Complications at the time of second-trimester surgical abortion, or dilation and evacuation (D&E), are rare, ranging from 0.7–3.0% depending on the setting and definition of complication.1–5 Although D&Es are common and safe outpatient procedures, possible complications can include cervical laceration, uterine perforation, infection, and hemorrhage.3 Postabortion hemorrhage—specifically, hemorrhage related to disseminated intravascular coagulation (DIC)—is of particular concern owing to the possibility of excessive and uncontrolled blood loss, possibly requiring a transfusion or in extreme cases resulting in maternal death.6 Moreover, D&E for fetal death has been associated with higher rates of morbidity and mortality compared with D&E for pregnancy termination.1 Although numerous studies have described known risk factors for abortion complications,3,4 there is conflicting evidence about the association between fetal death and DIC and postabortion hemorrhage.
Case studies and review articles dating back to the 1950s describe an association between fetal death and coagulation disorders, especially in the case of a retained fetus.7–11 Disseminated intravascular coagulation can be the result of hemorrhage or a spontaneous or idiopathic process12,13; and potential mechanisms include platelet activation, excessive thrombin generation, and the release of tissue factor at the time of separation of the membranes and the placenta.6,13–15 Such hematologic changes may be especially pronounced in the context of prolonged fetal retention after fetal death. Coagulopathy mediated by thromboplastin-like material from products of conception after fetal death has been found in up to 25%16 and up to a third17 of the cases in which the deceased fetus was retained for longer than a month.
Despite the association, DIC is still a rare occurrence with fetal death. This may be because spontaneous delivery typically occurs within 2 weeks of fetal death, whereas more time may be required for coagulopathic changes.16 This is supported by a recent study demonstrating that time since fetal death (more than 4 weeks vs less) was associated with an increased risk of hemorrhage (23% vs 4%; P=.002).18 The few small studies evaluating the association between fetal death and DIC have not found a statistically significant association, but their findings do suggest that fetal death may be linked to morbidity and coagulopathy in unique ways.1,18,19
The limited evidence regarding the risk of postabortion hemorrhage in cases of fetal death makes it difficult to create guidelines for appropriate preoperative preparation, counseling of patients, and anticipation of interventions that may be needed. There are no well-controlled studies with a large enough sample size to rigorously evaluate the association of fetal death and abortion-related hemorrhage and DIC. The aim of this study is to determine the risk of postabortion hemorrhage for patients with fetal death in the second trimester using a large cohort from a public, urban abortion clinic.
We conducted a retrospective cohort study of D&Es at San Francisco General Hospital's Women's Options Center between February 2009 and April 2013. The Women's Options Center is an outpatient abortion clinic located within a large public hospital and affiliated with an academic medical center. The clinic serves women in the Bay Area as well as referrals from California and out of state and does about 1,800 abortions each year, approximately half of which are second-trimester procedures. Patients undergoing D&E abortions typically are seen for two-day appointments: the first day includes counseling, history and physical exam, consent, and dilator placement; the D&E is done on the second day. We offer nurse-administered intravenous moderate sedation with fentanyl and midazolam or anesthesiologist-administered deep sedation with propofol to all women undergoing D&E. We routinely use intraoperative ultrasound guidance, administer prophylactic antibiotics, and offer all forms of contraception. After D&E, patients recover for a minimum of 60 minutes before discharge.
Our primary outcomes were DIC or postabortion hemorrhage. We defined hemorrhage as estimated blood loss more than 500 cc or bleeding requiring interventions such as two or more doses of uterotonics, intrauterine balloon tamponade, uterine re-aspiration, transfusion of blood products, or additional surgery. We defined DIC as cases where the physician noted DIC on the operative or postoperative notes. Although we did not collect data on laboratory evaluation or confirmation of DIC, it is the practice of all Women's Options Center physicians to send labs in cases of suspected DIC.
Using an existing database of all abortions conducted at the Women's Options Center, we identified all D&Es done for fetal death. A comparison group included all other women seen during the same timeframe for D&E for pregnancy termination. We reviewed medical records for each case of hemorrhage to confirm that hemorrhage met the above definitions and to abstract further information regarding the management and resolution of complications. Cases documented as “hemorrhage” that did not meet any of the above definitions of a hemorrhage complication were no longer classified as hemorrhage. We excluded multiple gestations and cases of abnormal placentation as well as cases where demographic and obstetric history were not available. We abstracted data using REDCap, a secure web application for data collection and management.
The primary predictor in our analysis was diagnosis of fetal death. In unadjusted analyses comparing the fetal death cohort to the cohort of D&Es for other reasons, we assessed age, race–ethnicity, body mass index, parity, prior abortion, prior vaginal delivery, prior cesarean delivery, gestational age, need for mechanical dilation on the day of the D&E, and physician training level (resident, family planning fellow, or attending). When appropriate, we compared proportions using chi-square tests with P-values and 95% CIs and Fisher's exact test for cell sizes of five or less. We then compared the primary outcomes of hemorrhage, DIC, and overall complications using logistic regression, adjusting for covariates that were associated with the outcome in unadjusted analyses at P≤0.1, only adjusting for as many as permissible based on the number of events for each outcome. We performed statistical analyses using STATA 11.2. We obtained approval for the study from the Committee on Human Research through the University of California, San Francisco.
During the study period, 92 D&Es were done for fetal death and 4,428 were done for other reasons. Women with fetal death were older (30.0 vs 26.5 years, P<.001), more likely to be nonwhite (77% vs 70%, P=.04), and presented at an earlier gestation (17.0 vs 19.8 weeks, P<.001) (Table 1).
In unadjusted analyses, overall complications with D&E occurred in 10% of the entire cohort, and major complications occurred in 2% with no differences between D&Es done for fetal death versus other D&Es. Hemorrhage was similar between the two groups (10% vs 7%, respectively, P=.28), whereas DIC was significantly more common in the fetal death group (2.0% vs 0.2%, P<.001) (Table 2). In unadjusted analyses, hemorrhage was significantly associated with increasing patient age, history of vaginal delivery, history of cesarean delivery, and increasing gestation (Table 3), and fetal death was significantly associated with increased odds of DIC (odds ratio [OR])=12.3, 95% CI 2.6–58.6, P<.001) (Table 4).
We conducted an adjusted analysis for the primary outcomes of hemorrhage and any abortion complication. We only conducted an unadjusted analysis for the association between fetal death and DIC, as the number of cases of DIC was too low to permit adjustment. After adjusting for all covariates, hemorrhage was significantly associated with fetal death (OR 2.9, 95% CI 1.4–6.0, P=.006), prior vaginal delivery (OR 1.7, 95% CI 1.3–2.2, P<.001), prior cesarean delivery (OR 2.2, 95% CI 1.7–3.0, P<.001), and each additional week of gestation (OR 1.3, 95% CI 1.3–1.4, P<.001). The results were the same regardless of whether we defined hemorrhage as estimated blood loss greater than 500 cc or as needing to apply interventions for hemorrhage. In the unadjusted analysis of DIC, fetal death was significantly associated with 12.3 times higher odds of DIC (95% CI 2.6–58.6) (Table 4). Finally, in our adjusted analysis of any abortion complication, we found significant associations with the following covariates: fetal death (OR 3.0, 95% CI 1.6–5.9, P=.001), prior vaginal delivery (OR 1.5, 95% CI 1.2–1.9, P<.001), prior cesarean delivery (OR 1.8, 95% CI 1.4–2.3, P<.001), and each additional week of gestation (OR 1.4, 95% CI 1.3–1.4, P<.001) (Table 5).
In this large observational cohort study examining postabortion hemorrhage and DIC after D&E, we found significantly increased risks of both hemorrhage and DIC among women with fetal death. Women undergoing D&E for fetal death were 2.9 times more likely to experience hemorrhage and 12 times more likely to experience DIC. To our knowledge, this is the first study to demonstrate a statistically significant increase in the risk of DIC associated with fetal death at the time of D&E. Our 0.2% incidence of DIC is also remarkably consistent with incidences reported in other studies.3,20,21
Consistent with our findings, a recent study demonstrated that the incidence of hemorrhage and DIC at the time of D&E for fetal death is low. They found no association between fetal death and DIC but did find that the risk of DIC was higher with increasing time since fetal death.18 This study was likely limited by sample size to detect significant associations, with less than one-tenth the number of patients as our study. Another study comparing 242 women who underwent uterine evacuation for fetal death or induced abortion concluded that treatment for fetal death in the second trimester was not significantly associated with increased maternal morbidity compared with induced abortions. However, when the authors excluded intravenous antibiotic use as indication of major maternal morbidity, they found fetal death was associated with significantly more morbidity than induced abortion alone. Although a higher transfusion rate was seen among the fetal death cohort compared with the pregnancy termination cohort (5.8% vs 0.8%), that difference was not statistically significant (P=.07), and it is not known whether these transfusions were administered for hemorrhage or DIC.19
In a study evaluating coagulopathy among D&Es done for fetal death and other reasons where excessive bleeding occurred, it was noted that initiation of bleeding was earlier in the pregnancy termination group compared with the fetal death group. In addition, no significant changes in coagulation parameters were noted in the pregnancy termination group with the onset or progression of bleeding, whereas coagulation changes were seen in the fetal death group, notably at the initiation of bleeding. The findings imply that there may be a different pathophysiology for bleeding among D&E cases for fetal death.1 Another study demonstrated that increasing gestational age is associated with DIC,21 which is consistent with findings from this study as well. We did observe an increased risk of hemorrhage among those with prior vaginal deliveries, cesarean deliveries, and increasing gestation, findings that are consistent with the literature.
A strength of our study was that it was large enough to detect associations with a rare outcome. We also had clear descriptions of the complications we measured. There were a few limitations to our study. For most cases, we did not have documentation of the time since fetal death, limiting any analysis of complication incidence by duration of fetal retention after fetal death. Given the association between prolonged fetal retention after fetal death and coagulopathy reported in other studies, research evaluating the association between time since fetal death and DIC risk in the setting of fetal death is warranted. Additionally, the comparison group was not randomly selected, but included all other patients seen during the study period provided they did not meet exclusion criteria.
Ultimately, women undergoing D&E with fetal death were found to have increased odds of DIC and hemorrhage. However, the overall incidence of DIC among women with fetal death was low (2%). There is no evidence that any preoperative measures alter the risk of DIC, but D&E providers should have a high suspicion for DIC if they encounter bleeding at the time of D&E. Although patients with fetal death can be cared for safely in an outpatient setting, providers may consider fetal death alongside other known risk factors when deciding what level of care is best. Given the low incidence of DIC, we do not recommend any specific or additional preoperative or intraoperative management for women undergoing D&E for fetal death.
1. Ben-Ami I, Fuchs N, Schneider D, Pansky M, Halperin R. Coagulopathy associated with dilation and evacuation for second-trimester abortion. Acta Obstet Gynecol Scand 2012;9:10–15.
2. Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011;117:788–92.
3. Frick AC, Drey EA, Diedrich JT, Steinauer JE. Effect of prior cesarean delivery on risk of second-trimester surgical abortion complications. Obstet Gynecol 2010;115:760–4.
4. Lederle L, Steinauer JE, Montgomery A, Aksel S, Drey EA, Kerns JL. Obesity as a risk factor for complications after second-trimester abortion by dilation and evacuation. Obstet Gynecol 2015;126:585–92.
5. Peterson WF, Berry FN, Grace MR, Gulbranson CL. Second-trimester abortion by dilatation and evacuation: an analysis of 11,747 cases. Obstet Gynecol 1983;62:185–90.
6. Kerns J, Steinauer J. Management of postabortion hemorrhage: release date November 2012 SFP Guideline #20131. Contraception 2013;87:331–42.
7. Corbett HV. The management of intra-uterine death of the foetus. J Obstet Gynaecol Br Emp 1958;65:100–5.
8. Moore CM, McAdams AJ, Sutherland J. Intrauterine disseminated intravascular coagulation: a syndrome of multiple pregnancy with a dead twin fetus. J Pediatr 1969;74:523–8.
9. Ratnoff OD, Pritchard JA, Colopy JE. Hemorrhagic states during pregnancy. N Engl J Med 1955;253:63–9.
10. Reid DE, Roby CC, Weiner AE. Coagulation defects in severe intrapartum and postpartum hemorrhage. JAMA 1956;161:1244–7.
11. Weiner AE, Reid DE, Roby CC, Diamond LK. Coagulation defects with intrauterine death from Rh isosensitization. Am J Obstet Gynecol 1950;60:1015–22.
12. Erez O. Disseminated intravascular coagulation in pregnancy—clinical phenotypes and diagnostic scores. Thromb Res 2017;151:S56–60.
13. Erez O, Mastrolia SA, Thachil J. Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management. Am J Obstet Gynecol 2015;213:452–63.
14. Erez O, Gotsch F, Mazaki-Tovi S, Vaisbuch E, Kusanovic JP, Kim CJ, et al. Evidence of maternal platelet activation, excessive thrombin generation, and high amniotic fluid tissue factor immunoreactivity and functional activity in patients with fetal death. J Matern Fetal Neonatal Med 2009;22:672–87.
15. Krikun G, Huang ST, Schatz F, Salafia C, Stocco C, Lockwood CJ. Thrombin activation of endometrial endothelial cells: a possible role in intrauterine growth restriction. Thromb Haemost 2007;97:245–53.
16. Thachil J, Toh CH. Disseminated intravascular coagulation in obstetric disorders and its acute haematological management. Blood Rev 2009;23:167–76.
17. Letsky EA. Disseminated intravascular coagulation. Best Pract Res Clin Obstet Gynaecol 2001;15:623–44.
18. Fontenot Ferriss AN, Weisenthal L, Sheeder J, Teal SB, Tocce K. Risk of hemorrhage during surgical evacuation for second-trimester intrauterine fetal demise. Contraception 2016;94:496–8.
19. Edlow AG, Hou MY, Maurer R, Benson C, Delli-Bovi L, Goldberg AB. Uterine evacuation for second-trimester fetal death and maternal morbidity. Obstet Gynecol 2011;117:307–16.
20. Kafrissen ME, Barke MW, Workman P, Schulz KF, Grimes DA. Coagulopathy and induced abortion methods: rates and relative risks. Am J Obstet Gynecol 1983;147:344–5.
21. York S, Lichtenberg ES. Characteristics of presumptive idiopathic disseminated intravascular coagulation during second-trimester induced abortion. Contraception 2012;85:489–95.