Alcohol Use and Fetal Alcohol Syndrome

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Here’s the RoshReview Question of the Week!

You respond to a precipitous vaginal delivery in the emergency department from a woman who has had no prenatal care. Following delivery, you notice the infant has abnormal facial features including low set ears, small eye openings, a flat nose, and an unusual-appearing upper lip. Which of the following was the fetus most likely exposed to?

Check out the link above to find out if you have the right answer!

Check out ACOG CO 496 for more on this topic!

We’ve talked before about opioid use, and also talked about some screening for substance use in primary care, but today we'll focus on alcohol use and abuse, and specific risks for pregnancy. 

Scope of the issue / definitions

  • At-risk alcohol use: 3+ drinks per occasion, or more than 7 drinks in a week for women

    • Alternatively, any alcohol use for those who are pregnant or at risk of becoming pregnant

  • Binge drinking: 3+ drinks per occasion

  • Moderate drinking: 1 drink daily

    • 50% of binge drinking occurs amongst otherwise moderate drinkers

  • Alcohol use disorder:

    • DSM-5 diagnosis of problematic alcohol use leading to clinically significant impairment or distress

  • What constitutes “one drink” ?

    • Beer or wine cooler: 12 oz

    • Table wine: 5oz

    • Malt liquor: 8-9 oz

    • 80-proof liquor (40% ABV): 1.5 oz

      • Notably, “mixed drinks” can contain 1-3 or more drinks in a single serving!

  • 28% of US adults fall into categories of unhealthy alcohol use, with 14% meeting criteria for alcohol use disorder.

  • In pregnancy, 30% of pregnant folks report any alcohol use; 8% reported binge drinking on at least 1 occasion

    • This rate has been increasing in the last 20 years despite efforts to decrease it. 

  • Alcohol use and risk for abuse in pregnancy is associated with other social risk factors, including:

    • AMA

    • Higher gravidity/parity

    • Inadequate prenatal care

    • Poor nutrition

    • Other substance use, including tobacco

    • Mental health problems

    • History of physical or sexual abuse, or IPV, or substance abuse by the partner/family

    • Social isolation, or living in rural areas during pregnancy

    • Poverty

Screening Tools to Identify at-risk drinking

Quantity based

  • Can inquire about number of drinks in a typical week, or binge drinking episodes over the past three months -- if positive on either question, then know patient is at risk.

TACE if 2 or more points, indicates positive screen

  • T - tolerance (how many drinks does it take to make you feel high?) 

  • More than 2 drinks = 2 points

  • A - annoyed (have people annoyed you by criticizing your drinking?)

    • Yes = 1 point

  • C - cut down (have you ever felt you ought to cut down on your drinking?)

    • Yes = 1 point

  • E - eye opener (have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?)

    • Yes = 1 point

AUDIT-C if 3 or more points, positive screen.

  • How often have you had an alcoholic drink in past year?

  • How many drinks did you have on a typical day when you were drinking in the past year?

  • How often did you have six or more drinks on one occasion in the past year?

Important caveat - if someone is pregnant or considering pregnancy, any positive answer to these questions should prompt further discussion regarding patient’s attitudes towards alcohol in pregnancy.

Also important to recognize there may be a false-negative screen more likely in pregnant folks -- they may be reluctant to admit use due to fear of consequences/reprimand. There are some who argue that clinicians should always directly ask patients, as opposed to using electronic or paper-based screens.

**If screen positive -- 

  • proceed with careful, non-judgmental assessment of drinking behavior

  • Provide a brief intervention - non-judgmental counseling regarding risks and recommendation for abstinence 

    • RCTs have shown high success in reducing alcohol consumption by 33-60%, or increasing rates of abstinence from EtOH in pregnancy!

  • If concern for alcohol use disorder, should be referred for professional alcohol treatment with psychiatry and medicine.

So what are the risks of EtOH use?

  • Alcohol is a known teratogen, with effects dependent somewhat on amount, pattern of consumption, genetics, nutrition, and other maternal substance exposures (i.e., smoking, other drugs).

  • There is no known safe “lower limit” of alcohol use!

    • Contrary to popular belief, international society guidelines have actually united in stating this. 

      • US, UK, France, Australia/New Zealand, Canada all have guidelines stating no safe limit for alcohol use.

    • 1st trimester exposure associated with significant facial and other structural anomalies as well as neurobehavioral effects and miscarriage

    • 2nd and 3rd trimester exposure increases risk for stillbirth, growth, neurobehavioral effects

  • Stillbirth

    • Even after adjusting for confounders, any alcohol intake is associated with increased risk

      • 1.37 / 1000 births for <1 drink/week

      • 8.83 / 1000 births for 5+ drinks/week

  • Fetal Alcohol Spectrum Disorders

    • Umbrella term encompassing a number of conditions, such as:

      • Fetal Alcohol Syndrome

      • Partial fetal alcohol syndrome

      • Alcohol related neurodevelopmental disorder

      • Neurobehavioral disorder associated with prenatal alcohol exposure

      • Alcohol-related birth defects

    • Estimated to affect 0.75% of pregnancies globally, with high prevalence in Europe and the US (1.5% in USA).

    • While we won’t review the specific diagnostic criteria, we can review some of the common features for each of these disorders that make up the criteria.

  • Craniofacial anomalies (classic)

    • Short palpebral fissures

    • Thin vermillion border (i.e., thin upper lip)

    • Smooth philtrum (the typically indented area above upper lip)

  • Other Anomalies

    • Ears: “railroad track ears” 

    • Hands: altered palmar crease (“hockey stick” of upper palmar crease)

    • Heart: CHD risk is about 2% (1% in gen pop) and can be highly varied

  • Fetal growth restriction

    • Highly prevalent and part of most diagnostic criteria, with small growth persistent into childhood/adulthood

    • Estimates of 30-50% prevalence of FGR

  • Neurodevelopmental outcomes

    • Small head size (HC<10%, occurring in up to 45%) or microcephaly (HC <3%, occurring in about 12%)

    • Other structural brain anomalies (~20%)

    • Recurrent non-febrile seizures

    • Impairment in gross motor function such as balance, coordination

    • Cognitive or intellectual deficits - generally lower IQ 

      • prev of IQ < 70: 8% with prenatal alcohol exposure, 20% if full FAS

    • Developmental delays

    • Neurobehavioral impairments (i.e., sensory processing, self-regulating behavior)

Obesity and Pregnancy

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Definition and Epidemiology

  • Obesity - classified by BMI 

    • Prevalence of obesity has increased to 34.0% in women 20-39 years in 2010  

ACOG PB 230

Effect of Obesity on Pregnancy 

  • Pregnancy Loss 

    • Increased risk of SAB (1.2 OR) and recurrent miscarriage (OR 3.5) 

    • Also have increased risk of pregnancies affected by neural tube defects, hydrocephaly, and other anomalies 

  • Pregnancy Complications 

    • Antepartum

      • Medical issues: increased risk of cardiac dysfunction, proteinuria, sleep apnea, nonalcoholic fatty liver disease 

      • Pregnancy issues: increased risk of gestational diabetes, preeclampsia, stillbirth 

        • Risk of stillbirth increases with increasing obesity

          • OR 1.71 for BMI 30-34.9

          • OR 2.0 for BMI 35.0-39.9

          • OR 2.48 for BMI >40

          • OR 3.16 for BMI > 50

        • Of note, the practice bulletin does point out that black pregnant people with obesity have a higher risk of stillbirth than white pregnant people - discusses that while this is not a biological reason, is a proxy for likely negative influence of racism on health 

    • Intrapartum

      • Increased risk of cesarean delivery, failed trial of labor, endometritis, wound rupture/dehiscence, and venous thrombosis  

      • Decreased likelihood of VBAC after TOLAC 

    • Postpartum Complications - increased risk of future metabolic dysfunction 

    • Fetal complications - increased risk of growth abnormalities 


  • How Can We Manage Obesity Before And During Pregnancy 

  • Pre-pregnancy Counseling 

    • Discussion of control of obesity with weight loss (either surgical or non-surgical) 

    • Even small weight loss can be associated with improved outcomes (even 5-10%) 

    • Can try motivational interviewing 

      • Encourage diet, exercise, and behavior modification 

    • Medications 

      • Not recommended pre-pregnancy or during pregnancy 

  • During Pregnancy 

    • Recommended weight gain 

      • Overweight: recommend 15-25 lb weight gain 

      • Obese: recommend 11-20 lb weight gain 

      • There is a lack of data regarding short-term and long-term maternal and newborn outcomes, no recommendation for lower targets for pregnant women with more severe degrees of obesity 

    • Congenital Anomalies

      • As previously discussed, increased risk of congenital anomalies, but detection of these anomalies is significantly decreased with increasing maternal BMI 

      • Cell-free DNA test failures are also more frequent in patients that are obese. This is because a minimum fetal fraction of 2-4% usually is needed. The median fetal fraction between 10-14 weeks is around 10%, but with increasing BMI, it’s associated with decreased fetal fraction. 

      • Can consider repeating screening if it’s because of early gestation, but not recommended if there are ultrasound findings of anomalies 

    • Metabolic Disorders - screen for glucose intolerance and OSA at first antenatal visit with history, exam, and labs 

      • Sleep medicine evaluation 

      • Can consider early glucose screening; if negative, repeat at usual time of 24-28 weeks 

    • Stillbirth and Antepartum fetal testing 

      • This is going to be different based on your institution 

      • Can consider weekly testing after 37 weeks for BMI 35-39.9 

      • Can consider weekly testing after 34 weeks for BMI >40 

  • Intrapartum 

    • Many studies that show an increased risk of C-section among overweight and obese women 

      • There are studies that show an increased length of time in labor; another study showed that maternal BMI was not associated with longer second stage 

      • Maybe consider allowing more time in first stage of labor before C-section in obese individuals? 

      • Remember that pregnant women with higher BMI have a higher rate of complications with elective repeat cesarean section - so not a reason to not TOLAC them! 

    • Some considerations during labor 

      • Consider anesthesia consult - especially if OSA. An epidural may be technically more difficult to place 

      • Antibiotics - may need to increase the amount of Ancef before C-section (remember usual is 2g). Increase to 3g if >120 kg 

  • Postpartum 

    • There is an increased risk of VTE in obese women, so definitely use your SCDs and encourage early mobilization  

    • In very high risk groups, discuss pharmacologic thromboprophylaxis 

      • Dose can be BMI stratified

        • BMI < 40: 40 mg Lovenox daily 

        • If BMI 40-59.9: 40 mg BID 

        • If BMI 60 or greater: 60 mg BID 

Headaches & Pregnancy

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What are the different types of headaches? 

  • Migraine 

    • Episodic disorder that is usually manifested as unilateral headaches, sometimes associated with nausea or light/sound sensitivity 

    • Common disorder that affects 12-15% of general population 

    • Can occur over several hours to several days 

    • Different phases of migraine:

      • Prodrome - can occur in up to 77% of people, usually can be symptoms like yawning, depression, irritability, food cravings, neck stiffness, etc 

      • Aura - 25% of people will experience an aura that is gradual, sometimes visual (bright lines), auditory (tinnitus, etc), somatosensory, motor, or even can be smell 

      • Headache - usually unilateral, tends to be throbbing 

      • Postdrome - sometimes can happen. Head movement may cause pain in location of the previous headache 

    • Triggers - can be different for different people. Common triggers are things like menstrual cycle, stress, etc 

  • Tension headache 

    • Usually moderate headaches with bilateral, non-throbbing quality 

    • Often described as “pressure,” sometimes may feel like a band around the head (headband area) 

    • Precipitated usually by stress

  • Cluster headache 

    • Severe headache that can be accompanied by autonomic symptom, come in “clusters”  

    • It is a type of trigeminal autonomic cephalagia (TACs) 

    • Usually characterized by severe orbital, supraorbital, or temporal pain, and also with autonomic features. Always unilateral. 

    • Different from migraines because these patients usually prefer to move around or pace, can be restless (people with migraines want to lie down in a dark room) 

    • Autonomic symptoms: ptosis, miosis, tearing, rhinorrhea, nasal congestion on the same side as the pain 

  • Secondary headaches

    • Have an underlying cause (i..e., headache is a symptom of the problem) - this is something we may need to be worried about.

      • More benign: sinusitis, URI, idiopathic intracranial hypertension (IIH) 

      • More serious: tumor, bleeding, meningitis.

Evaluating a Headache 

  • History 

    • Your usual history, but be sure to ask about age of onset of headaches (has this been going on for 20 years, or just today?), presence of aura/prodrome, frequency and intensity

    • # of headaches/month, site of headache/other symptoms associated

    • Current meds 

    • Changes in vision, association with trauma, changes in work/lifestyle, timing around menstrual cycle 

  • Physical 

    • Blood pressure and pulse - always in pregnancy — worry about preeclampsia!

    • Palpation of neck, head, and shoulder 

    • Full neuro exam 

  • Labs and Imaging 

    • CT or MRI are common modalities 

    • Consider imaging if danger signs are present (i.e., abnormal neuro exam)

    • Also consider lumbar puncture if there is concern for infection 

When should I be worried about a headache? 

  • Low Risk Features

    • Age <50

    • Features that are typical of primary headaches (see above) 

    • History of similar headaches, no change in usual headache or new symptoms 

    • No abnormal neurologic symptoms  

  • Higher Risk Characteristics

    • Fever, abrupt onset, older age, neurologic deficit (including altered mental status), history of tumors, papilledema

    • Change in previous pattern, headache with positional change, post-trauma, painful eyes (or change in vision!) 

    • And of course, pregnancy!

    • Reason for emergency eval: thunderclap headache, Horner syndrome or other neurologic deficit, concern for meningitis or encephalitis, papilledema, possible carbon monoxide exposure. 

What are typical headache treatments? 

  • Non-Pregnant 

    • Migraine Headache

      • Analgesics like NSAIDs, Tylenol; treating earlier in the course is more effective 

      • If unresponsive, can consider triptans or ergots 

      • If still severe, consider ketorolac and a dopamine receptor blocker (ie. prochorperazine and metoclopramide)  

      • Some patients may need to be on medications like triptans or beta blockers to prevent headaches 

        • Preventive first line agents are propranolol, amitriptyline, topiramate 

    • Tension Headache

      • Usually rest, hydration

      • NSAIDs, acetaminophen 

      • Then consider caffeine, metoclopramide, diphenydramine, etc. 

    • Cluster Headaches

      • Oxygen! Try it first if available - 100% oxygen inhalation 

      • If not available, then subcutaneous sumatriptan (3mg-6mg); can also use intranasal if subq not available 

        • Administer the intranasal sumatriptan to the contralateral side because patients with cluster headaches and other trigeminal autonomic cephalalgias have rhinorrhea or nasal congestion that is on same side as pain.

      • Prevention: verapamil… agent of choice for initial preventative therapy. Can also start with a short course of prednisone

        • This is because we know that cluster headaches come in… you guessed it! Clusters!  

  • In Pregnancy 

    • May need to avoid NSAIDs in certain trimesters 

    • Start with Tylenol (650-1000mg), then can ad metoclopramide 10 mg 

    • Can also try combination like butalbital-acetaminophen-caffeine 

      • Other options are things like diphenhydramine (benadryl), or prochlorperazine, as some types of headaches may be associated with n/v and can help with this 

    • Consider fluids if someone is dehydrated (again, n/v in pregnancy) 

    • Magnesium sulfate or magnesium oxide sometimes can help. If someone has frequent headaches, there is some data that magnesium can prevent headaches 

    • If still bad, consider NSAID, but usually should not be used after 32 weeks to prevent closure of the PDA; usually a one time dose is ok 

    • Third line = opioids because they can be addicting and can worsen other issues of pregnancy like nausea/vomiting/constipation 

    • Triptans - if not responding to anything else, can consider triptans. Most studies showing exposure in pregnancy have been reassuring (most studies are with sumatriptan) 

      • Long term triptan use in pregnancy - discuss individually with patient 

      • Limited data, but from registries, no increased risk of major malformation

      • If patients can use other meds, try those first, but if refractory and need sumatriptan, ok to use 

    • Other things to consider if refractory: 

      • Glucocorticoids, peripheral nerve blocks 

      • Call your neurology colleagues!

    • Meds to avoid 

      • Ergotamine - do not use because can cause tetanic uterine contractions 

The Surgical Abdomen in Pregnancy

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A “surgical” or “acute abdomen” is a serious acute intra-abdominal condition accompanied by pain, tenderness, and muscular rigidity, for which emergency surgery should be contemplated.

This can be complicated by pregnancy because there are many physiologic and anatomic changes in pregnancy that can sometimes change the presentation of what we usually associate with acute abdomen 

Anatomic and physiologic changes in pregnancy

  • Enlarging uterus 

    1. Uterus becomes intra-abdominal organ instead of pelvic organ at 12 weeks.

    2. Can increase from 70g → 1110g and hold up to 5 L volume.

    3. Uterus can compress ureters → can look like hydronephrosis and mimic urolithiasis.

    4. Will displace other abdominal organs (mostly the viscera):

Zachariah SK et al. Management of acute abdomen in pregnancy: current perspectives. Int J. Womens Health. 2019;11:119-134.

  •  A relaxed and stretched abdominal wall can mask guarding.

  • Additional physiologic changes: 

    • GI: 

      • Delayed emptying of stomach, relaxed lower esophageal sphincter (remember: blame progesterone for everything!) → increase nausea/vomiting, bloating, GERD

      • Also decreased GI transit (slower motility d/t relaxed GI smooth muscles, again d/t progesterone) → Constipation 

        • Nausea and/or constipation with associated symptoms can confound clinical gestalt when evaluating acute abdomen.

    • Heme:

      • Leukocytosis -standard in pregnancy, though can give impression of infection.  

Recognizing the Acute Abdomen in Pregnancy 

  • If someone comes with acute abdomen signs, you should treat them as if they have an acute abdomen until proven otherwise:

    • Abdominal rigidity, rebound, tenderness, guarding 

  • Causes of acute abdomen in pregnancy:

Some clinical pearls for more common causes of acute abdomen in pregnancy: 

  • Appendicitis: Classically taught that the appendix is displaced in pregnancy, BUT RLQ pain is still the most common symptom. Fever might be present in some patients.

    • Ultrasound has sensitivity of 67-100% and specificity of 83-96% in pregnancy (first line imaging).

    • CT has sensitivity of 86% and specificity of 97% - usually not used as much due to concerns for radiation.

    • MRI has high sensitivity and specificity - generally 2nd line, if if ultrasound is inconclusive.

    • Treatment: SURGERY! 

  • Cholecystitis: Murphy’s sign is still typically positive.

    • Ultrasound is the investigation of choice with sensitivity >95%.

    • Treatment: 

      • Admission, make NPO, give antibiotics.

      • Symptoms of cholecystitis may abate within 7-10 days of starting nonoperative treatment, but there is high risk of recurrence or serious complication.

      • In first and second trimester → good surgical candidates should undergo cholecystectomy.

      • In third trimester Nonoperative medical management with abx and fluid therapy should be tried first to allow delay of choley until postpartum, owing to technical difficulty in performing at this gestational age.

      • Remember, this is ONLY if it’s uncomplicated. If there is any sign of sepsis, perforation, or disease progression on antibiotics → immediate surgery.

A Word on Imaging 

  • Recall our prior episode on imaging in pregnancy! The quick version:

    • Try ultrasound first for acute abdomen. Usually has high sensitivity and specificity, but the efficacy can decline after 32 weeks of gestation because of technical difficulties due to enlarging uterus 

    • Next is MRI, generally.

    • For ionizing radiation:

      • Risk of radiation exposure on a developing fetus depends on both the dose of radiation and gestational age at which exposure occurs.

      • Fetal mortality is most significant in the first 2 weeks of conception (3-4 weeks pregnant).

      • Most vulnerable period for teratogenicity is during organ development (usually up to 12 weeks).

      • Risk of ionizing radiation-induced fetal harm is negligible at 50 mGy or less and risk of malformation increases only slightly with doses >150mGy.

        • Usual dose of CT abdomen/pelvis is about 25 mGy, and can be reduced to 13 mGy with automated exposure control facility in modern CT scanners.

A Word on Mode of Surgery 

  • We are not general surgeons! 

  • However, multiple studies show that laparoscopic surgery is less invasive and is feasible and safe in select pregnant patients.

  • If you can time surgery, the best time is 2nd trimester or very early 3rd tri 

    • Pregnancy itself does not increase postoperative morbidity in pregnant women compared to nonpregnant women.

    • Timing works due to decreased exposure of fetus to anesthetic agents during organogenesis and decreased risk of SAB compared to 1st trimester.

    • In second trimester, uterus is not so big that it is hard to work around.

  • Obstetricians should be able to counsel/provide for intraoperative or peri-operative fetal monitoring if indicated and feasible — generally pre/post doptones pre-viability, and a discussion about continuous monitoring if after viability.

  • Postoperative care considerations:

    • If viable fetus, there should be additional monitoring of fetal heart rate and uterine activity post operatively.

    • If not viable, there should be dop tones obtained both before and after surgery 

    • For post-op pain, usual post-op care is usually permissible.

      • Avoid NSAIDs if possible after 32 weeks due to concern for premature closure of the fetal ductus arteriosis.

Second Trimester Abortion

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Second Trimester Abortion: Legal Issues

  • In the US, 1.2 million abortions occured in 2008.

    • Of these, approximately 10% took place after 13 weeks, with more than half occurring between 13 and 15 weeks. 

    • Only 1.3% of abortions are performed at or after 21 weeks gestation.

  • There are varying state-level statutes that may limit the gestational age for obtaining an abortion, or the type of abortion treatment that can be offered.

  • The Guttmacher Institute maintains an overview of abortion laws by state. Some highlights from them:

    • 43 states have gestational age limits on when abortion can be performed. These range from 20 weeks to viability, with some statutes currently being challenged in court that could restrict access as early as 6-15 weeks.

    • 21 states prohibit “partial-birth” abortions, which is a misnomer that we will explain momentarily.

      • 2 states have standing bans on standard dilation and evacuation (Mississippi and West Virginia), with an additional 9 having some enjoinment on enforcement of a ban on D&E. 

    • 26 states require waiting periods between counseling and a procedure. 18 states require specific counseling which may include false or misleading information on:

      • Link between breast cancer and abortion (5 states).

      • The ability of a fetus to feel pain (13 states).

      • Long-term mental health consequences of abortion (8 states).

Methods of 2nd Trimester Abortion

Dilation and Evacuation

  • Use of medication or mechanical techniques to dilate the cervix, followed by the use of grasping forceps to remove the fetus.

  • Most commonly achieved with osmotic dilators in combination with misoprostol for cervical ripening.

    • The success of cervical preparation at 18 weeks gestation and above may be improved with the use of mifepristone the night prior to the procedure in combination with osmotic dilators.

      • However mifepristone may also increase risk of pregnancy expulsion prior to the procedure, particularly if misoprostol is subsequently used for further dilation.

  • A variant of this technique is known by a variety of names such as “dilation and extraction” or “intact D&E,” in which further dilation is achieved which allows for removal of an intact fetus except for possible calvarial decompression. 

    • This has been labeled in some publications as partial-birth abortion and may be restricted to some degree in a number of jurisdictions. 

    • In order to avoid consequences associated with these laws, some experts advise preoperative feticidal injection with KCl or digoxin. 

Medical or Induction Abortion

  • Induction may also be used to achieve abortion, however this is less-cost effective, takes more time, and is more associated with complications.

  • Generally, this is achieved through similar techniques for cervical ripening to labor induction -- mechanical dilators or balloon catheters, misoprostol, and oxytocin. 

    • The most efficacious medical management is mifepristone administered 24-48 hours prior to misoprostol initiation, based on RCT evidence.

    • Osmotic dilators do not necessarily add benefit to misoprostol in this setting. 

  • Preoperative feticidal injection does not shorten the duration of induction, but may be used if preferable to the woman or provider to avoid transient fetal survival after expulsion. 

  • ACOG lists three primary techniques for medication abortion in the second trimester; ACOG and SFP note that the mife-miso regimen is the most efficacious for 2nd trimester induction abortion:

Hysterotomy or Hysterectomy

  • Abdominal surgery is rarely indicated for second-trimester abortion, but is occasionally indicated in the event other procedures fail or are contraindicated. 

  • A prior cesarean or uterine scar is not an indication for hysterotomy for abortion, or for the avoidance of misoprostol, at least up until about 28 weeks gestation.

    • Retrospective cohort studies have demonstrated an insignificantly increased risk of uterine rupture for women with one prior cesarean delivery around 0.28%, versus rupture risk for unscarred uteri around 0.04%.

      • There is insufficient data to guide management on women with 2+ CDs. 

    • However, this remains well below the established acceptable risk threshold with trial of labor after cesarean at term without misoprostol use (rupture risk for 1 prior CD at 0.5-0.7%). 

      • The risk of rupture is suspected to increase with misoprostol use at or after 28 weeks, based on TOLAC data.

Complications and Other Situations

  • Mortality is 0.6 / 100k legal, induced abortions, with that rate being tied to gestational age at the time of abortion.

    • At 21 weeks gestation or greater, the rate of mortality rises to 8.9 / 100k procedures.

    • Maternal mortality for live birth is 17.6 / 100k live births in USA (or double that for 21+wk abortion, by comparison).

  • Postabortion hemorrhage is defined as “blood loss > 500cc and/or bleeding requiring a clinical response such as transfusion or hospital admission.”

    • Rates of transfusion range from 0.1 - 0.7%, with higher rates seen for medical 2nd trimester abortion. 

    • Management is similar to hemorrhage after term vaginal delivery, ruling out retained products and uterine atony as primary causes.

      • Cervical laceration, uterine rupture, and abnormal placentation are also rarer but important concerns, particularly in more advanced gestational age and in women with prior cesarean delivery. 

  • Postabortion infection is uncommon, occurring in 0.1-4% of 2nd trimester abortions.

    • Antibiotic prophylaxis is indicated prior to dilation and evacuation.

      • SFP recommends 200mg doxycycline preoperatively.

      • The ACOG PB recommends use of 100mg doxycycline preoperatively and 200mg postoperatively

      • RCT methodologies on antibiotic use support solely preoperative antibiotic use as sufficient. 

  • Postabortion contraception placement in the form of IUDs additionally does not increase infection risk, but expulsion rates may be higher after abortion than with interval placement.

  • Reversible contraception of almost any kind (no diaphragms or cervical caps) can be initiated immediately post-abortion, and ovulation can resume as soon as 21 days post-procedure.