A 36 y.o. woman presents with altered mental status after a dilitation and extraction of a fetus dated at 23 wks and 6 days.

she is altered in the ED with a BP of 90 initially

clot is noted in the uterus with mild vaginal bleeding

What do you see in the abdomen?

In its landmark 1973 abortion cases, the U.S. Supreme Court recognized a constitutional right to abortion but held that states could prohibit abortion after fetal viability—the point at which a fetus can sustain life outside the uterus. While viability is generally considered 20 wks, some states Ohio, Georgia, Louisiana, Missouri, Alabama, Kentucky, South Carolina, and Texas have recently passed laws to limit abortions once a heartbeat is present at six weeks . Utah and Arkansas voted to limit abortions to the middle of the second trimester. However, as of June 2021, except for the Texas bill none of the laws are in effect due to court intervention. 

Our  patient traveled from Arkansas for a pregnancy termination. After a dilatation and extraction was performed by a University physician,she had an unrecognized perforation of the uterus and was in hemorrhagic shock from a uterine artery injury.  She was given blood in the ED after the ultrasound and taken to the OR where she underwent a hysterectomy. 

As the uterus enlartges the risk of abortion grows.

Only 1.3% of abortions are performed at 21 weeks or greater.  The reasons for these range from : fetal abnormalities,  maternal illness like eclampsia, or delayed recognition of pregnancy.  As gestational age increases, the risk of complications increases.  A first trimester abortion is usually done without anesthesia and  has a risk of uterine perforation of .05%. If the pregnancy is 13-20 weeks, anesthesia is usually required  and the risk of uterine perforation increases to 0.3%.  The cost of abortion varies but in the first trimester it is about 500-600 dollars while second trimester abortions can cost in excess of $2,000 if the patient has no insurance.   

Jones R, Finer L. Who has second trimester abortions in the United States? 2012 Jun;85(6) 544-51.

 Drey E,Foster D, Jackson R et al. Risk factors  associated with presenting for abortion in the second trimester. Obstet Gynecol 2006 Jun;107(1):128-35.

 Pridmore B, Chambers D.  Uterine perforation curing surgical abortion: a review of diagnosis and management and prevention. 1999. Aust NZ J  Obstetr Gynaecol.  Aug;39(3)349-53.