F i r s t - Tr i m e s t e r S u r g i c a l A b o r t i o n Tec h n i q u e Nicole Yonke,
MD, MPH
a,
*, Lawrence M. Leeman,
a,b MD, MPH
KEYWORDS First-trimester abortion Surgical abortion Electric vacuum aspiration Manual vacuum aspiration KEY POINTS First-trimester aspiration abortion is a safe and common procedure that usually occurs in an outpatient setting. Complication rates increase gradually with gestational age. Postabortal infection prophylaxis should be given before the procedure, not afterward. Cervical preparation with misoprostol or osmotic dilators is recommended after 12 weeks’ gestation and in adolescents. Manual vacuum aspiration is as effective as electric vacuum aspiration.
INTRODUCTION
Abortion is a safe, common procedure in the United States, with 1.21 million abortions performed in 2008 resulting in less than 0.3% of patients hospitalized with complications.1 Three out of 10 women will have an abortion by 45 years of age, with 74% of abortions occurring in an outpatient clinic.1,2 Medication abortions with mifepristone have increased in recent years, but 74% of all first-trimester abortions are aspiration procedures.3 Although women have a constitutionally protected right to an abortion since Roe v Wade in 1973, laws regarding gestational age limits, waiting periods, parental consent for minors, and counseling mandates vary state by state. It is imperative to be familiar and comply with local laws before performing pregnancy termination and to review updates frequently.
Funding Sources: None. Conflict of Interest: None. a Department of Family and Community Medicine, University of New Mexico, MSC 09 5040, 1 University of New Mexico, Albuquerque, NM 87131, USA; b Department of Obstetrics and Gynecology, University of New Mexico, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131, USA * Corresponding author. Department of Family and Community Medicine, University of New Mexico, MSC 09 5040, 1 University of New Mexico, Albuquerque, NM 87131. E-mail address: [email protected] Obstet Gynecol Clin N Am 40 (2013) 647–670 http://dx.doi.org/10.1016/j.ogc.2013.08.006 obgyn.theclinics.com 0889-8545/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
648
Yonke & Leeman
New data have emerged to support changes in first-trimester abortion practice in regard to antibiotic prophylaxis, cervical ripening, the use of manual vacuum aspiration, and pain management. This article addresses these new recommendations and reviews techniques in performing manual and electric vacuum uterine aspiration procedures before 14 weeks’ gestation, including very early abortion (12 wk gestation
Royal College of Obstetricians70 and Gynecologists
Consider cervical preparation for all procedures, but it is most beneficial when risk factors are present. “Evidence is insufficient to determine at what gestational age cervical priming should be routine.”
National Abortion Federation71
“Cervical dilation may be facilitated through the use of osmotic dilators or misoprostol, particularly in adolescents or women at risk for cervical stenosis.”
Planned Parenthood72
Use of cervical priming is optional for first-trimester abortions
SFP72
Cervical priming recommended for Adolescents, especially if gestational age is >12 wk All women at gestational age >12–14 wk Any women with initial difficult dilation
First-Trimester Surgical Abortion Technique
administration, sublingual administration is superior to vaginal administration when used 2 to 3 hours before the procedure but may be equivalent at later times and is associated with more nausea, vomiting, and diarrhea.16,18,19 Vaginal misoprostol results in superior dilation and fewer side effects compared with oral administration 3 hours before a procedure.20 Buccal administration is less studied; but based on its pharmacologic similarities to vaginal administration, it is effective at 400 mcg given 3 to 4 hours before a procedure.15,21 See Table 6, “Misoprostol for cervical priming.” Waiting longer than 3 to 4 hours to perform a procedure after the administration of misoprostol may result in bleeding and passing of POC before the procedure. A recently published study comparing 125 women between 12 and 15 weeks’ gestation receiving 400 mcg of buccal misoprostol or one hygroscopic polyacrylonitrile dilator administered 3 to 4 hours before a procedure found both methods to be equivalent regarding pain with the procedure, procedure time, complications, and satisfaction; however, women receiving misoprostol had more pain associated with cervical ripening.21 In contrast, a study comparing one medium-sized Laminaria and 400 mcg of vaginal misoprostol found equivalent dilation with both regimens, but more pain with cervical ripening was reported in the Laminaria group.22 Both the Cochrane and SFP reviews found misoprostol and osmotic dilators to be equivalent for cervical ripening but that there is little data to support their use for reducing complications in first-trimester procedures.15,16 One large trial (that was not included in
Table 6 Misoprostol for cervical priming Route
Regimen
Advantages
Disadvantages
Vaginal
400 mcg 3–4 h before procedure Higher doses did not improve cervical dilation Lower doses were less effective
Likely more effective than oral administration
After 4 h more likely to pass pregnancy before procedure
Buccal
400 mcg 3–4 h before procedure
Similar pharmacokinetics as vaginal Avoids vaginal administration
Less data on use
Sublingual
400 mcg 2–3 h before procedure 400 mcg is more effective than 200 mcg but associated with more side effects
More effective than oral regimen Equivalent or possibly more effective than vaginal Quicker onset of action Avoids vaginal administration
More GI side effects
Oral
400–600 mcg 3–20 h before procedure
Avoids vaginal administration
Preferred by staff Longer onset of action
Abbreviation: GI, gastrointestinal. Adapted from Allen RH, Goldberg AB, Board of Society of Family Practice. Cervical dilation before first-trimester surgical abortion (
MD, MPH
a,
*, Lawrence M. Leeman,
a,b MD, MPH
KEYWORDS First-trimester abortion Surgical abortion Electric vacuum aspiration Manual vacuum aspiration KEY POINTS First-trimester aspiration abortion is a safe and common procedure that usually occurs in an outpatient setting. Complication rates increase gradually with gestational age. Postabortal infection prophylaxis should be given before the procedure, not afterward. Cervical preparation with misoprostol or osmotic dilators is recommended after 12 weeks’ gestation and in adolescents. Manual vacuum aspiration is as effective as electric vacuum aspiration.
INTRODUCTION
Abortion is a safe, common procedure in the United States, with 1.21 million abortions performed in 2008 resulting in less than 0.3% of patients hospitalized with complications.1 Three out of 10 women will have an abortion by 45 years of age, with 74% of abortions occurring in an outpatient clinic.1,2 Medication abortions with mifepristone have increased in recent years, but 74% of all first-trimester abortions are aspiration procedures.3 Although women have a constitutionally protected right to an abortion since Roe v Wade in 1973, laws regarding gestational age limits, waiting periods, parental consent for minors, and counseling mandates vary state by state. It is imperative to be familiar and comply with local laws before performing pregnancy termination and to review updates frequently.
Funding Sources: None. Conflict of Interest: None. a Department of Family and Community Medicine, University of New Mexico, MSC 09 5040, 1 University of New Mexico, Albuquerque, NM 87131, USA; b Department of Obstetrics and Gynecology, University of New Mexico, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131, USA * Corresponding author. Department of Family and Community Medicine, University of New Mexico, MSC 09 5040, 1 University of New Mexico, Albuquerque, NM 87131. E-mail address: [email protected] Obstet Gynecol Clin N Am 40 (2013) 647–670 http://dx.doi.org/10.1016/j.ogc.2013.08.006 obgyn.theclinics.com 0889-8545/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
648
Yonke & Leeman
New data have emerged to support changes in first-trimester abortion practice in regard to antibiotic prophylaxis, cervical ripening, the use of manual vacuum aspiration, and pain management. This article addresses these new recommendations and reviews techniques in performing manual and electric vacuum uterine aspiration procedures before 14 weeks’ gestation, including very early abortion (12 wk gestation
Royal College of Obstetricians70 and Gynecologists
Consider cervical preparation for all procedures, but it is most beneficial when risk factors are present. “Evidence is insufficient to determine at what gestational age cervical priming should be routine.”
National Abortion Federation71
“Cervical dilation may be facilitated through the use of osmotic dilators or misoprostol, particularly in adolescents or women at risk for cervical stenosis.”
Planned Parenthood72
Use of cervical priming is optional for first-trimester abortions
SFP72
Cervical priming recommended for Adolescents, especially if gestational age is >12 wk All women at gestational age >12–14 wk Any women with initial difficult dilation
First-Trimester Surgical Abortion Technique
administration, sublingual administration is superior to vaginal administration when used 2 to 3 hours before the procedure but may be equivalent at later times and is associated with more nausea, vomiting, and diarrhea.16,18,19 Vaginal misoprostol results in superior dilation and fewer side effects compared with oral administration 3 hours before a procedure.20 Buccal administration is less studied; but based on its pharmacologic similarities to vaginal administration, it is effective at 400 mcg given 3 to 4 hours before a procedure.15,21 See Table 6, “Misoprostol for cervical priming.” Waiting longer than 3 to 4 hours to perform a procedure after the administration of misoprostol may result in bleeding and passing of POC before the procedure. A recently published study comparing 125 women between 12 and 15 weeks’ gestation receiving 400 mcg of buccal misoprostol or one hygroscopic polyacrylonitrile dilator administered 3 to 4 hours before a procedure found both methods to be equivalent regarding pain with the procedure, procedure time, complications, and satisfaction; however, women receiving misoprostol had more pain associated with cervical ripening.21 In contrast, a study comparing one medium-sized Laminaria and 400 mcg of vaginal misoprostol found equivalent dilation with both regimens, but more pain with cervical ripening was reported in the Laminaria group.22 Both the Cochrane and SFP reviews found misoprostol and osmotic dilators to be equivalent for cervical ripening but that there is little data to support their use for reducing complications in first-trimester procedures.15,16 One large trial (that was not included in
Table 6 Misoprostol for cervical priming Route
Regimen
Advantages
Disadvantages
Vaginal
400 mcg 3–4 h before procedure Higher doses did not improve cervical dilation Lower doses were less effective
Likely more effective than oral administration
After 4 h more likely to pass pregnancy before procedure
Buccal
400 mcg 3–4 h before procedure
Similar pharmacokinetics as vaginal Avoids vaginal administration
Less data on use
Sublingual
400 mcg 2–3 h before procedure 400 mcg is more effective than 200 mcg but associated with more side effects
More effective than oral regimen Equivalent or possibly more effective than vaginal Quicker onset of action Avoids vaginal administration
More GI side effects
Oral
400–600 mcg 3–20 h before procedure
Avoids vaginal administration
Preferred by staff Longer onset of action
Abbreviation: GI, gastrointestinal. Adapted from Allen RH, Goldberg AB, Board of Society of Family Practice. Cervical dilation before first-trimester surgical abortion (
