PCB
* Limits are based on ability to follow very early pregnancy with serial serum hCGs afterward to ensure pregnancy has been evacuated. On the other end of the spectrum, many providers do not provide surgical abortions after the first trimester in their gynecologic office.
Additional consideration must be paid to government-mandated protocols for abortion counseling including waiting periods, scripted patient information, and ultrasound requirements. These protocols are purported to help women make more informed decisions but many of them have not been found to improve care. They are often medically inaccurate.[18]
It is important to address patient’s mental health and to assess their emotional support needs. Patients in a vulnerable emotional state or with a lack of personal support, may benefit from a referral to other health and social service agencies or hotlines.[18]
Finally, contraceptive counseling is a critical component of informed consent. Patients should be informed about their options for preventing a subsequent unintended pregnancy.
Medical evaluation
Before a woman undergoes a first trimester abortion, a full medical history should be obtained. Many women with stable, chronic medical conditions such as hypertension, diabetes, or asthma may be safely managed in the office setting.[19] Consultation with the patient’s primary care physician or specialist may be necessary before deciding whether women with uncontrolled chronic diseases should be referred to a hospital based setting for a surgical abortion. Such conditions include history of stroke, impaired renal function, hepatic disease with elevated prothrombin time, cardiomyopathy, active lupus flare, pulmonary hypertension, and severe psychiatric illness.[19] This consultative process must be expedited for the medically complex patient, as delaying abortion care may place vulnerable women at risk of complications with increasing gestational age.[20]
Once a patient is deemed eligible to undergo abortion in the office setting, confirmation of pregnancy with a urine pregnancy test or ultrasound is necessary.
Physical exam should confirm normal vital signs and no evidence of an active pelvic infection. Laboratory evaluation includes Rh (D) antigen status, sexually transmitted infection testing for chlamydia per Centers for Disease Control and Prevention (CDC) recommendations, and anemia screening.
Determining gestational age
Clinicians typically date pregnancy from the first day of the last menstrual period (LMP). This method of dating can be inaccurate for women with irregular periods, who were using contraception when they became pregnant, or who are postpartum and breastfeeding. Other patients may not experience pregnancy symptoms. A bimanual exam is useful to estimate uterine size and position, but a fibroid uterus or obesity may confound the ability to accurately date a pregnancy. Increasingly, more abortion providers will confirm gestational age with an ultrasound.[21, 22] Ultrasound can also identify uterine anomalies or ectopic pregnancy prior to attempting a procedure.
Although ectopic pregnancy tends to be less frequent in the abortion population, women with risk factors or symptoms should be evaluated for ectopic pregnancy prior to offering medical or surgical abortion.[15, 23] If ultrasound does not confirm an intrauterine or ectopic pregnancy, but the patient is highly motivated to have an abortion on that day, she may safely undergo uterine aspiration with tissue inspection and human chorionic gonadotropin (hCG) follow-up to rule out ectopic pregnancy or failed abortion.[23, 24] Facilities must be able to track these patients and send out pathology specimens if products of conception are not definitely identified. Additionally, these women must be counseled that they will need follow-up appointments, blood draws, and possible ultrasounds to confirm resolution of the pregnancy.[23]
Medical abortion
Medical abortion medications
Mifepristone is a progesterone antagonist derived from norethindrone that promotes decidual necrosis, cervical softening, increased uterine contractility, and prostaglandin sensitivity. Misoprostol is a prostaglandin E1 analogue that causes uterine contractions and cervical softening.
Candidates for medical abortion
Most women will qualify for medical abortion if they are of the appropriate gestational age. Absolute contraindications include hemoglobin less than 9.5 g/dL, confirmed or suspected ectopic pregnancy, intrauterine device (IUD) in place, current long-term corticosteroid therapy, chronic adrenal failure, known coagulopathy, anticoagulant therapy, and intolerance or allergy to mifepristone or misoprostol. Furthermore, women with severe liver, renal, respiratory, vascular or cardiac disease may not be appropriate candidates. Patients who cannot comply with follow-up, desire a quick resolution of undesired pregnancy, or cannot understand the instructions, may be better served by a surgical procedure.[15]
Regimens
FDA-approved regimen
The only regimen approved by the Food and Drug Administration (FDA) in the United States is 600 mg of mifepristone administered orally, followed by misoprostol 400 mcg administered orally 48 hours later. The efficacy of this regimen is 92% up to 42 days of gestation. This regimen is not routinely recommended or used.
Evidence-based regimens
Other evidence-based regimens are considered superior to the FDA-approved regimen for both efficacy and safety. The most successful regimen consists of mifepristone 200 mg orally, followed by misoprostol 800 mcg, taken buccally, vaginally, or sublingually 24–48 hours later with success rates of 95%–99% up to 63 days gestational age.[15, 25] An alternative option with similar success rates is the use of vaginal misoprostol 800 mcg six hours or less after taking mifepristone.[26] A recent study also demonstrated a success rate of 93% among women 63–70 days gestational age.[27] Figure 13-1 depicts the mifepristone medication and the associated patient agreement.
Medical abortion medication (mifepristone) and patient agreement (Danco).
Adverse events
Bleeding and cramping are normal side effects of the medical abortion. Table 13-2 illustrates the expectations that should be discussed with women for medical abortion and recovery.
| What to expect after taking the misoprostol pills at home: |
1. Cramping and bleeding are normal. 2. Symptoms will start two to four hours after taking misoprostol and will be heaviest when the pregnancy is expelled. 3. It can be normal to have lemon-sized blood clots and to soak up to two pads an hour for two hours. 4. The side effects of misoprostol include nausea, vomiting, dizziness, mild fever, and chills for 24 hours. |
| When to call about an emergency: |
1. Fever of 100.4˚F (38˚C) or higher for more than 24 hours after taking misoprostol 2. Soaking more than two maxi pads an hour for more than two hours 3. Passing greater than lemon-sized blood clots for two hours or more 4. Bleeding heavily for more than 12 hours in a row 5. Severe vomiting and inability to eat or drink for more than six hours 6. Abdominal pain or cramping that does not improve with oral NSAIDs, narcotics, heating pads, or rest 7. Weakness, nausea, abdominal pain, vomiting, diarrhea more than 24 hours after taking misoprostol |
Adverse effects are typically mediated by dose and route of misoprostol. These include nausea, vomiting, diarrhea, headaches, dizziness, and low-grade fevers. Oral or sublingual administration more commonly results in gastrointestinal side effects as compared to vaginal and buccal routes. Adjunct medications – nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, and anti-emetics – may be helpful in mediating side effects.
Follow-up
Follow-up is required to confirm that the abortion is complete. Ultrasound has traditionally been the gold standard to confirm expulsion of the gestational sac. It is normal to see blood products and decidua on ultrasound, and in the absence of excessive bleeding, these findings do not represent need for uterine evacuation.[15, 28]
Prerequisite follow-up ultrasound may be a barrier to medical abortion for some women.[29] Assessing symptomatology in conjunction with a serum human chorionic gonadotropin (hCG) level is an accurate way of ensuring completion of the procedure while minimizing the number of in-person visits.[28, 29] An 80% decrease in serum hCG values one week after abortion is highly correlated with completed abortion and results in fewer surgical interventions than ultrasound follow-up. Blood draws may also be more accessible for patients than ultrasound.[29, 30]
Complications
Complications from medical abortion are rare and generally fall into the categories of excessive bleeding, infection, retained gestational sac, and ongoing pregnancy.
Excessive bleeding requiring emergent curettage occurs in approximately 0.2% of patients within the first 24 hours. It is imperative that providers offering medical abortion have training in surgical abortion or be able to refer to a physician who does.[15]
Serious infections are extremely rare after medical abortion. The most serious infections that have been associated with medical abortion are caused by the clostridial species.[31] Suspicions of intrauterine or systemic infection after medical abortion should prompt patient admission to the hospital for evaluation, broad-spectrum antibiotics, and supportive management.[15]
Evidence of a persistent gestational sac on ultrasound without evidence of fetal cardiac activity or continued development, may be managed expectantly, as long as the patient does not have continuing symptoms of pregnancy or prolonged excessive bleeding. The sac may pass spontaneously, even two weeks after mifepristone. Other options include repeating a dose of the misoprostol or undergoing surgical evacuation.[15]
The rate of ongoing pregnancy after medical abortion is less than 1%. If an ongoing pregnancy is diagnosed, uterine aspiration is suggested. If the patient strongly wishes to avoid surgical intervention a repeat dose of misoprostol may be attempted, which will successfully expel the pregnancy 36% of the time.[32]
Mifepristone and misoprostol are considered teratogenic, with increased risks of several congenital anomalies. Patients with ongoing pregnancies should be encouraged to undergo additional treatment to complete their abortions.[15]
First trimester surgical abortion
The appropriate office candidate
When performing surgical abortion in an office setting, providers should ensure that technical comfort with the procedure exists. Emergency precautions must be in place. Patients with more complex scenarios may be safer in a surgical center or hospital setting. Such complexities include suspected ectopic pregnancy with undiagnosed adnexal mass, uterine anomaly or significant cavity distorting lesion, uterine infection or sepsis, hemodynamic instability, or anemia with hemoglobin of less than 8 mg/dL.
MVA, EVA, dilators, and cannula
Abortion can be performed in the office with a standard set of tools that include a suction device, cannula, and dilators (Figure 13-2).
Both electric and mechanic suction apparatuses are available. The Mechanical Vacuum Aspirator (MVA) is a 60-mL syringe cylinder that creates up to 60 mmHg of pressure and can accommodate up to a 14 mm cannula for evacuation of the uterus. The MVA is typically quieter than an Electric Vacuum Aspirator (EVA), but may require multiple passes at higher gestational ages. The EVA is an electric suction machine with single-use tubing that can accommodate cannulas used to evacuate any sized uterus. MVAs and EVAs are equally efficacious in completing an abortion in the first trimester with equivalently low rates of complications. Patients may prefer the quiet of the MVA; however, providers prefer the EVA for its greater speed and ease of use at later gestational ages.[33, 34]
Rigid or flexible cannulas are available. Providers typically choose the cannula size that is roughly equivalent to gestational age in weeks. There are no differences in cervical injury, infection, blood transfusion, incomplete abortion, or need for repeat aspiration based on cannula types.[34] For dilator choice, the Society of Family Planning advocates for tapered dilators such as Pratt or Denniston. Blunt Hegar dilators may require more force and increase the risk of perforation.[35]
Cervical preparation
There is insufficient evidence to support the use of universal cervical preparation for patients in the first trimester, beyond dilation with mechanical dilators. This is based on very low rates of cervical injuries and clinically apparent uterine perforation in the first trimester, which are 0.1/10,000 to 10/10,000 and 0.1/1,000 to 4.0/1,000, respectively. The risks of these injuries are increased in certain subgroups; therefore, the Society of Family Planning recommends cervical preparation for adolescents, especially if the gestational age is greater than 12 weeks; all women greater than 12–14 weeks gestational age; and any women with initially difficult dilation.[35]
Misoprostol is the standard cervical preparation given prior to first trimester abortion in the office setting. It is inexpensive, it starts working within 2 hours, and it can be administered by a variety of different routes. It is most commonly given vaginally or buccally because these routes result in fewer gastrointestinal side effects while still maximizing cervical preparation. The recommended dose is 400 mcg administered three to four hours prior to the procedure.[35, 36] Although osmotic dilators can been used for cervical ripening prior to procedures, they typically require overnight placement for optimal effect.
The surgical abortion procedure
After consents have been signed, the patient is placed in the dorsal lithotomy position. A bimanual exam is performed to confirm the position and the size of the uterus. A speculum is placed and the cervix identified. The cervix may be cleansed with betadine, chlorhexadine or saline.[37] Then 1 mL or 2 mL of 1% lidocaine is injected at the anterior lip of the cervix and a tenaculum is placed. A paracervical block may be used at this point for analgesia (see “Pain Management”). The cervix is then sequentially dilated with sterile dilators to admit a suction cannula of the appropriate size.
If using an MVA, the plunger is withdrawn and locked to create suction, and the appropriately sized cannula is attached to the syringe with care to keep the tip of the cannula sterile. The cannula is then passed into the uterine cavity, the valves are opened to activate the suction, and the contents of the uterus are aspirated using a twirling or back-and-forth motion. If using an EVA, the cannula is attached to the tubing, the thumb switch is closed to generate suction, and a similar motion is employed to evacuate the uterus.
The uterus is considered empty when involution is palpated, there is a uniformly gritty or sandpaper sensation with passage of the cannula over the endometrium, and there is no evidence of additional tissue passing through the cannula.
After aspiration is complete, the products are inspected by rinsing them with water and then floating them over a backlight to identify tissue. Depending on gestational age, a gestational sac, chorionic villi, blood, decidua, and possibly fetal parts can be seen (Figures 13-3 and 13-4). If the villi are hydropic or there is suspicion of a molar pregnancy, the tissue should be sent for pathologic evaluation. If a pregnancy cannot be confirmed, a repeat aspiration may be performed. The tissue may be sent for pathologic analysis to identify whether an intrauterine pregnancy is present, serial serum hCG levels should be followed, and the patient should receive ectopic precautions.
Uterine aspirate and products of conception at 10 weeks gestation.
Once the abortion is deemed complete, all instruments should be removed from the vagina and bleeding should be evaluated. The patient should be monitored to ensure that her vitals are normal and that her bleeding and pain are appropriate. Once the patient is stable to go home, she should be given discharge instructions and emergency contact information.
Complications
Complications of first trimester abortion are extremely rare with a rate of less than 1% for any complication and a hospitalization rate of only 0.3%.[38] Hemorrhage is among the more common complications and may be caused by uterine atony, abnormal placentation, cervical laceration, coagulopathy, or retained products of conception.[39] Uterine perforations occur in 0.1/1,000 to 0.3/1,000 of procedures, and are usually at the fundus, resulting from the suction cannula.[35] Incomplete abortion may require reaspiration or administration of misoprostol to expel retained tissue. Other complications include cervical lacerations, hematometra, post-abortal infections, ongoing pregnancy, and vasovagal episodes (Table 13-3).
