Hesperian Health Guides

Hesperian Health Guides

Complications of Abortion

A woman with any of the danger signs after abortion needs medical help fast! She should go immediately to a health center or hospital where she can get the care she needs. Most of the time the womb must be emptied completely using vacuum aspiration (MVA) or a D and C. In the meantime, the information on the next 8 pages may help if transport is not available immediately or if medical care is very far away.

Early treatment of abortion complications prevents illness, infertility, and death. Seek help quickly if you have problems after an abortion. DO NOT WAIT!

a woman leaning on pillows with a pool of blood between her legs

Heavy bleeding from the vagina

Heavy bleeding is the most common problem after an abortion. It is usually caused by pieces of the pregnancy that are left in the womb. The womb cannot squeeze itself shut and keeps bleeding. This is called an incomplete abortion. If the pieces are removed, often the bleeding will stop. Sometimes the bleeding is caused by a torn cervix which must be stitched for the bleeding to stop.

A woman is bleeding too much if she soaks more than 2 heavy pads or cloths in one hour for 2 hours in a row. A slow, steady trickle of bright red blood is also dangerous. When this happens, a woman may quickly lose a dangerous amount of blood. If it is not possible to get medical help immediately, try to stop the bleeding.

To stop the bleeding

a woman leaning on pillows and rubbing her lower belly

A woman who is bleeding too much may be able to help her womb squeeze shut with massage. She can do this herself or have someone else do it. Rub or massage the lower belly very hard while lying down or squatting.

If there are pieces of tissue stuck in the womb or cervix, she may be able to push them out herself by squatting and bearing down as if passing stool or giving birth.

Even if these treatments seem to work, get medical help as soon as possible. The woman will need antibiotics and may still need to have her womb emptied completely.

Emergency Help for Too Much Bleeding

Health workers and others trained in giving a woman a pelvic exam may be able to follow these steps to try and stop the bleeding until the womb can be emptied.

IMPORTANT! Because the entrance to the woman's womb is open, putting anything inside her vagina is very dangerous. She can get a serious infection. Only do this if the bleeding is so heavy the woman's life is in danger.
  1. Wash your hands and the woman‘s genitals with soap and clean water.

  2. Put a clean latex or plastic glove or a very clean plastic bag on one hand. The gloved hand should not touch anything before it goes into the woman’s vagina.

  3. Have the woman lie on her back with her feet and knees apart. Help her relax.
  4. Use sterile forceps to remove any tissue you see at the opening of the womb.
  5. If you have a sterile speculum (you can get the right instruments from an IUD kit if you have one), put it into the vagina so you can see the opening of the womb. If you can see tissue or clots or lumps of blood there, try to get hold of them with sterile forceps or clamps and gently remove them.

  6. a woman's cervix seen through a speculum in her vagina
    the cervix, opening of the womb
  7. If you do not have a speculum, reach inside the woman’s vagina with your gloved hand, first with 1 finger, and then with 2 fingers.

  8. Feel for the cervix. It will feel more firm and smooth than the skin around it. It looks like this.

  9. Move your finger across the opening and feel for bits of the pregnancy that may be sticking out of the opening. They will feel like soft meat. Gently try to remove them. If the pieces are too slippery, take your hand out and wrap 2 fingers with sterile gauze, or a clean cloth that has been boiled in water, and try again to remove them.

  10. After you have removed the pieces, put your gloved hand into the woman’s vagina with two fingers under the womb. With your other hand, rub or massage her belly to help stop the bleeding. Her womb should be between your 2 hands.

  11. More Information
    how to give an injection
  12. Give the woman an injection of ergometrine (0.2 mg) in a large muscle, such as her buttock or thigh. Then give her one 0.2 mg pill or injection of ergometrine every 6 hours for 24 hours. Or you can use misoprostol: give 600 mcg by mouth or insert 600 mcg into the rectum (wear gloves).

  13. Give antibiotics to prevent infection immediately. She is at high risk of infection because the womb is open to germs.

  14. If she is awake, give her fluids to drink. If she is unconscious, see the next page.
  15. TRANSPORT!


  16. Take her to a hospital right away, even if you think you have removed the tissue and the bleeding has stopped. She still needs to have her womb emptied completely. If the bleeding does not stop, continue to rub or massage her lower belly while taking her to the hospital.

Shock

Shock is a life-threatening condition that can result from heavy bleeding. Bleeding inside the body can also cause shock.

DANGER! Heavy bleeding can cause SHOCK, which can kill. Transport immediately.

Signs:
  • very fast heart rate, more than 100 beats a minute for an adult
  • pale, cold, damp skin
  • pale inner eyelids, mouth, and palms
  • fast breathing, more than 30 breaths a minute
  • confusion or unconsciousness (fainting)
Treatment if she is conscious:
  • Lay the woman down with her feet higher than her head.
  • Cover her with a blanket or clothes.
  • If she can drink, give her sips of water or rehydration drink.
  • Help her to stay calm.
  • If you know how, start a fast intravenous drip (IV) with a wide needle, or start rectal fluids.
Treatment if she is unconscious:
  • Lay her on her side with her head low, tilted back and to one side, and her feet high.
a woman lying on a cot that is raised at one end by stacks of bricks
Make sure her feet are
higher than her head.
  • If she seems to be choking, pull her tongue forward with your finger.
  • If she has vomited, clean out her mouth immediately. Be sure her head is low, tilted back and to one side, so she does not breathe vomit into her lungs.
  • Do not give her anything by mouth until she has been awake for one hour.

TRANSPORT!

  • If you know how, start a fast IV drip with a wide needle. If you do not, start rectal fluids.

Do not wait for a health worker. Take the woman for medical help or to a hospital right away. She needs medical help fast!

Infection

If there is infection, it is more likely to be a mild infection if the abortion was done sooner than 3 months (12 weeks) after the last monthly bleeding.

Serious infection is an infection that has spread into the blood (sepsis). A woman is more likely to have a serious infection if the abortion was done later than 3 or 4 months from the last monthly bleeding, or if there was an injury to the womb during the abortion. Sepsis is very dangerous and can also cause shock. Infection can happen because:

  • an unclean hand or object was put inside the womb.
  • pieces of the pregnancy were left inside the womb and they have become infected.
  • the woman already had an infection when she had the abortion.
  • a hole was made in the wall of the womb.
a woman holding her head, sweating and shaking
Signs of mild infection:
  • slight fever
  • mild pain in the abdomen
Treatment for mild infection:

To keep mild infection from becoming serious, treat it immediately with the medicines listed below. A woman needs more than one medicine because infections after abortion are caused by several different kinds of germs.

If the medicines listed below are not available, see the “Green Pages” for others that will work. A woman who is breastfeeding should use the treatment for womb infection after childbirth.

Signs of serious infection:
  • chills and high fever
  • muscle aches, weakness, and tiredness
  • swollen, hard, and painful belly
  • bad-smelling discharge from the vagina
a woman lying down, sweating and looking sick

TRANSPORT!

Treatment for serious infection:
  • Take the woman to a health center or hospital immediately.
  • Start the following medicines right away, even if you are already on your way to the hospital. If she can swallow, give her these medicines, with plenty of water:


Medicines for infection after abortion

Medicines by Mouth
This infection is usually caused by a mix of germs, so more than one medicine must be used to cure it.
Medicine: How much to give: When and how to give:
Give all 3 medicines
cefixime 400 mg 1 time only
and doxycycline
(avoid taking doxycycline if you are breastfeeding)
100 mg 2 times a day, for 14 days
and metronidazole 400 to 500 mg 3 times a day, for 14 days
IMPORTANT! If the woman is not improving within 24 hours of starting the first medicines, she needs to go to the hospital right away.


If the woman cannot swallow medicines and you know how to give injections or IV medicines, start giving the medicines listed on the next page. But do not delay. Take the woman for medical help or to a hospital right away. She needs medical help fast.


Injectable Medicines
Most of the medicines listed in the boxes below are injected in the vein (IV) or in the muscle (IM). Choose one box and give ALL the medicines in that box. Which box you choose will depend on what medicines are most available to you, but all the medicines in that box must be given to be effective.
IMPORTANT! Continue to give these medicines until the woman is free of fever for 48 hours. Then give medicines by mouth for 14 days. If she is not improving within 24 hours after starting the IV medicines, the woman needs to go to a hospital right away.
Medicine: How much to give: When and how to give:
Give all 3 medicines
ceftriaxone 250 mg IM, 1 time only
doxycycline
(avoid taking doxycycline if you are breastfeeding)
100 mg IV or by mouth, 2 times a day
metronidazole 400 to 500 mg IV or by mouth, 3 times a day
OR
Give all 3 medicines
ampicillin 2 grams the first time only,
then 1 gram each other time
IV or IM, 4 times a day
gentamicin 80 mg the first time only,
then 60 mg each other time
IV or IM, 3 times a day
metronidazole 400 to 500 mg IV or by mouth, 3 times a day
OR
Give both medicines
clindamycin 900 mg IV, 3 times a day
gentamicin 80 mg the first time only,
then 60 mg each other time
IV or IM, 3 times a day


Injury inside the body (internal injury)

An internal injury from an abortion is most often caused by a sharp object that makes a hole in the womb. The object may also cause damage to other internal organs, such as the tubes, ovaries, intestines, and bladder.

When a woman has internal injuries she may have severe bleeding inside her abdomen but almost no bleeding from her vagina.

Signs (she will have some or all of these):
a woman holding her ear to the belly of another woman
Listen for gurgles for 2 minutes.
  • her abdomen feels stiff and hard with no sounds or gurgles inside
  • very bad pain or cramps in the abdomen
  • fever
  • nausea and vomiting
  • pain in one or both shoulders
Treatment:

TRANSPORT!

  • Immediately take the woman to a hospital or clinic where she can have surgery. An injury inside the body must be repaired right away by a surgeon or it can lead to infection, shock, and death.
  • Do not give her anything by mouth—no food, no drink, not even water—unless it will take more than 12 hours to get to a health center. Then give water only in small sips. Or let her suck on a piece of cloth soaked in water.
  • If she has signs of shock, treat her for shock. Make sure nothing is blocking her mouth and that she can breathe.
  • Give her the medicines for infection, but only by injection or IV. If possible, give her a tetanus toxoid vaccination.


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