ABORTION PROCEDURES
Romaine Barrett April 2012
DEFINITION OF ABORTION
Synonyms:
Termination of pregnancy (TOP)
It is a medically directed miscarriage prior to independent viability, using pharmacological or surgical means.
ASSESSMENT
Medical History Physical Examination Laboratory studies
MEDICAL HISTORY
Obtain a brief and targeted gynaecologic & obstetric history
Issues of prior pregnancies Treatments during current pregnancy Prior gynaecological diseases Previous or current STIs GMC: DM, HTN, Heart disease, Anaemia, Bleeding disorders Gynaecological surgery
PHYSICAL EXAMINATION
Dating of the pregnancy Gynaecologic pathology (particularly STIs) Patient's suitability for an operative procedure under local sedation Vaginal or cervical discharge Nature of the cervix, and any lesions Ovarian pathology If the patient is planned for general anaesthesia, a typical screening preoperative physical examination should be performed
INVESTIGATIONS
Pregnancy tests Ultrasonography (Gestational age) Hemoglobin (Hb) or hematocrit (Hct) levels STI screening
gonorrheal culture chlamydial test
Rh typing Additional testing as indicated by findings on history and physical examination.
THE ABORTION PROCEDURES
Counselling Choice of method should be relevant for the gestational age. Antibiotic prophylaxis
Metronidazole 1 g rectally at the time of abortion, plus doxycycline 100 mg bd for 7 days starting post-abortion metronidazole 1 g rectally at the time of abortion plus azithromycin 1 g orally on the day of abortion
ABORTION PROCEDURES
Medical/Pharmacological Surgical
MEDICAL PROCEDURES
MEDICAL CARE
Misoprostol (alone) Methotrexate + misoprostol (MTX) up 7 wks Mifepristone +/- misoprostol up to 7 9 wks
Gestational age for the FDA-approved protocol is 49 days. Many protocols goes up to 63 days
Induction abortion after 21 wks
MIFEPRISTONE/MISOPROSTOL REGIMEN
Day 1:
mifepristone, typically 200 mg (600 mg PO is FDA regimen) - administered in the office.
misoprostol (800 mcg vaginally or 400 mcg PO) administered at home.
Day 2/3:
The FDA regimen is administering the medication on day 3 with a 4-hr observation period after insertion; however, if the patient is bleeding, the misoprostol may be used immediately, as soon as 8 hours after the mifepristone.
Day 7:
Office follow-up to determine if the abortion has been completed.
If the abortion is not complete
repeat misoprostol surgical abortion
INDUCTION ABORTION
after
21 wks rarely performed procedure Saline, urea, digoxin, or KCl is injected into the amniotic sac prostaglandins are inserted into the vagina pitocin (Synthetic oxytocin) is injected intravenously
SURGICAL PROCEDURES
SURGICAL CARE
Dilatation
and curettage (D&C) Dilatation and evacuation (D&E) Dilatation and extraction (D&X) Hysterotomy Hysterectomy
CERVICAL DILATATION AND PREPARATION
1st trimester TOP (esp. <10 wks) rarely need preoperative cervical preparation Late 1st trimester: preoperative dilatation with laminaria or medical treatment with prostaglandins is helpful 2nd trimester: the cervix needs preparation Forceful cervical dilatation can lacerate the cervix
significant bleeding cervical incompetence
LAMINARIA
Small
sticks of presterilized seaweed Only one laminaria is required for dilating the cervix with a 10-week pregnancy Most laminaria need at least 4 hours to be useful, but overnight use is indicated in cases that are further along
SINGLE - TOOTHED TENACULUM
CERVICAL PREPARATION
Oral,
buccal, or vaginally administered misoprostol in doses of 200-800 mcg
INTRAOPERATIVE CARE
"vocal
sedation" sedation
talking the patient through the procedure
heavy
Monitor appropriately Trained staff needed
1ST TRIMESTER SURGICAL ABORTION
manual aspiration 3 to 12 wks
Suction generates using a hand-held syringe
suction generated by a vacuum aspirator
vacuum aspiration up to 16 wks
Single-toothed tenaculums are used to grasp the cervix after it has been prepared with Betadine Local anesthetic is administered in a paracervical fashion
DILATATION & CURETTAGE - D&C
up
to 16 wks accomplished with similar dilatation procedures, but uterine emptying is accomplished with a sharp metal curette
SECOND-TRIMESTER SURGICAL PROCEDURES
Dilatation & Evacuation Dilatation & Extraction
DILATATION
after
& EVACUATION - D&E
16 wks safest and most common method of secondtrimester termination for experienced providers procedure requires the cervix to be dilated to 2-3 cm cervix is grasped with a single-toothed tenaculum after Betadine preparation procedure is accomplished using a combination of suction curettage and manual evacuation of the foetus and placenta.
DILATATION
& EVACUATION
Rupture membranes and aspirate amniotic fluid with suction. Use forceps (Bierer or Sopher) to remove the foetus. Remove the placenta with forceps and/or suction. Sharp curettage is performed with a curette. Use of intravenous oxytocin is standard practice.
SOPHER FORCEPS
BIERER FORCEPS
DILATATION & EXTRACTION (D&X)
after 21 wks similar to cases of dilatation and evacuation the foetus is removed in a mostly intact condition With an intact foetus, the family may hold their baby and have time to say good-bye as part of the grieving process Intra-amniotic or intra-foetal injection with digoxin to induce foetal death
3RD TRIMESTER PROCEDURES
3rd Trimester (not legal in a number of countries except in certain medical situations)
Induction Abortion D&X
EXTREMIS PROCEDURES
Hysterotomy Hysterectomy
COMPLICATIONS
Post abortion complications develop as a result of 3 major mechanisms: Incomplete evacuation of the uterus and uterine atony
hemorrhagic complications
Infection Injury due to instruments used during the procedure
Post abortion triad (i.e., pain, bleeding, low-grade fever) Hematometra Retained products of conception Uterine perforation Bowel and bladder injury Failed abortion Septic abortion; PID Cervical shock Cervical laceration Disseminated intravascular coagulation (DIC)
THE END
THINGS TO CONSIDER BEFORE TERMINATION
Confirm the patient is pregnant. Counsel to help her reach the decision she will least regret. Ask her to consider the alternatives (e.g. adoption), ask about her partner. Ideally, allow time for her to consider and bring her decision to a further consultation.
IF SHE CHOOSES TERMINATION:
Screen for Chlamydia (25% postoperative salpingitis if untreated) Discuss future contraceptive needs Check rhesus status - if negative, needs anti-D Offer follow-up - there may be problems around the time she would otherwise have delivered.
ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS GUIDELINES
All women should have access to a clinical assessment. There should be arrangements to minimise delay, e.g. direct access from referral sources other than GPs. All women should be offered an assessment appointment within 2 weeks of referral (ideally within 5 days). All women should undergo an abortion within 2 weeks of the decision to proceed (ideally 7 days). No woman should wait longer than 3 weeks from initial referral to the time of her abortion.
