Recently, HemAware received a question for our “Ask a Social Worker” column about having an abortion if you have a blood or bleeding disorder. You can find the social workers’ advice here.
In a previous article, we discussed the many considerations of pregnancy when you have a bleeding disorder. Because of the serious and sensitive nature of abortions, we also asked three physicians who specialize in treating women with blood and bleeding disorders to weigh in.
Ascension Illinois Saint Francis Hospital Evanston, Department of Gynecology
Abortions are medically necessary procedures, which, like many other medical procedures, can sometimes lead to the discovery of other medical conditions. Physicians and patients may notice heavy bleeding with cervical lacerations, chlamydia, fibroids and the spectrum of disorders in which all or part of the placenta adheres to the uterine wall. It’s important for physicians and patients to be aware of excessive bleeding with these or other conditions, and to discuss family bleeding history for other potential signs and symptoms.
Examples of When Family Bleeding History Transparency Helped Patients
- An adult woman chose to terminate a pregnancy due to complications with uterine fibroids. Significant bleeding occurred, and conversations revealed overwhelming signs of possible bleeding disorders in this individual and her family. After further testing, this individual was later diagnosed with type 1 von Willebrand disease.
- An adult woman was in her first trimester when she landed in the emergency room due to significant bleeding. An ultrasound revealed that a miscarriage had sadly occurred. During a procedure known as a dilation and curettage (D&C), the woman’s cervix appeared abnormal, and testing revealed that this individual had cancer growing on her cervix. If not for the D&C, this may not have been discovered until much later.
- A young adult trans male in the midst of transitioning went to the emergency room for complications due to a diagnosis of a sexually transmitted disease. While in the hospital, a pregnancy was found, alongside significant bleeding and hemorrhaging in a lower-body laceration. This individual’s personal and family history had many signs and symptoms of blood or bleeding disorders, and further conversations and testing were requested.
On this last note, it’s important for providers to understand the care, complexity, compassion and trust needed when caring for the LGBTQ community. Within this community, there is a range of structural/anatomical and medical/hormonal issues (e.g., thyroid disease, malignancies) that can increase not only the severity of bleeding but also the risk of complications associated with an otherwise very straightforward, common and typically incredibly safe outpatient surgical procedure.
Abortion isn’t the only ob/gyn procedure that can be seriously affected by bleeding or blood disorders. The potential for risk can increase whenever several gynecological conditions intersect, which is why it’s so vital to share your medical history and family genetic history with your physician.
Maureen K. Baldwin, MD, MPH, Ob/Gyn
Complex Family Planning Specialist, Oregon Health & Science University, Portland
If you are seeking an abortion and you know or suspect that you have a bleeding disorder, there are some things you should be aware of that might affect the procedure. Generally, bleeding risk with abortion is very low (less than 1%). Bleeding risks are basically the same between miscarriage and abortion, and between using medications or a procedure to evacuate the pregnancy. Bleeding complications are even more rare the earlier in pregnancy you are.
Providers who have a lot of experience managing uterine evacuation know that some people have more bleeding than others. Usually this is for a very short time, unless there is another medical condition (diagnosed or undiagnosed). Extra bleeding might occur when there is any amount of tissue or a blood clot inside the uterus that is preventing the uterus from cramping down right away after the rest of the pregnancy has come out. Extra bleeding also occurs when the uterine muscle isn’t cramping down very well. That can happen when there is a different shape to the uterus or when the uterine muscle isn’t functioning normally, as in the case of infection. Bleeding can also happen due to an unintentional injury during a procedure, but this is very rare. All these things can happen equally to someone with or without a bleeding disorder and are far less risky than giving birth.
Managing Excess Bleeding During Abortion Procedures
The treatments for extra bleeding with abortion are the same regardless of whether you have a bleeding disorder, and usually include suctioning to empty the uterine cavity completely and compressing the uterus—from the inside (a balloon), from the outside (external plus internal massage) or with medications that induce contractions. Using medications that help your blood clot can also help, but only if the underlying issue is fixed. Bleeding from a tissue injury is stopped with usual surgery methods, such as applying pressure or placing a stitch.
If you have a bleeding disorder, the amount of bleeding you might have during the time that it takes to coax your uterus to contract and stop bleeding might be a little more than what others experience. So, even though your chance of having extra bleeding is low, the chance that you could bleed more is why we recommend that you be in a place where you can get help more quickly. That means that you will be advised to undergo a procedural abortion rather than use medication, and you should be in a location where providers feel comfortable treating bleeding and are able to get quick access to extra treatments.
There are a couple of adaptations your provider might make during an abortion procedure if they know you have a bleeding disorder. Mainly, they might change the type of instrument used to grasp your cervix. They might recommend you have IV anesthesia instead of placing a numbing injection around the cervix. Even very small tissue injections can have oozing, which can take longer to stop in people with bleeding disorders.
After an abortion, most people bleed for up to three weeks. Bleeding is usually moderate to heavy for the first few days and includes passing some clots. After that, it tapers off. It might be heavier or last a little longer in people who usually have heavier periods. If you are worried, call your provider.
Finally, the main pain medications advised after abortion are usually ibuprofen or naproxen, both of which can interfere with platelet action and are not advised for people with bleeding disorders. You might ask your provider to write a prescription for a nonselective anti-inflammatory such as celecoxib, which is helpful for cramping and does not affect platelets.
In summary, this is the advice I offer for people with bleeding disorders seeking an abortion:
- Staying pregnant has higher risks for bleeding, so your decision to proceed with termination should not be based on your bleeding disorder.
- Procedures for abortion and miscarriage carry similar bleeding risks, and they are very low overall.
- Uterine evacuation should be performed in a place that can manage any extra bleeding quickly.
- Tell the scheduler that you have a bleeding disorder to make sure you are scheduled in the right place.
- The ideal location should be individualized and does not always need to be a hospital.
- Medication abortion is not recommended in most cases.
- Use of your usual pre-procedure prophylaxis such as DDAVP* or tranexamic acid (TXA) could be helpful.
- COX-2-specific nonsteroidal anti-inflammatory drugs are preferred over opioids for post-procedure cramping if nonselective COX inhibitors such as ibuprofen are not recommended.
- If you are calling with a concern about bleeding after your procedure, be sure to mention that you have a bleeding disorder.
Washington Center for Bleeding Disorders, Seattle; Professor of Medicine/Hematology, University of Washington
Women and adolescent girls with bleeding disorders can safely undergo pregnancy termination with bleeding disorder care. What, if any, treatment is needed for their bleeding disorder will depend on the type and severity of the disorder, their bleeding history and the specific procedure they are having.
In most circumstances, the termination would be viewed medically as a minor procedure, and precautions and treatment would be like those for other minor procedures. Additionally, in many circumstances, antifibrinolytic therapy, such as tranexamic acid, will provide sufficient hemostasis (stopping the flow of blood), but women with more severe disease may also require desmopressin or factor replacement therapy, depending on their disorder.
Typically, a woman would treat prior to the procedure with what is needed for her specific disorder and continue treatment after the procedure, often with antifibrinolytic therapy alone, for several days afterward. Von Willebrand factor and factor VIII levels increase with pregnancy. However, levels early in pregnancy are usually not increased sufficiently to preclude the need for treatment.
It is important that women communicate with their hemophilia treatment center (HTC) or bleeding disorder care provider prior to the procedure so that appropriate care and monitoring of their bleeding disorder can be instituted.
*DDAVP (Stimate, concentrated intranasal desmopressin) is not available, but a substitute drug is available through HTCs that are participating in a program with the Hemophilia Alliance and STAQ Pharma.