Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more
bleeding than procedural abortion, overall
bleeding for the two methods is minimal and not clinically different.
Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical
laceration, and retained tissue. Evidence for practices around
postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of
hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine
scar and complete
placenta previa seeking abortion at gestations after the first trimester should be evaluated for
placenta accreta spectrum. For those at high risk of
hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating
postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine
massage and medical
therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of
oxytocin as prophylaxis for
bleeding with dilation and evacuation;
methylergonovine prophylaxis, however, is associated with more
bleeding at the time of dilation and evacuation. Future research is needed on
tranexamic acid as prophylaxis and treatment and
misoprostol as prophylaxis. Structural inequities contribute to
bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.