CME 11/08/16 – How to make an inpatient referral

Here is Ryan’s talk on general advice on “how to make an inpatient referral”.



## = intranet links

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CME 04/08/16 – Facial Trauma

Here is Ranjit’s and Guy’s (Plastic Surgery Department) presentation on facial trauma.



le fort fractures

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Episode 84 – Congenital Heart Disease Emergencies

Congenital Heart Disease Emergencies on EM cases with Gary Joubert and Ashley Strobel.

You might be surprised to learn that the prevalence of critical cardiac disease in infants is almost as high as the prevalence of infant sepsis. And if you’re like me, you don’t feel quite as confident managing sick infants with critical heart disease as you do managing sepsis. Critical congenital heart defects are often missed in the ED. For a variety of reasons, there are currently more children with congenital heart disease presenting to the ED than ever before and these numbers will continue to grow in the future. When I was in medical school I vaguely remember learning the complex physiology and long lists of congenital heart diseases, which I’ve now all but forgotten. What we really need to know about congenital heart disease emergencies is what actions to take in the ED when we have a cyanotic or shocky baby in front of us in the resuscitation room. So with the goal of learning a practical approach to congenital heart disease emergencies using the child’s age, colour and few simple tests, Dr. Strobel and Dr. Joubert will discuss some key actions, pearls and pitfalls so that the next time you’re faced with that crashing baby in the resuscitation room, you’ll know exactly what to do.

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Recent Elective Abortion

Author: Courtney Cassella, MD (EM Resident Physician, Icahn School of Medicine at Mount Sinai) // Edited by: Alex Koyfman, MD (@EMHighAK)

Clinical Case / Intro

A 24-year-old female with no past medical history presents to the emergency department (ED) with two days of pelvic pain. Three days prior to presentation to the ED, the patient underwent a dilation and aspiration for termination of pregnancy. Physical exam revealed mild suprapubic tenderness to palpation, no cervical laceration, no cervical motion or adnexal tenderness, and moderate dark red blood in the vaginal vault.

In a 2015 study examining 54,911 abortions among fee-for-service California Medicare recipients, 1 of 115 women visited the emergency department for an abortion-related complication. Among these patients, one third received a pathologic diagnosis or treatment.1 This review will attempt to give a base for evaluating these post-procedure patients and provide a framework to help determine who has an abortion-related complication requiring obstetric and gynecology (OB-GYN) consultation.

Definitions and Terminology

  • Induced abortion: medical or surgical abortion
  • Early medical abortion: < 9 weeks gestational age with mifepristone, methotrexate, or misoprostol
  • Surgical abortion
    • Dilation and aspiration or curettage: < 13 weeks with suction or sharp curettage of the uterus
    • Dilation and evacuation: ≥ 13 weeks with suction and sharp curettage through a dilated cervix
  • Unsafe abortion: terminations by persons lacking necessary skill and/or in an environment lacking minimal medical standards
    • Brief note on Unsafe Abortion2-4: Globally, unsafe abortions account for 67,000 maternal deaths annually, the majority in African and Asia.3 The major complications are uterine perforation and bowel injuries. The leading cause of death is septic shock with or without hemorrhage. Although rare in the United States, given the high mortality emergency physicians should be aware of this entity.

Demographics5, 6

  • Estimated 1 million induced abortions in the US per year5
  • Method Type6
    • 5% by Early Medical < 9 weeks
    • 4% by Curettage ≤ 13 weeks
    • 7% by Curettage > 13 weeks
  • 9 abortions per 1,000 women aged 15-44 years5
    • Highest rate 23.3 per 1,000 women in the 20-24 age group6
Percentage of Total Legal Abortions by Age6
Age (years) Percent of all abortions (%)
< 15 0.4
15 – 19 12.2
20 – 29 58.2
30 – 39 25.5
≥ 40 3.7


Induced Abortion Complications Statistics

The complication rate of surgical abortions is 6.1%. These complications occur approximately 1 – 30 days post-procedure with a mean 5 days post-procedure.7 In a 2009 to 2010 report, the overall incidence of adverse events after medical abortion was noted to be 0.65% and major complication rates ranged from 0.1% to 0.23%.8 These complications were defined as events requiring admission, surgery, or blood transfusion.1,8,9 From 1998 to 2010, a total of 108 deaths were causally related to legal induced abortions, with a rate of 0.7 deaths per 100,000.10

Timing of Complications with Induced Abortion11

  • Immediate (within 24 hours): Bleeding, pain
    • Uterine perforation
    • Cervical lacerations
  • Delayed (between 24 hours and 4 weeks): Bleeding or Discharge
    • Retained products of conception
    • Endometritis
  • Late complications (> 4 weeks): Amenorrhea

Hemorrhage12, 13

Post-abortion hemorrhage is defined as clinical response to excessive bleeding (i.e. transfusion or admission) and/or bleeding in excess of 500 mL. 13

  • As much as 7% of women experience bleeding14
  • Risk factors
    • Unsafe abortion
    • Advanced maternal age
    • Insufficient cervical dilation
    • History of more than one cesarean delivery
    • Known bleeding disorder
  • Causes
    • Uterine atony
    • Cervical laceration
    • Uterine perforation or rupture
    • Abnormal placentation
    • Disseminated intravascular coagulation (DIC) (5%)
    • Retained products of conception
  • Key Components of the physical examination
    • Evaluate the cervix for lacerations
    • Conduct a bimanual examination to evaluate for uterine tone and location of a cervical laceration
    • Bedside ultrasound to assess for retained blood or tissue
  • Treatment13
    1. Resuscitate and transfuse as needed
    2. Evaluate for a cervical laceration and repair if found (see below)
    3. Uterine massage
    4. Urgent obstetrics/gynecology consult
    5. Consider uterotonic agents such as methergine, misoprostol, and oxytocin*
      • *Warning: Order only in consultation with OB-GYN
      • First line: Methergine 0.2mg IM or IV, repeat every five minutes, to a maximum of five doses
      • Misoprostol 800 to 1000mcg orally or rectally
      • Oxytocin 10U IM or 10-40U IV

 Cervical Laceration or Injury15

Cervical lacerations or injuries can be seen in anywhere from 0.1% to 3.3% of surgical abortions.7, 12 Most often cervical lacerations are seen as an immediate complication resulting in vaginal bleeding and therefore not as often seen in the ED.

  • Risk factors16
    • Provider inexperience
    • Abnormal uterine cavity
    • Increasing gestational age
    • Nulliparity
    • Adolescent age17
  • Treatment
    • Hemorrhage control
      • Small lacerations may be managed by applying pressure and if no resolution, hemostatic agents such as silver nitrate or Monsel’s solution can be used
      • Large lacerations must be closed with absorbable sutures
      • If hemostasis cannot be achieved vaginal packing may be employed while waiting for consultants
    • Fluids or blood products as indicated
    • Consult OB-GYN

Uterine Perforation15,18

The incidence of uterine perforation after surgical abortion varies between <0.1% and 2.3%14. Commonly, uterine perforation is recognized at the time of the procedure. However, small or partial thickness perforations may initially go unrecognized. Severe cases may cause bowel or bladder perforation.

  • Risk factors16, 19
    • Provider inexperience
    • Abnormal uterine cavity
    • Previous surgery to the cervix
    • Increasing gestational age
    • Multiparity
  • Symptoms
    • Vaginal bleeding
    • Pelvic pain or diffuse abdominal pain
    • Vaginal discharge (rare)
  • Physical examination
    • Vaginal bleeding
    • Suprapubic tenderness
    • Signs of peritonitis (late)
  • Work-up
    • Pre-operative laboratory testing
    • Abdominal x-ray (XR) to evaluate for free air
    • Computed tomography (CT) Abdomen/Pelvis with IV contrast
  • Treatment
    • Resuscitation and pain control as needed
    • Prompt OB-GYN consultation
    • Admit

Ectopic Pregnancy

It is easy to assume all women undergoing medical or surgical abortions have a confirmed intrauterine pregnancy. However, ectopic pregnancies have been found after induced abortions. In two studies, the rate of ectopic pregnancy was 0.7 and 1.77 per 1,000 women undergoing medical and early surgical abortion, respectively.8, 20 In the cases of early medical (<9 wk) or early surgical (<6 wk) abortion, a pseudogestational sacs may be confused with fetal demise of an intrauterine pregnancy. In order to avoid a catastrophic oversight, emergency physicians should risk stratify patients for ectopic pregnancy and if possible review imaging to ensure a confirmed fetal pole and gestational sac prior to the induced abortion. If there is any doubt about ectopic pregnancy radiology ultrasound should be performed.

  • Incidence of ectopic pregnancy in early medical abortion 0.7 per 1,0008
  • Incidence of ectopic pregnancy in early surgical abortion 1.77 per 1,00020
  • Risk stratify patients for ectopic pregnancy
    • Risk factors: Prior ectopic, history of tubal ligation or prior tubal surgery, history of pelvic inflammatory disease, and fertility treatment
    • See emDocs review article on “Ectopic Pregnancy”
  • Review pre-procedure imaging for documentation of intrauterine pregnancy

Retained Products of Conception21

Incidence of retained products of conception is 0.7% to 2.9%.7, 9 Retained products of conception can both present primarily as persistent bleeding or secondarily with an infection (see below).

  • Work-up
    • Complete blood count (CBC)
    • Coagulation panel – platelet count, prothrombin time (PT), partial thromboplastin time (PTT)
      • If abnormal obtain DIC screening
    • Blood type and screen
    • β-hCG
    • Basic metabolic panel (BMP)
    • Ultrasound
  • Treatment
    • Consult OB-GYN
    • Consider admission for dilatation and curettage if there is:
      • Evidence of infection (see below)
      • DIC
      • Retained products for more than 4 weeks

Septic abortion and Endometritis11, 21-23

  • Septic abortion – Spontaneous, medical, or surgical abortion complicated by pelvic infection infecting the products of conception (placenta and fetus)
  • Endometritis – infection of the endometrium
  • Risk Factors
    • Increasing gestational age
    • Retained products of conception
    • Delay in seeking medical attention
    • Unsafe abortion
    • Prolonged vaginal bleeding
  • Most common causes
    • Retained products of conception
    • Introduction of normal or pathologic vaginal bacteria by instrumentation
  • Symptoms
    • Fever
    • Abdominal or pelvic pain
    • Vaginal discharge or bleeding
  • Physical exam
    • Suprapubic tenderness to palpation
    • Closed os
    • Firm and tender uterus
    • Pus or foul smelling fluid from the cervix
  • Work-up
    • β-hCG
    • CBC
    • BMP
    • Lactic acid level
    • Blood type and screen
    • Blood cultures
    • Urinalysis
    • Ultrasound to evaluate for
      • Retained products of conception – thickened endometrium with echogenic contents
      • Adnexal masses
      • Free fluid in the cul-de-sac
    • Consider abdominal XR or CT for free air in the abdomen or gas in the myometrium
  • Treatment
    • Prompt obstetric consultation
    • Fluid resuscitation
    • Broad spectrum antibiotics covering normal vaginal flora and sexually transmitted diseases:

(14 days)

Doxycycline 100mg q12h AND Ceftriaxone 250mg IM
+/- Metronidazole 500mg q12h
Moderate – Severe Clindamycin 900mg IV q8h24 AND Gentamicin 5 mg/kg IV daily24

Doxycycline 100mg IV BID



Ampicillin/sulbactam 3g IV q6h
Cefoxitin 900mg IV q6h


Case Conclusion

The patient’s work-up was notable for an elevated white blood cell count, mild anemia, a plateau of β-hCG, and pelvic ultrasound consistent with retained products of conception. Obstetrics was consulted and the patient was admitted to ambulatory surgery for D&C of retained products of conception.


  • Immediate (<24 hours) complications of induced abortion include hemorrhage and pain, commonly caused by cervical laceration and uterine perforation.
  • Delayed (24 hours – 4 weeks) complications include retained products of conception and infection.
  • Key historical features to evaluate induced abortion complication risk are: prior cervical surgery, prior Caesarean section, increased gestational age, and parity.
  • Consider early OB-GYN consult in any post-abortion patient
  • Risk stratify patients for ectopic pregnancy
  • Review pre-procedure imaging for documentation of intrauterine pregnancy
  • Ultrasound is a key imaging modality for suspected delayed complications of induced abortion.
  • If you suspect septic abortion, cover for normal vaginal flora and sexually transmitted diseases

Further Reading / References

  1. Upadhyay UD, Desai S, Zlidar V, Weitz TA, Grossman D, Anderson P, et al. Incidence of emergency department visits and complications after abortion. Obstetrics and gynecology. 2015;125(1):175-183.
  2. Fawcus SR. Maternal mortality and unsafe abortion. Best practice & research Clinical obstetrics & gynaecology. 2008;22(3):533-548.
  3. Organization WH. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and association mortality in 2003. 5th ed. ed. Geneva: WHO; 2007.
  4. Sama CB, Aminde LN, Angwafo FF, 3rd. Clandestine abortion causing uterine perforation and bowel infarction in a rural area: a case report and brief review. BMC research notes. 2016;9(1):98.
  5. Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2011. Perspectives on sexual and reproductive health. 2014;46(1):3-14.
  6. Pazol K, Creanga AA, Jamieson DJ, Centers for Disease C, Prevention. Abortion Surveillance – United States, 2012. Morbidity and mortality weekly report Surveillance summaries. 2015;64(10):1-40.
  7. Heisterberg L, Kringelbach M. Early complications after induced first-trimester abortion. Acta obstetricia et gynecologica Scandinavica. 1987;66(3):201-204.
  8. Cleland K, Creinin MD, Nucatola D, Nshom M, Trussell J. Significant adverse events and outcomes after medical abortion. Obstetrics and gynecology. 2013;121(1):166-171.
  9. Ireland LD, Gatter M, Chen AY. Medical Compared With Surgical Abortion for Effective Pregnancy Termination in the First Trimester. Obstetrics and gynecology. 2015;126(1):22-28.
  10. Zane S, Creanga AA, Berg CJ, Pazol K, Suchdev DB, Jamieson DJ, et al. Abortion-Related Mortality in the United States: 1998-2010. Obstetrics and gynecology. 2015;126(2):258-265.
  11. Waller N. Complications of Gynecologic Procedures. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.
  12. ACOG Practice Bulletin No. 135: Second-trimester abortion. Obstetrics and gynecology. 2013;121(6):1394-1406.
  13. Kerns J, Steinauer J. Management of postabortion hemorrhage: release date November 2012 SFP Guideline #20131. Contraception. 2013;87(3):331-342.
  14. White K, Carroll E, Grossman D. Complications from first-trimester aspiration abortion: a systematic review of the literature. Contraception. 2015;92(5):422-438.
  15. Allen RH, Goldberg AB, Board of Society of Family P. Cervical dilation before first-trimester surgical abortion (<14 weeks’ gestation). SFP Guideline 20071. Contraception. 2007;76(2):139-156.
  16. Kaunitz AM, Rovira EZ, Grimes DA, Schulz KF. Abortions that fail. Obstetrics and gynecology. 1985;66(4):533-537.
  17. Cates W, Jr., Schulz KF, Grimes DA. The risks associated with teenage abortion. The New England journal of medicine. 1983;309(11):621-624.
  18. Pridmore BR, Chambers DG. Uterine perforation during surgical abortion: a review of diagnosis, management and prevention. The Australian & New Zealand journal of obstetrics & gynaecology. 1999;39(3):349-353.
  19. Grimes DA, Schulz KF, Cates WJ, Jr. Prevention of uterine perforation during curettage abortion. Jama. 1984;251(16):2108-2111.
  20. Paul ME, Mitchell CM, Rogers AJ, Fox MC, Lackie EG. Early surgical abortion: efficacy and safety. American journal of obstetrics and gynecology. 2002;187(2):407-411.
  21. Tucker R, Platt M. Obstetric and Gynecological Emergencies and Rape. In: Stone C, Humphries RL, editors. CURRENT Diagnosis & Treatment Emergency Medicine. 7e ed. New York, NY: McGraw-Hill; 2011.
  22. Lapinsky SE. Obstetric infections. Critical care clinics. 2013;29(3):509-520.
  23. Eschenbach DA. Treating spontaneous and induced septic abortions. Obstetrics and gynecology. 2015;125(5):1042-1048.
  24. Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. The Cochrane database of systematic reviews. 2015(2):CD001067.





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