatic or renal insufficienc$
OLLO68U,
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
(rt-er Inpatient Care:
'npatient treatment inclues repeat &FC, laparoscop$, an laparotom$ 2for treatment of complicate perforation, bo!el an blaer
in#uries, refractor$ bleeing3?
(rt-er O(tpatient Care:
'f the patient is ischarge from the E&, arrange efinite follo!-up care in 9-2 a$s !ith primar$ g$necologist?
*eterrence3,re%ention:
Eucate patients about contracepti"e measures to eter them from using abortion as a means of birth control?
,atient +d(cation:
*or eBcellent patient eucation resources, "isit eMeicineOs -regnanc$ an Reprouction Center
eMeicineOs patient eucation articles Miscarriage, Abortion, an &ilation an Curettage 2&FC3
!ISC+LLAN+OUS
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
!edical3Le)al ,it#alls:
&o not unerestimate the amount an rate of bleeing? 'n the supine position, more than <00 cc of bloo ma$ collect in the "agina
!ithout se"ere eBternal bleeing? Al!a$s perform a pel"ic eBamination on a postabortion patient !ho is bleeing?
Aggressi"el$ treat "aginal bleeing e"en if it seems minimal? /tabiliCe the patient !ith 2 large-bore '1s an !ith oB$gen? Closel$ monitor
"ital signs?
'n postabortion patients !ith abominal pain be$on the pel"ic area, suspect perforation an e"aluate !ith E5+/upright B-ra$s an
pel"ic ultrasoun? Consult a g$necologist an, if suspicion is high, insist on laparoscop$?
)he chance of a misse ectopic pregnanc$ al!a$s eBists? &o not presume intrauterine pregnanc$ in a patient !ho has #ust ha an
abortion0 she ma$ ha"e ha a misse ectopic pregnanc$?
&o not ela$ aministration of antibiotics if a patient has signs of se"ere postabortion infection? Aminister broa-spectrum antibiotics
before completing iagnostic !or%up?
/I/LIO'RA,H9
Author 'nformation 'ntrouction Clinical &ifferentials (or%up )reatment Meication *ollo!-up Miscellaneous +ibliograph$
&arne$ -&, e, .anboo% of 7ffice an Ambulator$ G$necologic /urger$? +lac%!ell /cience, 'nc0 99>=,90>?
Grimes &A, Cates ( 6r, &eaths from paracer"ical anesthesia use for first-trimester abortion, 99=2-99=<? 4 Engl 6 Me 99=6 &ec 960
29<22<3, 9:9=-9PMelineQ?
.a%im-Elahi E, )o"ell .M, +urnhill M/, Complications of first-trimester abortion, a report of 9=0,000 cases? 7bstet G$necol 9990 6ul0
=6293, 929-:<PMelineQ?
/am C, .ami MA, /!an 4, -$ometra associate !ith retaine proucts of conception? 7bstet G$necol 9999 Ma$0 9:2< -t 23,
>;0PMelineQ?
/hannon C, +rothers 8-, -hilip 4M, (ini%off +, 'nfection after meical abortion, a re"ie! of the literature? Contraception 200; /ep0
=02:3, 9>:-90PMelineQ?
/hulman /G, +ell C8, .ampf *E, 5terine perforation an small bo!el incarceration, sonographic an surgical finings? Emerg Raiol
2006 Aug 960PMelineQ?
/tuart G/, /heffiel 6/, .ill 6+, et al, Morbiit$ that is associate !ith curettage for the management of spontaneous an inuce
abortion in !omen !ho are infecte !ith .'1? Am 6 7bstet G$necol 200; /ep0 9992:3, 99:-=
/tubblefiel -G, *irst an secon trimester abortion? 'n, 4ichols &., e? G$necologic an 7bstetric /urger$? Mosb$-Gear +oo%0
999:,9096-90:0?
/tubblefiel -G, Grimes &A, /eptic abortion? 4 Engl 6 Me 999; Aug ;0 ::92<3, :90-;PMelineQ
/tubblefiel -G, -regnanc$ termination? 'n, 7bstetrics, 4ormal an -roblem -regnancies? :r e? Churchill 8i"ingstone0 9996,92;9-
92=6?
NOT+:
Meicine is a constantl$ changing science an not all therapies are clearl$ establishe? 4e! research changes rug an treatment therapies ail$? )he authors, eitors, an publisher of this #ournal ha"e use their best efforts
to pro"ie information that is up-to-ate an accurate an is generall$ accepte !ithin meical stanars at the time of publication? .o!e"er, as meical science is constantl$ changing an human error is al!a$s possible, the
authors, eitors, an publisher or an$ other part$ in"ol"e !ith the publication of this article o not !arrant the information in this article is accurate or complete, nor are the$ responsible for omissions or errors in the article or
for the results of using this information? )he reaer shoul confirm the information in this article from other sources prior to use? 'n particular, all rug oses, inications, an contrainications shoul be confirme in the
pac%age insert? *588 &'/C8A'MER