The first aim was to investigate the number of complications associated with induced abortions. The main finding after compiling the results was an increasing number of complications after medical abortions < 12 weeks that was statistically significant. Incomplete abortions were found to be the most common complication after medical abortions < 12 weeks. Concerning medical abortions > 12 weeks and surgical abortions, it has been difficult to discern whether there are any trends since the numbers of medical abortions > 12 weeks and surgical abortions are low and the cases of complications are few. The second aim was to evaluate the impact of bacterial screening on postabortal infections. The frequency of infections after induced abortions appeared to be equal or even lower among patients who had a bacterial infection upon screening and therefore did receive antibiotics. Despite bacterial screening, there were still patients who suffered from infectious complications.
When looking at the number of abortions each year (Fig. 1, Table 1), we can see an increase from 2008 when 533 abortions were performed, to 2015 when there were 805 abortions. This increase can primarily be explained by the addition of abortions being performed at Lidköpings Hospital from 2013 and forward. But this may not be the only reason. An increase in the number of abortions could be expected at this time because of the high number of children that were born in the early 1990’s [11]. Girls born during that decade should have reached an age of 20–24 years by now, and this is the age where the proportion of induced abortions is the highest. According to a statistical report from The National Board of Health and Welfare [1], the proportion of medical abortions has increased the last 15 years, while the proportion of surgical abortions has decreased. This matches our findings in Fig. 1 and Table 1.
There was a significant increase in the share of complications related to medical abortions < 12 weeks (RR 1.49, 95% 1.04–2.15). One potential reason is that the proportion of induced abortions performed at home has risen. It is likely that women who have medical abortions at home will visit our outpatient clinic in a greater extent since they do not have the direct help and support from a midwife. Later, they may have been diagnosed with a postabortal complication even though their symptoms are mild and could have resolved without any treatment. Table 4 shows that abortions at home are associated with a greater proportion of complications, but this is not statistically significant. This is likely due to of the low number of abortions performed at the hospital.
The number of infections after medical abortions < 12 weeks is 1.2%, which is low compared with Charonis et al.’s (2006) reported frequency of 2.4% [5]. The actual number of infections after medical abortions < 12 weeks in our study is, however, low: only 45 patients in 8 years, which makes the results difficult to validate. As many as 4.1% of the medical abortions < 12 weeks had to be supplemented by a vacuum curettage.
There were also six failed medical abortions that were excluded from the statistics (see excluded cases). A failed abortion must be interpreted as the worst kind of incomplete abortion. When reading the patient records, it was evident that many patients did not attend the follow-up visits. It is of utmost importance to explain to the patients why this appointment is so essential and to motivate them to come.
There were few surgical abortions compared to medical abortions, and the relative number of complications related to surgical abortions was low; most were infections, which we expected. When performing a vacuum curettage, there is always a risk that bacteria from the lower genitals will be brought up to the uterus, causing endometritis. Figure 3 shows a peak in the complication frequency during 2011–2013. However, according to Table 2, this increase only consists of a few more cases, so it could be just a coincidence. The total complication frequency after surgical abortions was 5.2%, which is consistent with previous research [5].
The prevalence of chlamydia among women undergoing induced abortions was consistent with previous research. One of the latest studies on the subject from Sweden by Bjartling et al. (2010) reported a prevalence of chlamydia of 2.8% compared to our average of 2.3% [4]. Mycoplasma was present in 2.7% of all the patients, which was nearly the same as Bjartling et al. (2010) (2.5%). The prevalence of gonorrhea was very low, as expected. Only one patient had gonorrhea, which is 0.02% of all patients. Bacterial vaginosis seems to be less prevalent in this study compared with others. The prevalence of bacterial vaginosis was 15.7%, compared with approximately 20% in two other Swedish studies [5, 6].
A comparison was made between all patients who tested positive for one or several bacteria upon screening and received antibiotics and those whose tests were negative. We found that the share of infectious complications was almost the same among patients who had tested positive at the screening. The screen and treat policy, where patients have to wait for the screening results before treatment does not appear to increase the risk and might be a better choice than antibiotic prophylaxis for all patients.
When including only surgical abortions, there was a greater difference between the two groups. There were fewer infectious complications among patients treated with antibiotics for chlamydia, gonorrhea, mycoplasma, or bacterial vaginosis. This indicates that antibiotics may have a positive impact, beyond treating the screened infections. There was, however, no significant difference between these groups, probably because of the low number of surgical abortions.
It is, however, clear that bacterial screening cannot prevent all cases of postabortal infections. There must be other bacteria involved, beyond those that are screened for. In a study from 2009, the presence of pathogens in cervical samples among 114 women with upper genital tract infections was investigated [12]. It showed that bacteria from the upper respiratory tract were detected more times than sexually transmitted bacteria. Haemophilus influenza, Group A streptococci, and Streptococcus pneumoniae were detected in nine cases compared with C. trachomatis and N. gonorrhoeae, which were identified in seven of the patients. Perhaps bacteria from the upper respiratory tract are involved in developing postabortal infections or increasing bacterial resistance could play a role.
This study has several limitations. The timeline of 30 days regarding the follow-up of the patients proved to have disadvantages. Some patients did not contact the gynecological clinic for their postabortal problems until after 30 days, which leads to an underestimation in the amount of complications. One limitation is that some patients may be missing in our statistics since they sought medical help somewhere other than at Skaraborg Hospital. However, there are few private gynecological clinics in the area, so it can be assumed that the majority of the complications are represented in this material.
Another limitation is that antibiotic treatment for the screened infections could not always be given prior to the abortion since the analysis for chlamydia, gonorrhea, and mycoplasma takes 2 days. This means that antibiotics were sometimes given one or 2 days after the day of the abortions. This dilemma primarily affects medical abortions, which are often initiated the same day as the appointment at the gynecologist. Surgical abortions are usually performed after a week or so, which facilitates the timing of the treatment. According to a study by Larsson et al. [7], the time from abortion to infection is usually four to 5 days.
Another limitation is that various individuals were involved in categorizing the complications. This may have resulted in misdiagnosis. In other words, patients who appeared to be similar to each other might have been categorized differently.
One of the strengths in this study is the size of the study group. A total of 4945 induced abortions were included, which gave a fairly accurate depiction of the incidence of bacterial infections in the screening process and of the overall complication frequency.
