You are in: eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery Surgical Management of AbortionArticle Last Updated: Jun 16, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Natalie E Roche, MD, Department of Obstetrics, Gynecology and Women's Health, Assistant Professor, University of Medicine and Dentistry of New Jersey Natalie E Roche is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Association of Reproductive Health Professionals, International AIDS Society, National Medical Association, and New York Academy of Sciences Coauthor(s): Susanna J Park, MD, Department of Obstetrics, Gynecology and Women's Health, Assistant Professor, University of Medicine and Dentistry of New Jersey; Denise James, MD, Assistant Professor, Department of Obstetrics, Gynecology and Women's Health, University of Medicine and Dentistry of New Jersey Editors: Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University; Chief, Division of Reproductive Genetics, Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern Memorial Hospital Author and Editor Disclosure Synonyms and related keywords: surgical management of abortion, termination of pregnancy, TOP, menstrual extraction, manual vacuum aspiration, suction curettage, dilation and extraction, dilation and evacuation, dilatation and evacuation, D&E, hysterotomy, laparotomy, hysterectomy, products of conception, POC, Roe v Wade INTRODUCTIONSection 2 of 11
  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 ProcedureAll 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. ProblemAbortion 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. FrequencyThe Centers for Disease Control and Prevention (CDC) data are based upon information on legally induced abortions voluntarily submitted by states and by 2 areas of occurrence (ie, District of Columbia, New York City). The most current figures were compiled in 2001; this information does not include statistics from the states of Alaska, California, or New Hampshire. The Alan Guttmacher Institute (AGI) is a private organization that is not subject to the reporting limitations of state health departments. AGI contacts abortion providers directly and provides abortion data every 4-5 years. A previous report documented a discrepancy of approximately 12% between statistical figures presented by the CDC compared with those of AGI (the latter generally having higher estimates). CDC figures were used for this article. A total of 853,485 legal induced abortions were reported to the CDC for 2001 from the 49 reporting areas. This reflects a decline of 0.5% from the number of legal induced abortions reported for 2000 from the same reporting areas. The abortion rate in the United States has steadily declined from a peak of 29.4 per 1000 women aged 15-44 years in 1990 to a low of 16 per 1000 women in 2001. The decline in the abortion rate has been attributed to a decrease in the number of unintended pregnancies, increased use of condoms and long-acting hormonal contraceptives in young women, reduced or limited access to abortion services, including the passage of abortion laws that affect adolescents (eg, parental consent, notification laws and mandatory waiting periods), and a shift in the age distribution of women toward the older and less fertile ages. The abortion rates reported for the United States were higher than those reported for Canada and Western European countries but lower than the rates reported for China, Cuba, most of Eastern European countries, and certain newly independent states of the former Soviet Union. Most abortions in the United States were performed in the first trimester: 59% of abortions were performed at less than 8 weeks' gestation and 88% of abortions were performed at less than 13 weeks' gestation. Few abortions were performed in the second trimester: 4.3% at 16-20 weeks and 1.4% at more than 21 weeks. In 2000 (the most recent year for which data are available), as in previous years, deaths related to legally induced abortions occurred rarely at less than one death per 100,000 abortions, making surgical abortion one of the safest surgical procedures performed in the United States. The trend over the last reported years (1992-1997) has been toward abortions performed earlier in gestation. From 1992 (when detailed data on early abortions were first available) through 2001, data have indicated steady increases in procedures performed at less than 6 weeks' gestation with decreases occurring in the percentage of abortions performed at 8-12 weeks' gestation. The proportion of abortions performed at more than 13 weeks has varied little since 1992. Abortions performed early in pregnancy are associated with lower risks of mortality and morbidity. Early surgical abortions ( <6 wk) has been shown to be safe and effective with complication rates comparable with that of mifepristone and vaginal misoprostol. For the abortions reported in the United States, the vast majority are performed using surgical methods. For women whose type of procedure was adequately reported, 95% of abortions were performed by curettage (which includes dilatation and evacuation [D&E]) and 0.5% were performed by intrauterine instillation. The percentage of abortions performed by D&E (curettage) at more than 13 weeks' gestation increased from 31% in 1974 (the first year for which these data were available) to 96% in 2001, while the percentage of abortions performed by intrauterine instillation at more than 13 weeks' gestation decreased from 57% to 0.5%. The increase in D&E (and the associated decrease in intrauterine instillation) is likely attributable to the lower risk of complications associated with D&E. Hysterotomy and hysterectomy were used in less than 0.01% of all abortions. EtiologyAbortion is by definition a reproductive 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. ClinicalThe 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:
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. 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. INDICATIONSSection 3 of 11
Elective abortion is the termination of pregnancy for nonmedical indications as determined by the patient. Therapeutic abortion is termination of pregnancy for medical indications, including the following:
RELEVANT ANATOMYSection 4 of 11
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.
CONTRAINDICATIONSSection 5 of 11
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.
WORKUPSection 6 of 11
Lab Studies
Imaging Studies
Other Tests
Histologic FindingsRequirements 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:
TREATMENTSection 7 of 11
Medical therapySurgical 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 therapyThe following methods are available for surgical abortion:
Abortions performed earlier in gestation have a lower risk of morbidity and mortality. In the United States, 88% of abortions are performed at 13 weeks' gestation or less. Ninety-seven percent of abortions are performed using surgical methods. A randomized trial demonstrated comparable acceptability among both patients and physicians of manual vacuum aspiration and suction curettage with regard to procedure time, blood loss, complications, anesthesia requirement, recovery time, pain perception, and overall satisfaction. The only significant factor was noise audibility noted with suction curettage, a distinct advantage of manual vacuum aspiration. In the second trimester, options for abortion include D&E, D&X, labor induction methods, and hysterotomy/hysterectomy. D&E is considered the safest form of abortion in the second trimester. In contrast, D&X is reputed to pose a greater health risk to the mother (increased risk of cervical incompetence, uterine rupture, abruption, amniotic fluid embolism, and uterine trauma) when compared with that of D&E. However, no published data exist regarding the frequency or complication rates for D&X. Further, no prospective trials have been conducted comparing the morbidity or mortality rates of D&E and D&X. A retrospective study has shown comparable complication rates and obstetric outcomes between these 2 procedures when performed by experienced physicians. Labor induction methods have increasing morbidity/mortality as compared with that of D&E. Hysterectomy/hysterotomy procedures have the highest risk of complications but still have a role in special clinical situations (stenotic cervical os, placentaaccreta, leiomyoma obstructing cervical os, etc). Women with a history of prior cesarean delivery are at particularly increased risk of morbidity/mortality when undergoing labor induction as a form of surgical abortion. Labor induction resulted in a 20-fold increased odds ratio of uterine rupture and 2-fold increased risk of blood transfusion in women with a history of prior cesarean delivery as compared with those without a uterine scar. Thus, women with a history of a prior cesarean delivery should undergo either D&E or D&X as the method of surgical abortion. Preoperative detailsProvide 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 (sublingual or vaginal) is optional. For D&E and D&X, pelvic ultrasonography 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 more than 20 weeks. Termination of fetal life with adjunctive infusion methods (amnioinfusion of a hyperosmolar urea solution, intracardiac KCL, or intrafetal/intra-amniotic digoxin) prior to D&E or D&X for gestations of more than 20 weeks is optional. Though injection of these substances do not conclusively render the D&E or D&X procedure more efficient, patients may prefer termination of the fetus prior to the procedure. 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 detailsFor manual vacuum aspiration, suction curettage, D&E, and D&X, 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. The maximum recommended dose is 4.5 mg/kg of body weight. In general, inject a maximum of 2 mL at the tenaculum site, 3:00, 5:00, 7:00, 9:00, and 12:00; deeper blocks can be achieved with an additional maximum 2-mL injection at 2:00, 5:00, 7:00, and 10:00. Epinephrine 1:200,000 may render the lidocaine more effective because it reduces absorption of lidocaine and decreases the risk of a vasovagal reaction. 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, products of conception (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, placement of a paracervical block is common. 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 common but can increase bleeding. 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 or with the presence of 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. This allows the uterus to contract, thereby closing the venous sinuses. This results in limitation of blood loss and reduction of the risk of an amniotic fluid embolism, one of the major causes of morbidity and mortality of late abortions. Further, evacuation of all the amniotic fluid allows for accurate measurement of blood loss. 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. D&X is a variant of D&E. For D&X, the fetus must be in a breech position. This may require internal podalic version prior to the procedure. The preparatory procedure is similar to that of D&E. As with D&E, adequate dilatation is key. Following amniotomy and aspiration of amniotic fluid with suction, the fetus is delivered in the footling breech position. If the fetal head becomes entrapped in the cervix, partial evacuation of the intracranial contents using suction is performed to effect vaginal delivery of an intact fetus. For manual vacuum aspiration, suction curettage, D&E, and D&X, it is imperative that all fetal tissue is thoroughly removed from the uterus. Failure to do so may result in postabortion hemorrhage. Furthermore, a clot or devitalized tissue (retained placenta) remaining in utero can be a nidus for infection. Such incomplete abortions accounted for the high rates of septic abortions that occurred in the first half of the 20th century. 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 detailsFor 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. For second-trimester abortions, the most critical evaluation is measurement of the fetal foot length as an estimation of gestational age. Counsel the patient regarding pain management (ibuprofen 400-600 mg or equivalent medication is usually sufficient). Review signs and symptoms of complications, including severe 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 (tetracycline or nitroimidazole) is an option. Doxycycline 100 mg PO 1 hour prior to the procedure and 200 mg PO after the procedure. Alternatively, metronidazole 500 mg PO bid for 5 days. 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 and D&X, methylergonovine (0.2 mg PO every 4 h for 6 doses) may be considered. Because most terminations of pregnancies in the United States are performed on unintended pregnancies, counseling regarding fertility and contraceptive management are mandatory. In 83% of women, ovulation occurs in the first menstrual cycle post abortion. In first-trimester abortions, contraception should be initiated immediately postoperatively. Intrauterine devices (IUD) can be safely inserted at the time of the abortion procedure. Follow-upFor 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. For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Procedures Center. Also, see eMedicine's patient education articles Miscarriage, Abortion, and Dilation and Curettage (D&C). COMPLICATIONSSection 8 of 11
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 and D&X, 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, Pitocin (40 units in 1 L crystalloid) or intramuscular/intracervical Methergine (methylergonovine maleate) or intramuscular Hemabate (15-methyl prostaglandin), removal of retained products, and repair of perforation as indicated. In cases where hemorrhage cannot be adequately controlled despite the above measures, pelvic embolization, if available, may be effective. If ineffective, hysterectomy should be performed as a life-saving measure. Prevent hemorrhage by ensuring complete evacuation of the uterus, avoiding use of general anesthesia, and obtaining adequate cervical dilation. In conditions in which hemorrhage is anticipated (such as known placenta accreta), preoperative placement of catheters, prophylactic pelvic embolization, or readiness to place catheters are options that should be considered in an effort to minimize the need for emergent hysterectomy. Abortion-related hemorrhage due to retained tissue can occur up to several weeks after the procedure. In general, blood loss in excess of that of a normal menstrual period is considered significant and should prompt reaspiration. Infection Fever greater than 102°F (39°C) within 72 hours of the abortion should be considered septic abortion due to retained products. Treatment requires reaspiration followed by intravenous antibiotics (cefoxitin, clindamycin, chloramphenicol, cephalosporin with ampicillin, or penicillinase-resistant penicillin). Fever less than 102°F (39°C) should be treated with reaspiration and oral antibiotics (doxycycline 100 mg bid for 10 d). 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 to be performed in 2-3 weeks. 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. Anesthesia risks The use of local anesthesia is favored over general anesthesia because the latter poses a greater risk of maternal complications. Allergic reactions to local anesthetic can be treated by intravenous epinephrine or intramuscular diphenhydramine. Significant complications from local anesthesia are most often due to toxic levels of the anesthetic resulting in convulsions and cardiopulmonary arrest. To avoid exceeding toxic dose levels, do not administer more than 20 mL of 1% lidocaine, or the equivalent, for a paracervical block. Treatment of cardiopulmonary arrest consists of cardiopulmonary resuscitation and basic life support. OUTCOME AND PROGNOSISSection 9 of 11
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. Multiple studies have confirmed that most women do not experience emotional distress post abortion. This is equally true with regard to adolescents (aged 14-21 y). Reactions post abortion are influenced by the woman's experience with the pregnancy and the decision-making process to undergo an abortion. A number of studies have challenged the once widely held notion that terminations of pregnancies increased the risk of adverse pregnancy outcomes in subsequent pregnancies. These studies have shown a lack of a causal relationship between induced abortions, including second-trimester abortions, and increased obstetrical complications in an ensuing pregnancy. FUTURE AND CONTROVERSIESSection 10 of 11
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. Of all the surgical methods of abortion, D&X remains the most controversial. The Partial-Birth Abortion Ban, which is the government term for D&X, was signed into law by President Bush on November 5, 2003. Physicians who testified in support of this ban stated that D&X, in comparison with that of D&E or labor induction, increased a woman's risk of cervical incompetence, uterine rupture, abruption, amniotic fluid embolism, and uterine trauma. However, these assertions were not based upon published data as little medical literature exists regarding the safety of D&X. Though retrospective, the study by Chasen et al provides evidence that D&X has comparable complication rates and obstetric outcomes as that of D&E. The American College of Obstetrics and Gynecology (ACOG) policy statement on D&X is as follows: "An intact D&X, however, may be the best or most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman, and only the doctor, in consultation with the patient, based upon the woman's particular circumstances, can make this decision...The intervention of legislative bodies into medical decision making is inappropriate, ill advised, and dangerous." Controversy about the use of fetal tissue will increase, as will the moral, ethical, and legal debates about abortion. REFERENCESSection 11 of 11
Surgical Management of Abortion excerpt Article Last Updated: Jun 16, 2006 |
