8/10/23, 15:52 Abortion Complications: Background, Pathophysiology, Etiology

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Abortion Complications
Updated: Jan 25, 2022
Author: Slava V Gaufberg, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...

OVERVIEW

Background
Complications of spontaneous miscarriages and therapeutic abortions include the following:

Complications of anesthesia

Postabortion triad (ie, pain, bleeding, low-grade fever)

Hematometra

Retained products of conception

Uterine perforation

Bowel and bladder injury

Failed abortion

Septic abortion

Cervical shock

Cervical laceration

Disseminated intravascular coagulation (DIC)

The term "septic abortion" refers to a spontaneous miscarriage or therapeutic/artificial abortion

complicated by a pelvic infection.

Pathophysiology
Postabortion complications develop as a result of 3 major mechanisms as follows: incomplete
evacuation of the uterus and uterine atony, which leads to hemorrhagic complications; infection; and
injury due to instruments used during the procedure.

In septic abortion, infection usually begins as endometritis and involves the endometrium and any
retained products of conception. If not treated, the infection may spread further into the myometrium
and parametrium. Parametritis may progress into peritonitis. The patient may develop bacteremia and

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sepsis at any stage of septic abortion. Pelvic inflammatory disease (PID) is the most common
complication of septic abortion.

Etiology
Two major factors contribute to the development of septic abortion: retained products of conception
and infection introduced into the uterus.

Retained products of conception due to incomplete spontaneous miscarriage or therapeutic abortion

Introduction of infection into the uterus: Pathogens causing septic abortion usually are mixed and
derived from normal vaginal flora and sexually transmitted bacteria. These organisms include the
following:

Escherichia coli and other aerobic, enteric, gram-negative rods

Group B beta-hemolytic streptococci [1]

Staphylococcal organisms [2]

Bacteroides species

Neisseria gonorrhoeae

Chlamydia trachomatis

Clostridium perfringens

Mycoplasma hominis

Haemophilus influenzae

Epidemiology
United States statistics

Frequency of complications depends on gestational age (GA) at the time of miscarriage or abortion
and method of abortion (see the Gestational Age from Estimated Date of Delivery calculator).
Complication rates according to gestational age at the time of abortion are as follows:

8 weeks and under - Less than 1%

8-12 weeks - 1.5-2%

12-13 weeks - 3-6%

Second trimester - Up to 50%, possibly higher

A study that estimated the abortion complication rate on a total of 54,911 abortions, including those
diagnosed or treated at emergency departments, found that abortion complication rates are
comparable to previously published rates even when ED visits are included. The abortion complication
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8/10/23, 15:52 Abortion Complications: Background, Pathophysiology, Etiology

rate for all healthcare sources came to 2.1% (n = 1156) for medication abortion, 1.3% (n = 438) for
first-trimester aspiration abortion, and 1.5% (n = 130) for second-trimester or later abortions. [3, 4]

Medical/Legal Pitfalls
Do not underestimate the amount and rate of bleeding. In the supine position, more than 500 mL of
blood may collect in the vagina without severe external bleeding. Always perform a pelvic examination
on a postabortion patient who is bleeding.

Failure to aggressively treat vaginal bleeding, even if it seems minimal: Stabilize the patient with 2
large-bore IVs and with oxygen. Closely monitor vital signs.

Failure to diagnose uterine perforation may lead to life-threatening complications: In postabortion

patients with abdominal pain beyond the pelvic area, suspect perforation and evaluate with kidney,
ureter, and bladder (KUB)/upright radiographs, pelvic ultrasonography, or CT. Consult a gynecologist
and, if suspicion is high, insist on laparoscopy.

Failure to diagnose ectopic pregnancy: The chance of a missed ectopic pregnancy always exists. Do
not presume intrauterine pregnancy in a patient who has just had an abortion; she may have had a
missed ectopic pregnancy.

Failure to promptly administer broad-spectrum antibiotic therapy may result in complications, including
sepsis and septic shock. Do not delay administration of antibiotics if a patient has signs of severe
postabortion infection. Administer broad-spectrum antibiotics before completing a diagnostic workup.
[5]

Failure to obtain information about recent termination of pregnancy may lead to a wrong diagnosis or
delayed/inappropriate treatment.

Failure to evacuate retained products of conception from the uterus leads to treatment failure and
possible complications.

Failure to diagnose bowel injury may lead to life-threatening complications.

Prognosis
Morbidity/mortality

Mortality and morbidity depend on gestational age at the time of miscarriage or abortion. [6] In the
United States, mortality rates per 100,000 abortions are as follows: fewer than 8 weeks, 0.5%; 11-12
weeks, 2.2%; 16-20 weeks, 14%; and more than 21 weeks, 18%. [7, 8]

Septic abortion remains a primary cause of maternal mortality in the developing world, mostly as a
result of illegal abortions. Unsafe abortions account for nearly one half of abortions, [9] and
morbidity/mortality occurs particularly often women who live in developing nations. [10, 11, 12, 13]

According to the World Health Organization, about 68,000 women die each year due to complications
from unsafe abortions, with sepsis as the main cause of death. [14] In the United States in 2010 (the
most recent year for which data were available), 10 women reportedly died from complications of legal
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induced abortion. [15] There were no reports of deaths associated with known illegally induced
abortions; however, this may be due to reporting issues.

In the United States, mortality from septic abortion rapidly declined after legalization of abortion. Death
now occurs in less than 1 per 100,000 abortions. Figures for most European countries are similar to
US rates.

The risk of death from septic abortion rises with the progression of gestation.

Complications

Other problems to be considered include the following:

Perforated viscus
Acute peritonitis

Complications of septic abortion may include the following:

Pelvic inflammatory disease

Peritonitis

Hemorrhage

Sepsis

Septic shock

Inferior vena cava thrombosis

Patient Education
For patient education resources, see Pregnancy Center, as well as Miscarriage, Abortion, and Dilation
and Curettage (D&C).

Clinical Presentation
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