Procedural abortion is the process of aspirating or extracting a pregnancy from a gravid uterus. This procedure is one of the most common procedures people who can become pregnant will have in their lifetime and it has a long track record of safety. Clinicians who perform these procedures should consider choice of setting, anesthesia, and risk of complications such as hemorrhage and other complications. Access to this procedure is increasingly limited due to restrictions on abortion.
Key points
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Procedural abortion is any abortion that involves instrumentation of the uterus, most commonly uterine aspiration or extraction with forceps.
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Most procedural abortions nationwide are performed in outpatient clinics. However, clinicians may elect to perform procedures at a higher level of care (ambulatory surgical centers or operating rooms).
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There are many options for managing discomfort during procedural abortion and decisions should consider setting, gestational duration, patient desires, and staff training.
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Complications of procedural abortion are rare. Providers should be aware of how to manage complications such as reactions to anesthesia, hemorrhage, infection, and perforation.
| ASA | American Society of Anesthesiologists |
| CAD | coronary artery diseases |
| CVA | cerebrovascular accident |
| DM | diabetes mellitus |
| ESRD | end-stage renal disease |
| HTN | hypertension |
| IV | intravenous |
| MI | myocardial infarction |
| PAS | placenta accreta spectrum |
| SFP | Society of Family Planning |
| TIA | transient ischemia attack |
| UAE | uterine artery embolism |
Introduction
The preferred term “procedural abortion” encompasses all abortion techniques that utilize instrumentation. Today this primarily includes uterine aspiration (either manual or electric) in the first trimester or dilation and evacuation/extraction in the second trimester. Year over year, medication abortion accounts for an increasing proportion of all abortion types in the formal health care system in the United States, officially surpassing procedural abortion in 2020. This shift is likely because medications are more accessible than procedural abortion, which requires travel to a brick-and-mortar clinic that is staffed with a clinician skilled and able to provide this care. Travel presents an insurmountable barrier for many patients due to financial burden, need to maintain privacy, inability to arrange childcare, or time off of work. , Yet, some patients would prefer procedural abortion due to its rapid resolution of pregnancy, decreased blood loss, or ability to complete under the direct supervision of a clinician. Further, procedural abortion may be the safer method of abortion for patients with medical comorbidities, such as bleeding disorders or cardiac conditions, or patients in the second or third trimester of pregnancy. It is imperative that this method of abortion be available a nd accessible to all patients, a distant reality for most people living in the United States today.
Discussion
Safety of Procedural Abortion
Procedural abortion is extremely safe, with rates of morbidity and mortality much less than childbirth. Complication rates depend on type of procedure, weeks of gestation, length of follow-up, and protocols used to detect complications. Published complication rates vary between studies but are overall extremely low, ranging between .002% and 2.1%. , Most of these complications are minor, such as bleeding that resolves with medication or need for reaspiration of the uterus.
Mortality from legal abortion is also extremely rare, estimated around 0.7 per 100,000 legal abortions per year. This contrasts with maternal mortality, defined as death within 12 months of delivery, which as of November 2023 in the United States was 18.6 per 100,000 deliveries for the last year. The most common causes of abortion-related mortality have changed over time : in the decade after legalization, anesthetic complications accounted for the highest percentage of deaths overall. Today, hemorrhage is the most common cause of abortion-related mortality in the second trimester, while infection is the most common cause of mortality in the first trimester.
Choice of Procedure Setting
Access to procedural abortion depends on state restrictions and availability of a trained provider and appropriate clinical setting. Most procedural abortions in the first and second trimesters take place in an outpatient clinic setting (68%). , From the 2008 National Abortion Federation survey of providers, half of clinics offered abortions past 20 weeks gestation and 25% up to 24 weeks gestation. Some clinics may offer outpatient abortion to 26 weeks gestation or beyond, although some systems may plan for later procedures to be performed in the operating room with general anesthesia.
Additionally, in some cases, hospital-based abortion care may be preferred given the clinical circumstance, but not be possible due to abortion restrictions. Patient characteristics such as obesity which may exceed maximum weight limit for clinic examination tables, presence of severe anemia, ability to obtain intravenous (IV) access, or presence of other medical comorbidities complicating the procedure or anesthetic care may favor hospital-based care. Further, pregnancy conditions such as placenta accreta spectrum or anomalies causing measurements larger than expected for gestational duration (eg, ventriculomegaly) may prompt recommendation for hospital-based care. These decisions are always made within the context of local access to hospital-based care (or lack thereof) and, in limited settings, clinicians in shared decision-making with patients may elect to proceed with clinic-based care due to an absence of other options.
In systems that have access to all anesthetic options, patients’ preferences for level of sedation may dictate the safest location for the procedure. Additionally, cost of these options, especially when deeper or general anesthesia is only offered in a hospital or outpatient surgery center setting, can be an important factor as well. To safely provide outpatient moderate sedation, clinics and clinicians are encouraged to follow the American Society of Anesthesiologists Task Force recommendations on preprocedural evaluation, preparation, intraprocedural monitoring, as needed emergency support and recovery care ( Box 1 ). Although the surgeon performing the procedural abortion can oversee moderate sedation with a nurse, deep sedation and general anesthesia necessitate a distinct role, typically of more advanced anesthesia providers such as anesthesiologists, certified registered nurse anesthetists, or anesthesia assistants.
Preprocedure
Patient evaluation
Reviewing medical records and medical history
Physician examination
As needed, laboratory testing
Patient preparation
As needed, consultation with medical specialists
Informed consent to anesthesia
Fasting instructions
Intraprocedure
Monitoring a
Level of consciousness
Respiratory function (ventilation and oxygenation)
Hemodynamics (blood pressure, heart rate, electrocardiogram)
Emergency Support (available as needed)
Reversal agents ( eg, naloxone, flumazenil)
Emergency airway equipment
Individual capable of establishing patent airway and IV access
Rescue support (eg, chest compressions, defibrillator or automatic external defibrillator, advanced cardiac life support [ACLS] trained individual, ability to call for emergency services)
Postprocedure
Recovery care
Monitor patients until they are at their baseline level of consciousness.
Monitor oxygenation until no longer at risk for hypoxemia.
Monitor ventilation and circulation regularly until suitable for discharge.
Have defined discharge criteria.
When considering safest anesthesia options for patients, the American Society of Anesthesiologists (ASA) recommends use of a physical classification system tool to assess fitness prior to surgery ( Table 1 ). All pregnant patients will be at least ASA class II, mild systemic disease. Patients with ASA class greater than II should be evaluated to determine if they would be better served in a higher level of care such as an operating room.
| American Society of Anesthesiologists (ASA) Physical Status Classification | Definition | Examples, Including, but not Limited to: |
|---|---|---|
| ASA I | A normal healthy patient | Healthy, nonsmoking, no or minimal alcohol use |
| ASA II | A patient with mild systemic disease | Mild diseases only without substantive functional limitations. Examples include (but are not limited to): Current smoker, social alcohol drinker, pregnancy, obesity (30 < body mass index [BMI] <40), well-controlled diabetes (DM)/hypertension (HTN), mild lung disease |
| ASA III | A patient with severe systemic disease | Substantive functional limitations; 1 or more moderate to severe diseases. Examples include (but are not limited to) poorly controlled DM or HTN, chronic obstructive pulmonary disease, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, end-stage renal disease (ESRD) undergoing regularly scheduled dialysis, history (>3 mo) of myocardial infarction (MI), cerebrovascular accident (CVA), transient ischemia attack (TIA), or coronary artery diseases (CAD)/stents. |
| ASA IV | A patient with severe systemic disease that is a constant threat to life | Examples include (but are not limited to) recent (<3 mo) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, disseminated intravascular coagulation, acute respiratory distress, or ESRD not undergoing regularly scheduled dialysis. |
| ASA V | A moribund patient who is not expected to survive without the operation | Examples include (but are not limited to) ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction |
| ASA VI | A declared brain-dead patient whose organs are being removed for donor purposes |
Selecting the Appropriate Anesthesia
There are several options for anesthesia for procedural abortion. Patients and their providers may consider factors such as patient’s general health, procedural setting, and desired level of sedation ( Table 2 ) that guide which option may be best for each case. It is important to consider that the experience of pain in abortion care may be influenced by several factors other than physical pain, including psychological or social pain (eg, stigma, social isolation, grief etc.). The impact of anesthetic interventions on these types of pain may not be captured by studies, which commonly rely on the Visual Analog Scales or numeric rating scale to quantify pain on a linear scale. Nevertheless, most patients rate their abortion-related pain as moderate to severe.
| Minimal Sedation Anxiolysis | Moderate Sedation/Analgesia (“Conscious Sedation”) | Deep Sedation/Analgesia | General Anesthesia | |
|---|---|---|---|---|
| Responsiveness | Normal response to verbal stimulation | Purposeful a response to verbal or tactile stimulation | Purposeful a response following repeated or painful stimulation | Unarousable even with painful stimulus |
| Airway | Unaffected | No intervention required | Intervention may be required | Intervention often required |
| Spontaneous Ventilation | Unaffected | Adequate | May be inadequate | Frequently inadequate |
| Cardiovascular Function | Unaffected | Usually maintained | Usually maintained | May be impaired |
| Note : The table above and definitions below are intended to guide the assessment of a patient’s level of sedation at any moment which can change during the procedure. Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. This is typically accomplished by a single oral dose of a sedative or an analgesic administered before the procedure. Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully a to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. This is typically accomplished by titration of intravenous (IV) sedatives and/or analgesics during the procedure. Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully a following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. This is typically accomplished by titration of IV sedatives and/or analgesics and/or anesthetics during the procedure. General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (“Conscious Sedation”) should be able to rescue patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue patients who enter a state of General Anesthesia. | ||||
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