Incomplete Medical Abortion: Common Concerns and Next Steps

Medical abortion, incomplete expulsion?

Hello, Doctor.
I discovered I was pregnant on March 10 of this year.
The next day, on March 11, I went to the obstetrics and gynecology department for an examination, and I was 6 weeks and 2 days along.
However, I decided not to continue with the pregnancy, so I took RU486 for a medical abortion that same day.
On March 13, I returned for a follow-up and took three doses of Misoprostol.
I stayed in the hospital for two to three hours to check via ultrasound whether the pregnancy had been expelled.
The doctor said the embryo had been expelled and sent me home without prescribing any medication.
I experienced daily bleeding, which gradually decreased in volume.

During my follow-up on March 27, I mentioned that I was still bleeding, so a pregnancy test was conducted, which showed two lines.
An ultrasound was performed again, and the doctor indicated that it seemed like retained products of conception.
I took two more doses of Misoprostol and was advised to return if I continued to bleed after two weeks.
I experienced minimal pain and continued to have slight bleeding daily, which was dark brown in color.

On April 9, I had a heavier flow of dark red-brown blood with a blood clot, which startled me.
I had been feeling lower back pain and abdominal discomfort, initially thinking it was my period, but it didn’t seem like a normal menstrual flow.
On April 10, during my follow-up, I reported that I was still bleeding.
The doctor performed an ultrasound and said it appeared that there were still some retained tissues.
A pregnancy test was conducted, which showed one line, indicating no signs of pregnancy, and I was instructed to take two more doses of Misoprostol.
I did not feel any significant changes after taking the medication and had minimal bleeding.
The doctor suggested that I would need a hysteroscopy for further evaluation.
I have a few questions:
1) Is it possible to have a medical abortion and still have retained products of conception without any signs of pregnancy?
2) On March 27, the ultrasound indicated retained products of conception, but why did the follow-up two weeks later suggest there might be retained tissues? Is it possible that the ultrasound was not clear? It seemed like the doctor only glanced at it.
3) Does this mean I will ultimately need a surgical procedure to clean out the uterus? I have read that a hysteroscopy with a cold knife is less damaging to the uterus.
4) I have a history of cesarean section, and I have a scar on my uterus.
Could this affect the flow of menstrual blood?
Thank you, Doctor.
🙏

Lan, 30~39 year old female. Ask Date: 2021/04/10

Dr. Wu Xianghui reply Obstetrics and Gynecology

1.
Medical abortion may result in incomplete miscarriage.
2.
There are issues with the ultrasound examination; it is necessary to consult the original physician's office for clarification.
3.
Induced abortion, being a non-natural factor, can inherently lead to complications such as infection, intrauterine adhesions, and infertility.
4.
A cesarean section scar and a retroverted uterus can indeed predispose to the retrograde flow of menstrual blood into the pelvic cavity.

Reply Date: 2021/04/10

More Info

Understanding incomplete medical abortion can be a complex and concerning issue for many women. Based on your experience, it seems you have encountered a series of challenges following your decision to undergo a medical abortion using RU486 and Misoprostol. Let's address your questions and concerns systematically.

1. Incomplete Abortion with No Signs of Pregnancy: It is indeed possible to experience incomplete abortion without any signs of pregnancy. After taking RU486 and Misoprostol, the body may expel the pregnancy tissue, but sometimes not all of it is expelled. This can lead to ongoing bleeding or the presence of retained products of conception, which may not show up on a pregnancy test if the levels of hCG (human chorionic gonadotropin) have dropped sufficiently. The absence of a positive pregnancy test does not necessarily mean that all tissue has been expelled; it may simply indicate that the hormone levels have fallen below the detectable threshold.

2. Ultrasound Findings and Follow-Up: The discrepancies in ultrasound findings can be frustrating. Ultrasound is a valuable tool, but it has its limitations. The initial ultrasound may have indicated that the tissue was expelled, but as time passes, retained tissue can become more apparent, especially if it is not fully expelled. It is not uncommon for ultrasound results to vary slightly between visits, particularly if the retained tissue is small or if the ultrasound is not performed with high-resolution equipment. If you feel that the ultrasound was not thorough enough, it is reasonable to seek a second opinion or request a more detailed examination.

3. Need for Surgical Intervention: If the ultrasound indicates that there are still retained products of conception, it may be necessary to consider a surgical procedure, such as dilation and curettage (D&C) or hysteroscopy, to clear the uterus. Hysteroscopy, especially with a cold knife technique, is often preferred as it can be less traumatic to the uterine lining compared to traditional D&C. However, the decision should be made in consultation with your healthcare provider, who can assess your specific situation and recommend the best course of action.

4. Previous Cesarean Section and Uterine Issues: Your history of a cesarean section and the condition of your uterus can indeed affect menstrual flow and the expulsion of tissue. Scar tissue from a previous surgery can lead to adhesions or changes in uterine shape, which might complicate the process of expelling menstrual blood or retained tissue. Additionally, a retroverted uterus (tilted backward) can sometimes make it more challenging for the uterus to contract effectively, potentially leading to issues with bleeding or incomplete expulsion.

In conclusion, it is crucial to maintain open communication with your healthcare provider regarding your symptoms and concerns. If you continue to experience abnormal bleeding, pain, or other symptoms, it is essential to follow up promptly. Seeking a second opinion or consulting with a specialist in reproductive health may provide you with additional insights and options for your care. Remember, your health and well-being are paramount, and you deserve thorough and compassionate medical attention.

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