TREATMENT
Medical therapy: Surgical abortion may be used as a backup for failed medical abortions. For a discussion of medical abortion, see Therapeutic Abortion.
Several modalities can be used to prepare the cervix for dilation at the time of surgical abortion, including oral and vaginal prostaglandin analogues.
Surgical therapy: The following methods are available for surgical abortion:
Manual vacuum aspiration (menstrual extraction) is used at 4-10 weeks of gestation and is 99.2% effective.
Suction curettage is used at 6-12 weeks of gestation.
Curettage is used at 4-12 weeks of gestation but is not currently used because of increased blood loss and retained POC compared to suction.
Dilation and extraction (D&E) is used at 13-24 weeks of gestation.
Hysterotomy is used at 12-24 weeks of gestation and is reserved for the rare instances in which all other methods of abortion have failed or are contraindicated.
Hysterectomy is reserved for rare instances in which other gynecological pathology dictates removal of the uterus.
Women whose abortions are performed earlier in gestation have lower risks of morbidity and mortality. In the United States, 88% of abortions are performed at 13 weeks of gestation or before. Ninety-seven percent of abortions are performed using surgical methods.
In the second trimester, options for abortion include D&E, labor induction methods, and hysterotomy/hysterectomy. D&E is the safest form of abortion in the second trimester, followed with increasing morbidity/mortality by labor induction methods and, finally, hysterectomy/hysterotomy, which holds the highest risk.
Preoperative details: Provide detailed counseling about procedure, risks, complication rates, and alternatives. For manual vacuum aspiration, suction curettage, and D&E, obtain the patient’s medical history with an emphasis on bleeding disorders and allergies. Obtain the patient’s obstetric/gynecologic history with an emphasis on last menstrual period (LMP), fibroids, and uterine anomalies. Perform a pelvic examination to determine uterine size and position and to exclude pelvic mass(es). Lab work is required, including—at minimum—a pregnancy test and an Rh status. Vaginal probe ultrasound can be used as indicated for preoperative confirmation of pregnancy, gestational age, and location of pregnancy, and it can be used postoperatively to confirm termination of the pregnancy.
Assess the patient's need for pain relief, and administer pain medication. (Ibuprofen 600-800 mg or equivalent medication is usually sufficient.) Administering misoprostol (0.4 mg PO or 0.8 mg intravaginally) is optional before the procedure in order to dilate the cervix. For suction curettage, administering 2.5-5 mg of diazepam to an unusually agitated patient on arrival is optional.
For suction curettage, make sure the patient has nothing by mouth (NPO) after midnight the day of the abortion if the patient elects to have general anesthesia. Perform pelvic ultrasound as indicated. Passive dilation with laminaria, Dilapan, or misoprostol is optional.
For D&E, pelvic ultrasound is routine, as is passive dilation with laminaria or Dilapan. Double placement of laminaria or Dilapan separated by a minimum of 6 hours is routine for gestations of longer than 20 weeks. Termination of fetal life with intracardiac potassium chloride prior to D&E for gestations of longer than 20 weeks is optional.
For hysterotomy/hysterectomy, perform preoperative care as for all major surgery. Hysterotomy/hysterectomy requires regional or general anesthesia, and pelvic ultrasound is mandatory. Consider obtaining a second opinion prior to the procedure. The procedure requires intensive counseling because of the increased morbidity and mortality rates associated with it and because of fertility issues.
Intraoperative details: For manual vacuum aspiration, suction curettage, and D&E, place the speculum in the vagina and prepare the vagina with Betadine or an alternative.
For manual vacuum aspiration, placing a paracervical block using chloroprocaine 1% or lidocaine 0.5% or 1% is optional. Grasp the anterior lip of the cervix with the tenaculum. Pass the appropriately sized suction tip into the uterus or gently dilate the cervix with suction tips of increasing size or metal dilators. After the suction tip is placed in the uterus, prepare the syringe by creating a vacuum and attach the tip to the syringe. Blood, POC, and bubbles will enter the syringe. Gently rotate the suction tip while gradually withdrawing the syringe to the internal os (do not remove the suction tip beyond the cervix). The procedure is complete when a gritty sensation is appreciated, when the uterine walls adhere to the suction tip (drag is felt), when foam appears in the tip/syringe, and when no more tissue is evacuated from the uterus. Examine POC.
For suction curettage, paracervical block is routine. After the suction tip is placed in the uterus (see above), attach it to the suction tubing and activate suction. Gently rotate the suction tip from the fundus to the cervix until POC have been removed. Use of a metal curette after suction curettage is routine. Soft suction tips are less likely to damage the uterus than rigid tips, but they have the disadvantage of a greater tendency to clog. Soft tips are less likely to permit entry into the uterus in the case of extreme flexion of the uterus and myomas.
In the case of extreme flexion of the uterus, place the tenaculum on the posterior lip of cervix; this may allow entry into the uterus. Use of polyp forceps for removal of the placenta is optional. POC can be identified in the suction tubing during the procedure. Completion of the procedure is identified when the uterus decreases in size, no more tissue is obtained, pink-red foam appears at the os or tubing, and a gritty sensation is felt with the suction tip or curette. Use of intravenous oxytocin is an option. Examine POC to identify the fetus, placenta, and/or sac.
For D&E, assess the patient's need for anesthesia. Place the speculum in the vagina. Remove passive dilators and assess for adequate dilatation. Use of metal dilators to obtain adequate dilation is an option. Adequate dilation is the key to safety and ease of the procedure. Grasp the anterior lip of the cervix with the tenaculum. Paracervical block with local anesthetic plus vasopressin at 5 U/15 mL of local anesthesia is an option to reduce blood loss.
Rupture membranes and aspirate amniotic fluid with suction. Use forceps (Bierer or Sopher) to remove the fetus. Remove the placenta with forceps and/or suction. Sharp curettage is performed with a curette. Use of intravenous oxytocin is standard practice. The procedure is completed when all of the fetus is identified on gross examination, the placenta is identified, the uterus decreases in size, vaginal bleeding is minimal, and no additional tissue is obtained on curettage.
For hysterotomy, obtain anesthesia. The patient is prepared and draped in the usual fashion for abdominal surgery. A skin incision is made, and the anterior abdominal wall is opened in the usual fashion. The uterus is identified, the uterine incision is made, and the uterine cavity is entered. The fetus is removed from the uterus in the sac, or the membranes are ruptured and the fetus is delivered. The placenta is then removed. Intravenous oxytocin is administered; intravenous antibiotics are optional. The uterine incision is closed, usually in 2 layers. After adequate hemostasis is obtained, the abdominal incision is closed in the usual fashion.
For hysterectomy, the uterus can be removed by vaginal or abdominal approach, as dictated by the size of the uterus and the indication for the hysterectomy. POC are usually removed intact at the time of hysterectomy.
Postoperative details: For manual vacuum aspiration, suction curettage, and D&E, administer RhoGAM as indicated. Surgical complications are rare. Observe the patient for a minimum of 20-30 minutes after the procedure. Postoperative pain, bleeding, syncope, and/or an increase in uterine size require immediate attention. Consider the possibility of retained POC, uterine perforation, cervical laceration, hematometra, or heterotopic pregnancy. Perform postoperative evaluation of POC in all cases.
Counseling regarding fertility and contraceptive management are mandatory. Counsel the patient regarding pain management (ibuprofen 400-600 mg or equivalent medication is usually sufficient). Review signs and symptoms of complications, including severe pain and increasing pain, heavy vaginal bleeding (more than menstrual flow), vaginal bleeding lasting longer than 2 weeks, fever and/or chills, and syncope or near syncope. Antibiotic prophylaxis may be considered. Schedule a follow-up visit 2 weeks after the procedure.
For suction curettage, the length of postoperative observation is determined by the type of anesthesia used.
For D&E, methylergonovine (0.2 mg PO every 4 h for 6 doses) may be considered.
Follow-up care: For manual vacuum aspiration, suction curettage, D&E, and hysterotomy/hysterectomy, schedule a follow-up visit in 2 weeks (1-2 wk after hospital discharge for hysterotomy) to evaluate the patient for complications, to initiate contraception if not previously initiated, to review culture results if not previously reviewed, and to evaluate the pathology results.
COMPLICATIONS
Complications of surgical abortion vary with the technique used and the gestational age of the pregnancy. In general, the more advanced the gestational age at abortion, the higher the complication rate, and the more invasive the operative procedure, the higher the complication rate.
First-trimester abortion
Complication rates are low: 0.071% for hospitalization and 0.846% for minor complications. Abortion complications requiring hospitalization include incomplete abortion (0.028%), sepsis (0.021%), uterine perforation (0.009%), vaginal bleeding (0.007%), inability to abort (0.003%), and combined pregnancy (0.002%). Minor abortion complications include infection (0.46%), repeat suction (0.18%), cervical stenosis (0.016%), cervical tear (0.01%), seizure (0.004%), and underestimate of dates (0.006%).
Manual vacuum aspiration has the following complication rates: infection, 0.7%; perforation, 0.05%; retained POC, 0.5%; and repeat aspiration, 0.5-0.25%.
Second-trimester abortion
In D&E, the skill and experience of the physician are the most important factors in maintaining a low complication rate. Complication rates are low but increase with gestational age. Abortion complications requiring hospitalization include perforation, hemorrhage, infection, retained POC, and inability to complete abortion. Overall rates of hospitalization are 0.6% at 13 weeks of gestation and 1.4% at 20-21 weeks of gestation. Coagulopathy is a rare complication in D&E, occurring in 191 of 100,000 cases.
Avoid complications by obtaining adequate cervical dilatation through using passive dilators in abortions at 14 weeks of gestation and longer and by using double placement of passive dilators at longer than 20 weeks of gestation. Have appropriate instruments available for morbidly obese patients because standard instruments may not be long enough. Match the surgeon’s skill and experience to the gestational age of the pregnancy to be terminated. Choose an inpatient setting for patients with severe medical conditions, anemia, placenta praevia (or other abnormal placentation), pelvic masses or large leiomyomas, or vein problems (eg, no intravenous access). Choose to delay the operative procedure in patients with acute infection, severe vaginitis, or uncertain pregnancy dating.
Choose hysterotomy/hysterectomy as a last resort because these procedures have the highest morbidity and mortality rates of all abortion methods.
Damage to cervix
Risk is increased with previous surgery to the cervix or laceration. Damage can be associated with forceful dilation with metal dilators and may be associated with damage to cervical vessels, with hemorrhage and parametrial hematoma formation. Repair damage using a transvaginal approach or laparoscopy/ laparotomy. Prevent damage by avoiding forceful dilation. Passively dilate the cervix using passive dilators and/or prostaglandin analogues. Delay the procedure if adequate dilation is not achieved.
Hemorrhage
Hemorrhage can be caused by atony, retained products, or perforation. General anesthesia increases the risk of atony. Blood loss of more than 300 mL in the first trimester is considered excessive. Treatment includes uterine massage, oxytocin or methylergonovine maleate, removal of retained products, and repair of perforation as indicated. Prevent hemorrhage by ensuring complete evacuation of the uterus, avoiding use of general anesthesia, and obtaining adequate cervical dilation.
Perforation
Perforation can occur with sound, dilators, curette, suction tip, forceps, or passive dilators. Increased risk is associated with previous surgery or laceration involving the cervix, previous uterine surgery, and grand multiparity. In the first trimester, most perforations are in the body of the uterus. Perforation can be recognized when an instrument passes endlessly, heavy or persistent vaginal bleeding occurs, signs of peritoneal irritation appear, or fat or other tissue appears in the specimen. If perforation is made with the sound or dilator, stop the procedure and observe the patient for a minimum of 1 hour. Antibiotic prophylaxis and ultrasound are options. Reschedule the procedure for another day. If perforation occurs with suction tip or curette, stop the procedure. Options include observation if the patient is stable and the abortion is complete, laparoscopy if hemorrhage is suspected or the abortion is incomplete, and laparotomy if the patient is unstable.
Mortality from abortion
Mortality rates are highest with the most invasive procedures and with increasing gestational age, as follows: 0.4 of 100,000 cases at less than 8 weeks of gestation, 3 of 100,000 cases at 13-15 weeks of gestation, and 12 of 100,000 cases at longer than 21 weeks of gestation. Causes of death include infection, hemorrhage, pulmonary embolism, anesthesia complications, and amniotic fluid embolism. Death rates with hysterotomy/hysterectomy are 64.9 of 100,000 cases at 13-15 weeks of gestation and 123 of 100,000 cases at longer than 21 weeks of gestation.
OUTCOME AND PROGNOSIS
Surgical abortion is a safe and commonplace procedure in the United States, and the risk of complications is small. Most complications are managed safely, with minimal long-term consequences. Fertility after abortion is only at risk in the rare instance in which a major complication occurs.
Late complications include cervical scarring and stenosis, Asherman syndrome (uterine synechiae), postinfection tubal damage, mandatory cesarean delivery after hysterotomy, and loss of fertility after hysterectomy.
Psychiatric illness after abortion occurs most commonly in patients with psychiatric illness prior to the abortion procedure. No evidence supports the existence of an abortion trauma syndrome.
FUTURE AND CONTROVERSIES
The decrease in total numbers of abortions is expected to continue, as is the trend toward earlier abortions. The total percentage of surgical abortions is expected to decrease with the US Food and Drug Administration (FDA) approval of medical abortion. The total percentage of surgical abortions is expected to decrease because of lack of availability of trained providers. Nonsurgical management of incomplete, inevitable, and missed abortions is expected to rise as a result of the experience with medical abortion. Cost and complications of the management of abortion (induced and therapeutic) are expected to decrease as nonsurgical management increases. Controversy about the use of fetal tissue will increase, as will the moral, ethical, and legal debates about abortion.
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