Date Published: December 2, 2018
Author(s): Camille A. Clare, Gabrielle E. Hatton, Neela Shrestha, Michael Girshin, Andre Broumas, Danielle Carmel, Mario A. Inchiosa.
To determine whether there is a difference in intraoperative bleeding with inhalational versus noninhalational anesthetic agents for patients undergoing suction dilatation and curettage for first-trimester induced abortion.
This is an IRB-approved retrospective chart review of the electronic medical records of patients undergoing induced abortion at gestational ages between 5 0/7 and 14 0/7 weeks of pregnancy at the New York City Health + Hospitals/Metropolitan. The records of 138 patients who underwent suction dilatation and curettage for induced abortion between June 2012 and June 2014 were reviewed for an association between anesthetic technique and intraoperative hemorrhage. Twenty patients received inhalational anesthetic agents, while 118 received intravenous anesthetics. Blood loss was estimated by the operating gynecologists.
The mean intraoperative blood loss for inhalational anesthetics (113.6 ml) was significantly higher than with noninhalational agents (40.2 ml) (p=0.007). Age, body mass index, and gestational age were not statistically different between the groups; the number of methylergonovine doses at induced abortion trended higher with inhalation anesthetics.
The difference in blood loss between the two types of anesthetic techniques was statistically significant. These findings may be important for patients with significant anemia or at an increased risk of bleeding, such as those with unrecognized coagulopathies.
Over one million pregnancies result in induced abortion in the United States each year . Recent studies have shown that the mortality risk from an induced abortion is 0.7 per 100,000 . Minor complications have dropped to an estimated eight per 1000 abortions by 1990, and major complications have decreased to 0.7 per 1000 induced abortions . Both hemorrhage and anesthetic complications have been the leading causes of abortion-related mortality. Hemorrhage is the leading cause of mortality during second-trimester induced abortions, and is the second leading cause of mortality in first-trimester induced abortions, following infection . Recent studies have documented the continued importance of postabortion hemorrhage; a conservative estimate of the incidence of hemorrhage of clinical consideration is approximately 1% of procedures [5, 6]. A large study reported the incidence of hemorrhage requiring blood transfusions at 0.4% .
Following Institutional Review Board (IRB) approval (L-11,256) from New York Medical College, New York City Health + Hospitals/Metropolitan, and the New York City Health + Hospitals, a single institution retrospective chart review was conducted. Patients who had complete anesthetic records and underwent suction dilatation and curettage for induced abortion from 5 0/7 weeks to 14 0/7 weeks of gestation between June 1, 2012, and June 1, 2014, were evaluated. A waiver of informed consent was obtained per IRB guidelines due to the retrospective chart review.
A total of 197 patients had first-trimester induced abortions in the time frame of the study. Of these, 182 patients received a prescription for methylergonovine postoperatively on discharge from the hospital. One hundred thirty-eight subjects, with electronic medical records and complete anesthesia records and estimated blood loss, were analyzed. Subjects overall ranged from 15 to 43 years; gestational ages ranged from 41 to 89 days; and BMI indexes ranged from 17 to 48 kg/m2. The two groups of patients showed no statistical differences in regard to these three parameters (Table 1).
Our study found a statistically significant difference in the blood loss in patients receiving inhalational versus noninhalational agents. Although total blood loss in both groups was not excessive, the greater blood loss with inhalation anesthetics may be of importance when approaching the patient at an increased risk of uterine bleeding during gynecologic procedures, such as those with recognized or unrecognized coagulopathies. Although increasingly rare, uterine hemorrhage is the leading cause of mortality during second-trimester induced abortions, and is the second leading cause of mortality in first trimester induced abortions.