Surgical Management of Abortion
INTRODUCTION
Abortion is the termination of pregnancy prior to viability of the fetus. Viability is the ability of the fetus to live independently from the mother and is defined as occurring at 24 weeks of gestation. Induced abortion can be elective (performed for nonmedical indications) or therapeutic (performed for medical indications). Abortion can be performed by surgical or medical means. This article is confined to a discussion of surgical methods of abortion.
History of the Procedure: All cultures have practiced abortion, and the practice of abortion has been documented as early as ancient times. Abortion is controversial and has been subject to an ongoing debate focused on 3 central questions: (1) When should abortion be allowed? (2) Who should make the decision about abortion, the individual or society? and (3) When does the fetus become human?
The answers to the 3 central questions have varied with time, place, and culture. In the United States, the modern debate about abortion began in the 1820s with antiabortion legislation targeted against high maternal mortality rates associated with abortion. Notable in the 20th century was Roe v Wade, the 1973 Supreme Court ruling that guaranteed the fundamental right of a woman to decide whether to terminate her pregnancy. The 1973 Supreme Court ruling did not end the controversy surrounding abortion, and it continues today with legislation and legal intervention at the state and federal levels.
Problem: Abortion is one of the most common surgical procedures performed for American women. Based on estimated lifetime risk, each American woman is expected to have 3.2 pregnancies, of which 2 will be a live birth, 0.7 will be an induced abortion, and 0.5 will be a miscarriage. Using 1996 data, this translates into 3.89 million live births, 1.37 million abortions, and 0.98 million miscarriages.
The abortion rate in the United States has steadily declined from a peak of 29.4 per 1000 women aged 15-44 years to a low of 22.9 per 1000 women in 1996.
Frequency: Most abortions in the United States were performed in the first trimester. Eighty-eight percent of abortions were performed at less than 13 weeks of gestation, 55% were performed at less than 8 weeks, and 18% were performed at less than 6 weeks.
The trend over the last reported years (1992-1997) has been toward abortions performed earlier in gestation.
Ninety-seven percent of abortions reported in the United States are performed using surgical methods.
Etiology: Abortion is by definition a failure. The failure can be the result of the mother’s lack of access to care, failure of the contraceptive method, failure to use contraceptives, or failure of the normal reproductive process (eg, fetal anomalies, fetal death, maternal illness).
Data from 1987 documented that 50% of all pregnancies in the United States were unintended. The large number of unintended pregnancies accounts for the bulk of pregnancy terminations in the United States.
Clinical: The decision to end a pregnancy may be made prior to the diagnosis of pregnancy. Many women present for pregnancy diagnosis with a simultaneous request for abortion. Women should be encouraged to have early diagnosis of pregnancy for the following reasons:
The earlier the diagnosis of pregnancy, the greater the number of abortion methods available.
Earlier diagnosis of pregnancy allows a greater chance for early abortion and lower complication rates.
Earlier diagnosis of pregnancy allows earlier diagnosis of possible ectopic pregnancy and lower complication rates.
Earlier diagnosis of pregnancy enables earlier entry into prenatal care and earlier diagnosis of indications for therapeutic abortion.
Obtain medical, surgical, and obstetric/gynecological history to help differentiate healthy pregnancies from abnormal pregnancies. Symptoms of normal pregnancy include anorexia, nausea, vomiting, breast tenderness, amenorrhea, and lethargy. Symptoms of abnormal pregnancy include abdominal pain, vaginal bleeding, passage of tissue, and near syncope or syncope.
Most elective abortions are performed in women aged 20-24 years. Most therapeutic abortions are performed in women older than 35 years. The most likely profile of patient requesting an elective abortion is that of an unmarried white woman who is younger than 25 years. Females younger than 15 years comprise fewer than 1% of all abortion patients. The number of unintended pregnancies has decreased, with a subsequent decrease in elective abortions. This decrease has been partially attributed to increasing condom and long-acting hormonal contraceptive use in young women and a shift in demographics to an older, less fertile female population.
Many patients who present with an abortion request are upset and frightened. Adequate counseling with discussion of all options available for the pregnancy and explanation of abortion options, risks, and complications is mandatory.
INDICATIONS
Elective abortion involves nonmedical indications for termination of pregnancy as determined by the patient.
Therapeutic abortion is termination of pregnancy for a medical indication, including the following:
Medical illness in the mother in which continuation of the pregnancy has the potential to threaten the life or health of the mother: Consider the present medical condition and a reasonable prediction of future circumstances because few medical indications are absolute.
Rape or incest
Fetal anomalies when pregnancy outcome is likely to be birth of a child with significant mental or physical defects
Fetal death
RELEVANT ANATOMY AND CONTRAINDICATIONS
Relevant Anatomy: Adequate evaluation of uterine size is mandatory. Physical examination may be inadequate for uterine sizing. Common causes of inadequate sizing by physical examination are obesity, uterine fibroids, patient apprehension with voluntary guarding, retroverted uterus, and firm abdominal musculature in young patients.
Obtaining ultrasound confirmation of gestational age prior to abortion in the second trimester is common practice.
A small or stenotic cervical os may prevent adequate dilatation for a surgical abortion.
Uterine leiomyoma may make uterine sizing by physical examination erroneous, dilatation of the cervix difficult or impossible, and introduction of suction tips and curets into the uterine cavity difficult or impossible. Ultrasound prior to abortion is recommended, and ultrasound guidance during the abortion procedure may be helpful.
Previous uterine surgery may increase the risk of perforation during surgical abortion.
Previous uterine surgery and high parity are associated with greater likelihood of placenta praevia, placenta accreta, and placenta percreta. Surgical abortion should be performed in a setting where blood transfusion and access to laparotomy are available.
Scarring of the cervix caused by cone biopsy or delivery may increase the risk of cervical stenosis and damage to cervix at dilatation. Consider passive dilatation with osmotic dilators (eg, laminaria, Dilapan).
Uterine anomalies (eg, uterine septum, double uterus) may make entry into and emptying of the uterus complicated. Ultrasound guidance during abortion procedures is recommended.
Multiple gestations may make surgical abortion more technically challenging. Adequate cervical dilatation and equipment appropriate to uterine size (not dates) is recommended.
For an adnexal mass, the physician must obtain an ultrasound to exclude ectopic pregnancy and to determine the nature of the mass.
Selection of the surgical abortion procedure primarily depends on the gestational age of the pregnancy.
Careful consideration of choice of anesthesia must be based on the medical, psychiatric, and emotional condition of the patient. Local anesthesia affords greatest safety. General anesthesia is associated with greater risk of anesthesia complications and hemorrhage.
Contraindications: Absolute contraindications are virtually unknown. If abortion presents a medical risk to the patient, then continuation of the pregnancy presents an even greater risk. The type and timing of an abortion procedure or method may be contraindicated based on the medical, surgical, or psychiatric condition of the patient.
Medical abortion is contraindicated in patients with clotting disorders, severe liver disease, renal disease, cardiac disease, and chronic steroid use.
Surgical abortion is contraindicated in patients with hemodynamic instability, profound anemia, and/or profound thrombocytopenia.
The rare instance of placenta accreta and percreta in the second trimester may necessitate laparotomy with hysterotomy or hysterectomy.
WORKUP
Lab Studies:
A pregnancy test, blood-type determination, and CBC count are the minimum lab studies required for abortion.
A pregnancy test is required because non–pregnancy-related causes of amenorrhea exist.
Blood-type determination is required so that women who are Rh negative can be identified and treated with RhoGAM to prevent sensitization of subsequent pregnancies.
A CBC count is recommended to identify patients with significant anemia. These patients are at increased risk for clinically significant blood loss that may necessitate transfusion (particularly in procedures performed in second-trimester pregnancies). The patients are best managed in a setting where transfusion is available.
Screen for common sexually transmitted diseases (eg, chlamydia, gonorrhea, HIV, hepatitis B) in geographic areas with high prevalence (eg, urban, inner city) and in age groups commonly at risk (women <25 y).
Additional testing is dictated by findings on history and physical examination.
Coagulation studies are indicated in patients with a history of bruising, abnormal bleeding, hemorrhage with previous surgical procedures, or petechiae on physical examination.
Liver function tests are indicated in patients with ethyl alcohol abuse, hepatitis, hepatomegaly, or jaundice.
Renal function tests are indicated in patients with histories of renal disease or dialysis.
Imaging Studies:
Pelvic ultrasound is indicated prior to surgical abortion under the following circumstances:
Dates of conception are uncertain.
Uterine sizing by physical examination is inadequate.
A discrepancy between the uterine size and date of conception exists.
The pregnancy is in the second trimester.
Uterine leiomyoma are present.
Uterine anomalies are known or suspected.
Adnexal or pelvic masses are known or suspected.
The patient has vaginal bleeding.
The patient has pelvic pain.
The patient has had a previous ectopic pregnancy.
Chest x-ray films may be indicated by history and physical examination findings.
Other Tests:
ECG may be indicated based on age, history or physical examination findings, and type of anesthesia requested.
Histologic Findings: Requirements for pathological examination of products of conception (POC) after surgical abortion are determined by state regulations. Many states require examination of fetal tissue after abortion. Request pathological examination of tissue in the following circumstances, even if no state requirement exists:
Tissue obtained is less than expected based on gestational age.
Scant tissue is obtained.
Tissue is abnormal in appearance (eg, grapelike appearance consistent with molar pregnancy).
Ectopic pregnancy is suspected.
Sac, placental, and/or fetal tissue are not identifiable on gross examination in a first-trimester abortion.
Placental and/or fetal tissue are not identifiable on gross examination in a second-trimester abortion. Tissue inconsistent with POC is identified in the specimen (eg, fat).
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