Abortion Risk: Disseminated Intravascular Coagulopathy

Disseminated intravascular coagulopathy (DIC) is also known as consumptive coagulopathy or disseminated intravascular coagulation.

It's a double-whammy for the patient: excessive blood clots form, bringing a risk of tissue starvation and gangrene and/or sepsis; and the blood thins excessively, bringing a risk of exsanguinating hemorrhage.

The most common cause of abortion-related DIC is amniotic fluid embolism, which is when amniotic fluid gets into the mother's blood stream. This can be caused by lacerations of the uterus, or by compromised blood vessles when the placenta detaches. Infection, either localized in the uterus or generalized (septicemia), can also trigger DIC.

Usually when there is a bleeding injury, the body's reaction is localized; the blood only clots in the area of the tissue damage, preventing further bleeding. But in DIC, clotting factors are released throughout the entire body, causing abnormal clotting. The body then responds by sending out blood-thinning agents to clear out the abnormal clots. Normal clotting agents are tied up in the abnormal clots, and the thinned blood will leak out through minor lacerations, punctures (such as IV and injection sites), and the uterus.

Abortion lacerations can be caused in many ways:

• Tearing the cervix by attempting to dilate it too quickly
  
• Tearing the cervix by pushing the dilators in too hard, causing the cervix to tear loose from the tenaculum (a sharp pincers-like instrument used to hold the cervix steady)
  
• Poking a hole in the uterus or cervix with a dilator
  
• Poking a hole in the uterus with abortion instruments while reaching in to extract fetal parts
  
• Pushing pieces of the fetus through the uterus
  
• Scraping the uterus or cervix with bony parts of the fetus, especially the sharp-edged pieces of the crushed fetal skull

An open wound can be left in the uterus when the placenta is detached in several ways:

• Pulling the placenta away from the wall of the uterus too soon, before the uterus is ready to contract after being emptied
  
• Aggressively scraping the placenta away from the wall of the uterus with excess curretage
  
• Pulling away an abnormally attached placenta

Abnormally attached placenta is more likely to be a problem earlier in the pregnancy than at term, because as the uterus expands the placement of the placenta becomes higher and less likely to partially or completely cover the cervix.

Infection is usually caused either by contaminated instruments entering the uterus, or tissue being left in the uterus, where it rots.

Retained tissue is doubly dangerous because not only can it cause infection, it can prevent proper contraction of the uterus, leaving it more open to contaminants getting into the mother's bloodstream.

The fetal tissue most likely to cause DIC when it gets into the maternal bloodstream is fetal brain. There is much debate among the more conscientious abortionists about the best method of dealing with the fetal head. Some abortionists, such as Mildred Hanson, believe that it is best to suction the fetal brain out of the head before crushing it. This eliminates fetal brain matter from the area when the sharp pieces of fetal skull are being removes. These sharp bony fragments are the fetal parts most likely to scratch the cervix and allow fetal tissue to get into the mother's bloodstream.

Other abortionists, such as Warren Hern, argue that it is sometimes difficult to be sure that the structure you are grasping really is the fetal head and not some part of the mother's body. Hern recommends squeezing the structure and watching the mother's cervix to see if grey material (fetal brain) oozes out ("calvarium show"). The sight of "calvarium show" means that the grasped structure is indeed the head of the fetus and it is safe to extract it.

Since DIC can quickly become fatal, it is important that the abortionist, or the medical professionals treating the womam for her abortion complications, diagnose it quickly. Failure to anticipate and diagnose DIC led to the death of Vanessa Preston after an abortion by Curtis Boyd in Dallas on January 22, 1980.

Since second-trimester evacuation abortions were still new (read "experimental") at the time, Boyd and his staff didn't realize that there was a risk of DIC. When Vanessa went into cardiorespiratory arrest, they instituted emergency measures and resuscitated her, promptly transporting her to a hospital. There, emergency surgery was performed to address the uterine damage. Despite the best efforts of the trauma team, Vanessa died. An autopsy revealed that she had developed AFE and DIC during the abortion. This is what caused her cardiac arrest. When Boyd's staff resuscitated Vanessa, they caused a small laceration of her liver. This is typical in even properly performed CPR, and does not usually cause the patient much harm. However, because of the DIC, Vanessa's blood couldn't clot, and she bled to death from the liver laceration.

Boyd, to his credit, reported Vanessa's death to the Centers for Disease Control. He also wrote a medical journal article about her death, warning other abortionists that DIC could occur during second-trimester evacuation abortions.