Use of medications to decrease bleeding

during surgical abortion:

a survey of abortion providers' practices
in the United States
 Introduction
• Abortion is one of the most common surgical procedures in the
United States, with nearly one million procedures performed in
2014. Although complications from abortion happen infrequently,
one of the more commonly occurring is hemorrhage, reported in
1% to 6% of procedures.

• The prevalence range may be due to inconsistent definitions of

post-abortion hemorrhage; blood loss volume (250-500 mL),
treatment of bleeding, and the need for transfusion have all been
used to define blood loss. Medications commonly used to decrease
bleeding include methylergonovine maleate, misoprostol, oxytocin,
carboprost tromethamine, and vasopressin. Some providers
prophylactically use medications during surgical abortion to
decrease the risk of hemorrhage, while others only administer
these medications to treat excessive bleeding.
• Although the Society of Family Planning (SFP) presents an algorithm
for management of excess bleeding during abortion, the actual
practice of abortion providers throughout the country is neither
standardized nor well described.

• The National Abortion Federation (NAF) conducts periodic surveys

of abortion provider practices; however, they do not ask in-depth
questions about use of medications to prevent bleeding. With
minimal available evidence on how to best use medications to
decrease bleeding during surgical abortion, future randomized
controlled trials could evaluate the medications that providers
commonly use to provide evidence-based guidelines for abortion
care. The aim of this study is to document the medications most
commonly used to decrease bleeding during surgical abortion by a
population of United States providers.
 Methods
Subscribers consisted of clinical and research experts on abortion and contraception.
We excluded subscribers who were not abortion providers.
We asked providers about their :
(1) use of prophylactic medications to decrease bleeding during surgical abortion
(2) use of medications to treat excessive bleeding during surgical abortion
(3) preferred medications, timing, dosage, and route.
(4) basic demographic and clinical practice information.

Respondents could choose from pre-coded responses but were encouraged to provide
additional details if necessary. Three weeks after distributing the survey, we sent a
reminder email to all listserv subscribers and provided a final reminder in person at a
national academic abortion provider conference. The University of Hawaii Human
Studies Program Institutional Review Board approved this study.
We used R software version 3.0.3 to perform
data analysis. We investigated differences in
provider characteristics and typical practices
between those who routinely used prophylactic
medications to decrease bleeding during
abortion and those who did not using chi-square
and Fisher’s exact tests.
 Result
3.1 Prophylactic medications used by abortion providers
Result
For uterotonic medications, one provider (1%) started at less
than 13 weeks’ gestation, 11 (9%) at 13 to 16 weeks’, 30 (25%)
at 16 to 19 weeks’, nine (7%) at 19 to 22 weeks’, and four (3%)
at 22 to 24 weeks’ gestation. For vasopressin, 35 providers
(29%) initiated use at less than 13 weeks’ gestation, 45 (37%)
at 13 to 16 weeks’, 18 (15%) at 16 to 19 weeks’, and one (1%)
at 19 to 22 weeks’ gestation. Providers reported use of
medication combinations such as oxytocin and
methylergonovine above 16 to 18 weeks’ gestation or
oxytocin and misoprostol above 13 weeks’ gestation. A few
respondents stated that they used misoprostol for cervical
preparation and assumed that this had some prophylactic
uterotonic effects.
• Ninety-seven prophylactic medication users provided information
about their preferred dosing regimens. Respondents used
vasopressin most commonly as an intracervical plus paracervical
injection at doses of 4 to 10 units (most commonly 4 or 5 units),
and diluted it in 10- to 30-mL (most often 20 mL) of saline or
lidocaine. One provider diluted vasopressin in 500 mL of fluids to
administer intravenously. The majority used methylergonovine
intramuscularly. Respondents gave oxytocin at 10 to 40 units (most
commonly 20 units), primarily intravenously. One provider used it
paracervically. Providers administered misoprostol buccally,
vaginally, and rectally via doses of 400- to 1000-mcg (most
frequently 400- or 800-mcg). Finally, one provider reported
injecting carboprost intracervically during the paracervical block.
• Among providers who did not routinely use prophylactic medications
during surgical abortions, 83% (35/42) cited “poor medical evidence to
support use.” Providers also reported concern for side effects (10/42,
24%), cost (9/42, 21%), lack of a physiological mechanism (8/42, 19%),
difficulty obtaining medications (3/42, 7%), and other (8/42, 19%) as
reasons for not using prophylactic medications. Sixteen percent (7/42) of
these providers reported that they previously used prophylactic
medications but have changed their practice because of a shortage of
medications (namely methylergonovine) or a change in practice site. Fifty-
six percent (23/42) of providers who do not routinely use prophylactic
medications would do so in certain situations including coagulopathy
(n=13, 57%), abnormal placentation (n=12, 52%), history of bleeding
disorder (n=9, 39%), history of hemorrhage (n=9, 39%), grandmultiparity
(n=8, 35%), anticoagulant use (n=8, 35%), anemia (n=7, 30%), multiple
gestation (n=5, 22%), polyhydramnios (n=4, 17%), fetal demise (n=4, 17%),
prior Cesarean delivery (n=3, 13%), uterine fibroids (n=2, 9%), and uterine
anomaly (n=1, 4%).
3.2 Medications used to treat excessive bleeding by second-trimester abortion providers

The majority of our respondents (88%) provided second-trimester surgical abortions and gave
information on their preferences for treatments for bleeding (Table 3). Overall, Providers preferred
methylergonovine or misoprostol as a first- (91%) or second-line (76%) treatment. Fourteen percent
(20/148) of providers selected carboprost as a second-line treatment, in contrast to 1% who used it as
first-line treatment. Providers gave additional information about the routes and doses they preferred to
use as treatments for bleeding. Of the 110 providers who selected misoprostol, 94% (n=103) prefer 800
or 1000 mcg per rectum (n=95, 86%). Among the 25 who selected oxytocin as a treatment, 88% (n=22)
used it intravenously. We found no clear consensus on the dosage of oxytocin administered; 36% used
20 units (n=9), 24% used 40 units (n=6), and 20% used 10 (n=5) or 30 units (n=5). Providers using
vasopressin as a treatment (n=3) indicated they preferred a dose of 2 units intracervically. A few
providers stated that they inject methylergonovine or vasopressin transcervically into the myometrium
to treat heavy bleeding. Some second-trimester providers commented that access and cost of
medications affected their practice. For example, one provider previously used dilute IV vasopressin but
switched to oxytocin due to the cost of vasopressin.