Abortion
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INTRODUCTION |
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Background: In the US and
worldwide, elective termination of pregnancy remains common. Accurate statistics
have been kept since the enactment of the 1973 Supreme Court decisions
legalizing abortions. Since then, approximately 1.3-1.4 million abortions have
been performed annually in the US, and worldwide some 20-30 million legal
abortions are performed annually, with another 10-20 million abortions performed
illegally . Illegal abortions are unsafe and account for 13% of all maternal
mortality and serious complications. Death from abortion is almost unknown in
the US or in other countries where abortion is available on demand.
In spite of the introduction of newer, more effective, and more widely
available contraceptive methods, more than one half of the 6 million pregnancies
occurring each year in the US are termed unplanned by the women who are
pregnant. Of these pregnancies, approximately one half end in elective
terminations. Abortion is still one of the most common medical procedures
performed in the US each year, and more than 40% of all women will have a
pregnancy terminated by abortion at some time in their reproductive lives. Each
year in the US, almost 3% of all women of reproductive age terminate their
pregnancies. While women of every social class seek terminations, the typical
woman who terminates her pregnancy is young, white, unmarried, and poor.
The development of more advanced surgical techniques has allowed for safe
second trimester terminations and, statistically, more of these have been
performed. The Food and Drug Administration (FDA) recently has given approval to
Mifeprex (mifepristone, RU-486) for medical abortions. Multiple regimens for
medical terminations using medications approved by the FDA for indications other
than termination of pregnancy have come into use. The lack of abortion providers
to perform surgical terminations has led to the popular belief that individuals
not willing or not skilled enough (through training or licensure) to perform
surgical terminations will be willing to prescribe medications for medical
termination. This may be difficult to track statistically but may actually lead
to an increased number of abortions in the US.
A variety of medical, social, ethical, and philosophical issues affect the
availability of and restrictions on abortion services in the US. An
understanding of the laws (enacted, enjoined, and pending) on local and federal
levels is important to providers, and these legal ramifications are reviewed in
this chapter as well .
Abortion postoperative care often is provided at sites that did not perform
the termination of pregnancy, and strategies for follow-up care for women whose
pregnancies have been terminated are important for all providers of primary care
for women.
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Surgical termination
The development of accurate over-the-counter (OTC) pregnancy tests allows for
the diagnosis of pregnancy 1-2 weeks after conception. Terminations performed in
this very early time frame have been termed "menstrual extractions,?a historical
reference to a time when, prior to the availability of accurate pregnancy tests,
providers made the presumptive diagnosis based on clinical history and performed
extremely early suction evacuations without histologic tissue confirmation,
allowing for maximum confidentiality for both patient and provider.
Abortions performed prior to 9 weeks from last menstrual period (LMP) (7 wk
from conception) are performed either surgically or medically. From 9 weeks
until 14 weeks, an abortion is performed by a dilatation and suction curettage
procedure. After 14 weeks, surgical abortions are performed by a dilatation and
evacuation procedure. After 20 weeks of gestation, abortions can be performed by
labor induction, prostaglandin labor induction, saline infusion, hysterotomy,
dilatation and extraction, or intact dilatation and extraction. Most abortions
are performed in an ambulatory office setting under local anesthesia with or
without sedation.
Medical abortion
Medical abortion is a term applied to a medication-induced elective abortion.
This can be accomplished with a variety of medications administered either
singly or in succession. Medical abortion has a success rate that ranges from
75-95%, with about 2-4% of failed abortions requiring surgical abortion and
about 5-10% of incomplete abortions, depending upon the stage of gestation and
the medical products used. For a review of multiple studies see Kahn et al 2000.
Patients who select a medical abortion express a slightly greater satisfaction
with their route of abortion and, in the majority of cases, express a wish to
choose this method again should they have another abortion. Research needs to be
done to more clearly establish which protocol is best, which medications are
preferable, and how successfully women and adolescents can diagnose a complete
versus an incomplete abortion.
Although a critical shortage of providers to provide surgical abortions
exists, in a recent study by Koenig et al providers who do not perform surgical
abortions have indicated a willingness to provide medical abortions.
Medical abortions can provide some measure of safety in that they eliminate
the risk of cervical lacerations and uterine perforations. Some patients require
an emergency surgical abortion, and for safety concerns, patients undergoing
medical abortions need access to providers willing to perform an elective
termination.
The in September of 2000 the FDA approved mifepristone (RU-486) for use in a
specific medical regimen that includes misoprostol administration for those who
do not abort with mifepristone alone. Methotrexate and misoprostol are approved
drugs for other indications that can be used for medical termination of
pregnancy. Additional research will determine exactly which regimen is the best
for medical abortions.
Medical abortions have additional management issues for patients and
clinicians. The process involves bleeding, often heavy, which must be
differentiated from hemorrhage. Regardless of the amount of tissue passed the
patient must be seen for evaluation of the completeness of the process.
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Frequency:
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- In the US: Abortion statistics are available from a
variety of sources, including, the
CDC, the Alan Guttmacher
Institute, and the
National Abortion Federation. Information and specific instructions
regarding state requirements for abortion reporting are available from vital
statistics offices in each state health department. Comprehensive statistical
information is regarded as important in ensuring the utmost in patient safety
(Centers
for Disease Control and Prevention).
In 1996, approximately 20 women for every 1000 women aged 15-44 years had
an abortion, and for every 1000 live births, approximately 325 abortions were
performed . In the past 20 years, considerable progress has been made in the
technology used for second trimester abortion. This and the social milieu of
abortion have led to more women seeking terminations later in pregnancy. For
the current facts regarding abortions performed in various states at various
times in the pregnancy.
- Internationally: Globally, abortion mortality accounts
for at least 13% of all maternal mortality. New estimates are that 50 million
induced abortions are performed each year in developing countries, with some
20 million of these performed unsafely because of conditions or lack of
provider training. Maternal mortality is 600,000 per year due to
pregnancy-related causes, and 99% of these deaths are in developing countries.
Mortality/Morbidity: The safety of abortion is well
established, with infection rates less than 1%, and less than 1 per 100,000
mortalities occurs from first-trimester abortions. At every gestational age,
elective abortion is safer for the mother than carrying a pregnancy to term.
Race: In 1996, of the women who obtained legal abortions,
59.1% were white, 35, 2% were black, and 5.7% were other (of the other, 16.1%
were Hispanic).
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CLINICAL |
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History: Most terminations of
pregnancy are performed after a brief and targeted gynecologic and obstetric
history. Providers should obtain information about any prior pregnancies and
information regarding any treatment or care during this pregnancy. The history
taking also should focus on prior gynecologic disease with particular attention
to previous or current sexually transmitted infections (STIs). Information
regarding medical history that might be important includes a history of
diabetes, hypertension or heart disease, anemia or bleeding disorders, or
previous gynecologic surgery. A history of active medical problems may mean that
the patient needs to be medically stabilized prior to the abortion or have the
procedure performed in a facility that can handle special medical problems.
- Maternal indications for abortion
- With advances in perinatal care, few medical contraindications to
pregnancy exist. Perinatologists, obstetricians, and abortion counselors
prefer to put the risks in the context of statistical likelihood of
complications and then let the patient make her final decision.
- Women take on less risk, regardless of health or gestational age, to
terminate a pregnancy than to continue to term. These abortions have been
termed therapeutic abortions.
- Maternal medical conditions that carry significant risks in pregnancy
include severe diabetes with retinopathy, cardiac or renal complications,
advanced cardiac disease, renal failure, sickle cell disease, autoimmune
disease, and psychiatric disease.
- Cardiac conditions that still carry maternal mortality rates of 5-15%
include severe mitral stenosis, coarctation of the aorta, uncorrected
tetralogy of Fallot (TOF), aortic stenosis, myocardial infarction history,
and presence of artificial heart valves. Greater mortality rates have been
reported in women with coarctation of the aorta with vascular involvement,
pulmonary hypertension, Marfan syndrome with aortic involvement, and
myocardial infarction in pregnancy.
- Nondirective counseling can help a woman select her choice.
- Fetal indications for abortion
- Fetal conditions that are incompatible with life include anencephaly,
trisomy 13, trisomy 18, renal agenesis, thanatophoric dysplasia, alobar
holoprosencephaly, and some hydrocephalic cases.
- Many hypoplastic cardiac conditions also are incompatible with life.
However, with cardiac transplantation, some infants now can survive birth
with these defects.
- Anomalous conditions that are common and encountered in abortion
counseling include most fetal cardiac anomalies, trisomy 21, open and closed
neural tube defects, limb, face, or cleft abnormalities, esophageal or
duodenal atresia, chest and abdominal wall defects, cystic kidneys or
hydronephrosis, intracranial calcifications suggestive of viral disease, or
diaphragmatic defects.
Physical:
- A brief physical examination usually is conducted prior to an abortion
procedure. The focus is on dating the pregnancy, ensuring the absence of other
gynecologic pathology, particularly STIs, and assessing the patient's
suitability for an operative procedure under local sedation.
- Note any vaginal or cervical discharge, the nature of the cervix, and any
lesions. Document the presence or absence of any ovarian pathology.
- If the patient is going to have general anesthesia, a typical screening
preoperative physical can be performed.
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DIFFERENTIALS |
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Anemia
Cervicitis
Early Pregnancy Loss
Ectopic Pregnancy
Missed Abortion
Pelvic Inflammatory Disease
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Other Problems to be Considered:
Bacterial vaginosis
Cervical dysplasia or neoplasia
Ovarian masses
Uterine fibroids
Uterine anomalies
Multifetal gestations
Fetal anomalies
Maternal illnesses
Maternal allergies
Bleeding or clotting disorders
Grand multiparity
Cervical incompetence
Sexual
Assault
Psychological trauma
Bacterial endocarditis prophylaxis
Benign
Lesions Of The Uterine Corpus
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WORKUP |
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Lab Studies:
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- Pregnancy tests are used to confirm the presence of a pregnancy, and
home tests are reliable enough to accept their results in some cases.
- Hemoglobin (Hb) or hematocrit (Hct) levels always are assessed. Full CBC
is optional but may be indicated if abnormalities are detected with the Hb
or Hct test.
- STI screening typically includes a test for gonorrhea culture (GC) or
chlamydial test (CT). Screening for other STIs, such as syphilis or HIV
disease, is usually prohibitively expensive, but patients who are found to
have GC or CT should be offered these tests.
- Rh typing is always performed. ABO typing is optional.
- Use of human chorionic gonadotropin titers
- If an abortion is being performed prior to 5 weeks from LMP, titers
preoperatively can be very useful. Managing most abortion procedures without
an HCG titer is within the standard of care.
- Vaginal wet preparations, pH testing, or urine dipstick analysis usually
are performed for standard indications.
- If a woman is discovered to have a concomitant infection, it may need to
be treated before she has the abortion.
Imaging Studies:
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- First trimester sonography: The content of the examination is what
typically is expected for a first trimester screening examination. The focus
is on fetal number, the size and nature of the gestational sac, the
placental location, the uterus, and the ovaries. Document the presence and
nature of a yolk sac.
- Second and third trimester sonography: For second or third trimester
abortions, ultrasonography preoperatively is the standard of care. Conduct
these examinations like other second trimester screening exams. If anomalies
are detected, women should be offered a referral for targeted examinations
that can delineate specific fetal disease conditions. It is not unusual for
women to decline further investigation if their abortion decision does not
hinge on the specific findings.
Other Tests:
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- Papanicolaou (Pap) smears are optional specifically prior to procedure,
but patients should be informed of their need for Pap smears as part of their
postabortion contraceptive care.
Histologic Findings: Pathologic analysis of tissue typically
is performed for documentation purposes, but visual inspection of the products
of conception postprocedure is mandatory. Washing the blood clots off the tissue
obtained prior to visual inspection is helpful, and the presence of villi can be
detected more reliably after back lighting the specimen. In cases in which very
little tissue is obtained, the use of colposcopy may reveal villi. Pathologic
confirmation should be available within 24 hours if an ectopic pregnancy is
suspected or within a week to 10 days if no pathology is suspected. Many fetal
anomalies can be detected on anatomic inspection of the fetus, but only intact
procedures or induction of labor reliably offer a fetal specimen that can be
evaluated adequately.
Placental analysis typically reveals products of conception consistent with
gestational age. Preoperative ultrasound typically reveals placental
abnormalities, such as a molar gestation or choriocarcinoma, when present.
However, having histologic analysis reveal the presence of a partial molar
pregnancy or an incomplete molar pregnancy is not uncommon.
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TREATMENT |
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Medical Care: Once the pregnancy
has been confirmed, gestational age has been established, and the patient has
decided to abort, the procedure offered typically reflects the patient's stage
of gestation. Early abortions can be accomplished medically or surgically, but
most facilities do not have the technical ability or the protocols established
to offer medical abortions. Therefore, most abortions are performed surgically.
- Abortion counseling
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- Most abortion counseling focuses on the decision-making process, the
options for continuing the pregnancy, medical issues of the pregnancy,
information regarding the pregnancy itself, full disclosure of the risks of
continuing to term, information and options for the technique of the
abortion procedure, and, finally, information regarding a contraceptive
decision. Now that medical protocols are becoming more widely available, the
risks and benefits of both medical and surgical abortions should be
reviewed.
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- The counseling process is aimed primarily at the woman herself, as well
as those she chooses to have involved. Studies indicate that males are
involved in more than 40% of the decisions, but only scant research has been
done on male involvement in the process. Some women can reach a decision
quickly; others take longer to decide. The counseling process should offer
referrals for those who need ongoing support.
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- Of utmost importance is to ensure that the patient has had enough time
to consider her options and that she is not being coerced into her decision.
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- Many strategies can be used in the counseling session. Open-ended
questions bring out issues that are pertinent to the woman and encourage
meaningful exchange of dialogue. The patient's emotions should be validated,
and the counselor should encourage the client to explore her feelings in
more depth. Health care providers and counselors may not have the time or
the expertise to devote themselves to lengthy sessions, and not all women
are able to complete the process in a day if these issues need to be
explored before the abortion procedure.
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- Some state laws may apply to the counseling process. Some states have
mandatory waiting times between the information session and the actual
abortion, other states require family or parental notification, and some
states mandate that certain subjects be covered. Laws directed towards the
providers usually also exist. Providers have an obligation to find out about
their local laws and to comply with them.
- First and second trimester medical abortion
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- First trimester terminations are accomplished medically with misoprostol
alone, methotrexate-misoprostol combination regimens, or Mifeprex (RU-486)
with or without misoprostol. Other prostaglandins are in use in other
countries.
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- Medical abortions are indicated for women who consent to a medical
abortion but also are willing to undergo a surgical abortion if the medical
abortion fails. Gestational age usually is less than 42-49 days, but many
protocols including up to 63 days from LMP are in the literature. Literature
has also documented safety of medical abortion protocols between 11-13 weeks
is accumulating. Only scant reports exist of continuing pregnancies after
misoprostol, but the current data do not suggest a teratogenic action of
misoprostol exposure during pregnancy.
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- Contraindications to medical abortion vary depending upon the regimen
selected. Contraindications to mifepristone, include serious medical
problems, such as cerebrovascular or cardiovascular disease, severe liver,
kidney or pulmonary disease, preoperative anemia (<10 mg/dL), undiagnosed
ectopic pregnancy allergies contraindications to prostaglandin use, active
uterine bleeding, or large uterine leiomyomata.
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- The Mifeprex/misoprostol appointment schedule is as follows: On day 1,
Mifeprex 600 mg PO is administered in the office. On day 3, misoprostol 400
mcg PO or vaginally is administered at home and with 4 hours of observation.
Between days 12 and 20, the patient returns to the office to determine if
the abortion has been completed. If it has not, repeat misoprostol is
administered or the patient may undergo a surgical abortion.
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- The methotrexate/misoprostol regimen is similar. Methotrexate is
injected on day 1. On days 6-7, misoprostol is taken at home vaginally, and
the patient returns to the office on day 8 to determine if the abortion has
taken place. Misoprostol can be repeated and the patient monitored, or
surgical abortion may be completed.
- Prostaglandin-induced second trimester abortion
- Prostaglandin can be administered vaginally, orally, or via extraovular
or intra-amniotic infusion. The intra-amniotic route was associated with
greater rates of uterine rupture, although rarely, and has been abandoned
largely in favor of the safety and technical ease of oral or vaginal
administration.
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- In a recent comparison study by Perry of intra-amniotic
15-methyl-prostagalin F2-alpha and intravaginal misoprostol, the mean
evacuation time was slightly less in the intra-amniotic group, and the rate
of success by 24 hours was higher in the intra-amniotic group. The total
complete abortion rate and incidence of severe effects were similar in both
groups.
- Saline-induced abortion: Twenty years ago, saline-induced abortion was the
only viable means of aborting a mid–second trimester pregnancy, and most of the
literature regarding this technique is from that era. The process was long,
laborious, had some potentially serious adverse effects, and has been
abandoned for the greater maternal comfort offered by the dilatation and
extraction procedures that subsequently have been developed. However,
dilatation and extraction procedures are risky in the hands of inexperienced
providers or providers who do not perform the procedures often enough to
maintain competency. In these circumstances, the saline induced abortion can
be safely used.
Surgical Care: Documentation is an important part of the
surgical procedure. Preoperatively prepared standard operative reports are the
standard of care and should include documentation of several important features
including the patient's anatomical assessment (including uterine size), the
procedure and instruments used (including the size of the dilators and the
cannula used), the amount of blood loss, and the amount of tissue obtained.
- Cervical dilatation and preparation: Women having first trimester
terminations, particularly those at less than 10 weeks?gestation, rarely need
preoperative cervical preparation. For those in the later part of the first
trimester, preoperative dilatation with laminaria or medical treatment with
prostaglandins is helpful and should be at the discretion of the provider
performing the abortion. In the second trimester or beyond, the cervix needs
preparation. Forceful cervical dilatation can lacerate the cervix, which can
cause significant bleeding or in rare cases lead to cervical incompetence.
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- Laminaria: Laminaria japonicas are small sticks of presterilized seaweed
that can be inserted preoperatively to dilate the cervix. They are generally
thought to do this by absorbing water and swelling mechanically. Some
believe that other hormonal mechanisms are triggered, allowing the cervix to
dilate above the physical size of the laminaria. Only one laminaria is
required for dilating the cervix with a 10-week pregnancy. As the weeks and
the amount of dilatation the pregnancy termination requires progress, more
laminaria are inserted and left for longer amounts of time. Most laminaria
need at least 4 hours to be useful, but overnight use is indicated in cases
that are further along. Successive applications of increased numbers of
laminaria can be used for more than 24 hours if the pregnancy is very
advanced or if the cervix is unusually rigid.
Prior to insertion, Betadine preparation of the cervix is performed.
Laminaria insertion is simple, often requiring a single toothed tenaculum to
stabilize the cervix and no anesthesia. For cases in which several laminaria
must be inserted, 12 cc of lidocaine administered paracervically can provide
comfort. The patient must understand that laminaria insertion is the
beginning of the abortion procedure. Pregnancies have safely been carried to
term after laminaria insertion and removal, but late onset intrauterine
infection or chorioamnionitis is a concern. Counseling is used to be sure
the patient understands her risks once she starts the dilatation process.
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- Failure to dilate: Failure to dilate the cervix is not common, but if no
dilators (the smallest is a 3 mm) or laminaria can be admitted, this is the
diagnosis. Rare cases exist in which the cervix is so scarred, mostly from
previous pregnancies or deliveries, that the os cannot be viewed; the
patient may be advised to have a medical abortion. Waiting until the patient
is further in pregnancy is an option, as is dilating while watching with
sonographic control.
- Intraoperative care of patients undergoing surgical abortion
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- Most patients having an early termination of pregnancy can have their
abortion performed under "vocal sedation" (talking the patient through the
procedure) as well as local sedation. Most patients do not need an
intravenous access for medication.
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- If heavy sedation is selected, then intravenous fluids with lactated
Ringer solution or one half normal saline are suitable, at rates appropriate
for the patient's age and weight.
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- If a patient is administered intraoperative sedation, appropriate
monitoring includes vital sign assessment, assessment of the patient's
degree of sedation and responses, and assessment of the patient's pulse
oxygen level.
- First trimester surgical abortion
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- Early terminations are performed with little cervical dilatation and
using a hand held syringe or a small bore cannula attached to a suction
machine. Abortions performed with a syringe are referred to as manual
aspirations. Some authors still call them "menstrual extractions," from the
days when abortion was more stigmatized and women did not want the procedure
referred to as an abortion. Those performed with the suction generated by a
vacuum aspirator are referred to as a vacuum aspiration. Both procedures
take only a few minutes.
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- Single toothed tenaculums are used to grasp the cervix after it has been
prepared with Betadine. Local anesthetic is administered in a paracervical
fashion. The agent used is usually lidocaine 1-2% or Nesacaine 1%. No
epinephrine is necessary. The local anesthetic takes effect rapidly, and
studies of the exact route of administration (several spots around the
cervix or at 3 and 9 o'clock) have not shown large differences in efficacy.
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- For gestations of 6 weeks or less, cannulas of 3-6 mm can be used. For
gestations of 7-9 weeks, 5-9 mm cannulas are used. The suction cannulas can
be soft or rigid, straight or bent, and experienced providers can use either
type interchangeably. Both suction syringes and the suction machines
generate 60-70 mm Hg of pressure. Performing procedures at lower levels of
suction prolongs the procedure and, therefore, increases bleeding and
patient discomfort.
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- The amount of tissue obtained correlates with the stage of gestation and
the fetal number. The amount of bleeding can be very slight, 5-25 cc for
very early terminations, or as heavy as 100-250 cc. Amounts over 200 cc
blood loss usually are indicative of uterine atony. Cervical lacerations
increase the amount of blood lost.
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- Intravenous sedation with versed 2.5-5 mg can be performed, and rapidly
acting narcotics can be supplemented for pain relief. Others have had
success with sublingual diazepam, and intramuscular Toradol (ketorolac
tromethamine) can be used.
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- Abortions in the late first trimester are performed with or without
preoperative cervical dilatation with laminaria or misoprostol. If a woman
is multiparous, no preoperative dilatation is usually necessary, although
procedures under local anesthetic are more comfortable if the cervix has
been prepared.
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- Sounding should be performed with the cannula to protect the uterus
against perforation. The actual evacuation is performed by applying suction
to the syringe or via the machine. The completeness of the procedure is
ensured by the feel of the uterus against the instrument, the sound of the
uterine curettage, and the appearance of bubbles in the cannula. Sonographic
confirmation of completeness is helpful in some cases. The procedure takes a
few minutes to complete, and the estimated blood loss should be minimal
(5-10 cc range for very early abortion and 50-100 cc range for later
procedures).
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- Tissue inspection for completeness is an essential part of the
procedure.
- Dilatation and curettage
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- This specifically is a term that usually is applied to a diagnostic
gynecological procedure or the treatment of an incomplete abortion.
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- The procedure usually is accomplished with similar dilatation
procedures, but the uterine emptying is accomplished with a sharp metal
curette. These curettes are more dangerous than the flexible or rigid
plastic devices, which are used in the suction procedures, and are not
recommended for abortion procedures.
- Second trimester dilatation and evacuation
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- Dilatation and evacuation is the safest and most common method of second
trimester termination for experienced providers. These procedures are
accomplished with similar preoperative preparation to first trimester
preparation; however, the dilatation must be accomplished over hours and, in
some cases, days.
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- The procedure requires the cervix to be dilated to 2-3 cm, admitting at
least a #16 Hegar dilator or a size 53 French (Fr) dilator. The cervix is
grasped with a single-toothed tenaculum after Betadine preparation. The
procedure is accomplished using a combination of suction curettage and
manual evacuation of the fetus and placenta. Ultrasonic guidance is
valuable, and some providers use manual palpation of the fundus to guide the
use of the forceps that are used for evacuation. The forceps are used most
carefully in the lower uterine segment. The types of forceps used are Soper,
ring, or packing forceps, with Soper forceps being the most useful.
Uterotonics can help push the products of conception toward the internal os
to facilitate the process.
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- The procedure is longer and more uncomfortable than a first trimester
procedure, but many patients can comfortably go through the procedure with
local anesthesia. Blood loss for these procedures is in the range of 100-350
cc.
- Dilatation and extraction
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- This procedure is accomplished by cervical preparation similar to cases
of dilatation and evacuation, but the fetus is removed in a mostly intact
condition. The fetal head is made of cartilage and is able to be collapsed
after the contents are evacuated so that it may pass through the cervix.
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- Very few providers perform the procedure. It usually is reserved for
cases of maternal medical complications or fetal abnormalities.
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- With an intact fetus, the family may hold their baby and have time to
say good-bye as part of the grieving process. Reconstituting the fetal head
with a jellied substance can restore fetal anatomy.
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- The procedure also has been referred to as intact dilatation and
extraction and has been called "partial birth abortion" by abortion
opponents.
- Induction of labor
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- Most physicians have experience with the standard Pitocin protocols for
labor induction, and these can be used in the case of a second trimester of
pregnancy.
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- Premature rupture of membranes is one indication for this method.
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- Research generally indicates better success with prostaglandin methods,
and this method typically is not employed.
- Hysterotomy
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- Hysterotomy is reserved for very few cases. Large uterine leiomyomata
has been an indication for hysterotomy in the performance of an abortion,
and in the past, placental previa was another indication (recent reports
have shown that a dilatation and evacuation procedure can be performed
safely in some of these cases).
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- The uterine segment is never developed well enough to place the incision
there, so virtually all hysterotomies must be performed by classic uterine
incisions.
- Hysterectomy: Very few indications exist for the use of hysterectomies to
terminate pregnancies. The extra uterine vasculature that develops in
pregnancy makes hysterectomy more dangerous, and the incidence of hemorrhage
and complications rises.
- Surgical sterilization: Bilateral tubal ligation via minilaparotomy, tubal
fulguration, or tubal device occlusion is easily performed at the time of
first or second trimester abortion of pregnancy. Failure rates are high
because of the enlarged tubal structure and lumen, but the magnitude of risk
is not well established.
Consultations: The counseling process should offer referrals
for those who need ongoing support.
Diet: Patients may eat a regular diet.
Activity:
- Tampons, douche, and intercourse should be avoided for one week.
- Heavy activity or lifting should be avoided for a few days.
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MEDICATION |
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The procedure usually is performed under local
anesthesia. For those modestly tolerant of pain, either intravenous sedation or
administration of a preoperative antianxiolytic agent can be used. Narcotics can
be used for pain control but usually are not necessary. A variety of agents may
be useful for contracting the uterus postprocedure, although in a typical first
trimester procedure, none are necessary. Agents useful to control bleeding
include Pitocin, Methergine, or prostaglandins. Mechanical devices to control
hemorrhage can be useful as well, which typically consists of intrauterine
insertion of a Foley catheter.
Postprocedure pain and cramping are effectively treated with a variety of
analgesic agents (ie, NSAIDs, Tylenol, codeine, Vicodin).
Dinoprostone (Cervidil, Prepidil, Prostin E2) is a prostaglandin administered
vaginally and is approved specifically for the use at term in labor for cervical
preparation. It works almost as well as misoprostol, but it is very expensive
and not used for abortions for this reason alone.
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Drug Category: Local anesthetics -- A few
patients can tolerate cervical dilatation and suction curettage with no
anesthesia and also through relaxation techniques. Paracervical blockade
provides some additional cervical compliance in the dilatation phase as well as
all the anesthetic that is necessary for early abortion procedures.
Drug Name
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Lidocaine (Xylocaine) --
Used for paracervical block during procedure to keep patient comfortable.
Local anesthetic blocks nerve impulses by decreasing sodium influx across
neuronal cell membranes. Alternatively, chloroprocaine (Nesacaine) may be
used. |
Adult Dose |
Popular mixture used (12-20
mL in divided doses to be injected in each patient):
(1) 50 mL vial of 1% or 0.5% lidocaine and draw off 5 mL (2) add 2-4 U (0.1
mL) of vasopressin (3) add 5 mL of buffer (8.4% sodium bicarbonate)
If Atropine is added, dose is 2 mg/50 mL
Deep injections are more efficacious than superficial, inject 10-15 mL
halfway between the os and the periphery of the cervix at 4 sites (12, 3, 6,
9 o'clock) at a depth of 0.75-1 inch |
Pediatric Dose |
Not established |
Contraindications |
Documented
hypersensitivity; Adams-Stokes or Wolf-Parkinson-White syndrome; SA, AV, or
intraventricular heart if artificial pacemaker is not in place |
Interactions |
Increased toxicity with
cimetidine, beta-blockers; additive cardiodepressant action with
procainamide, tocainide; increases effects of succinylcholine |
Pregnancy |
B - Usually safe but
benefits must outweigh the risks. |
Precautions |
Associated with malignant
hyperthermia; increased risk of CNS and cardiac adverse effects in the
elderly; seizures, heart block, and AV conduction abnormalities have
occurred; caution with heart failure, hepatic disease, hypoxia, hypovolemia,
shock, respiratory depression, and bradycardia |
Drug Category: Prostaglandins -- Abortifacient
drugs of various types can be used for medical termination or treatment of
ectopic pregnancy. Rarely they are used to complete an incomplete surgical
abortion. This class of drugs includes misoprostol, gemeprost, and PG05 (15MF2
alpha prostaglandin).
Drug Name
¡@ |
Misoprostol (Cytotec) --
Not approved for use in pregnancy, yet is an invaluable medication widely
used for cervical preparation for abortion, labor induction, and as a
medical abortifacient. Provides safe, passive method of cervical dilatation
and should be considered for preabortion ripening when prior uterine surgery
(ie, LEEP, C-section) are known risk factors for uterine perforation during
surgical abortion. Can be administered orally or vaginally. Some studies
show premoistening tablets placed vaginally helps absorption. Patients can
be instructed in self-administration to help time the dose in synchrony with
their abortion procedure.
In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved
dilatation of the cervix of 8 mm or greater after 3 h postintravaginal
misoprostol 400 mcg, whereas only 16.7% of women achieved this after 2 h of
600 mcg. The 600-mcg group had slightly greater adverse effects (eg,
bleeding, abdominal pain, fever >38ºC). Dosage intended for cervical ripening
can induce abortion in some patients. Oral doses of 100-400 mcg can be
combined with vaginal insertion of prostaglandins to enhance cervical
dilatation.
|
Adult Dose |
Cervical ripening: 25-100
mcg (vaginally) for term pregnancies, lower doses may need to be repeated
q4-6h
Termination: 200-800 mcg, most patients do not need repeat dosing for 24 h
|
Pediatric Dose |
Not established |
Contraindications |
Documented
hypersensitivity; pregnancy not intended for termination; glaucoma; sickle
cell anemia; hypotension; mitral stenosis |
Interactions |
Antacids containing
magnesium may increase diarrhea |
Pregnancy |
X - Contraindicated in
pregnancy |
Precautions |
Inform patient of potential
adverse effects (eg, GI distress, cramping, bleeding); GI distress slightly
greater with oral administration. |
Drug Category: Antiprogesterones --
Antiprogesterone class of drugs for medical termination of pregnancy are used.
Other potential uses include postcoital contraception, leiomyomatas,
endometriosis, endometrial cancer, breast cancer, ovarian cancer, glaucoma,
myomas, and Cushing syndrome. Antiprogesterones do not effectively treat ectopic
pregnancy and should not be used for this indication.
Drug Name
¡@ |
Mifeprex (RU-486) --
Progesterone receptor antagonist, which has 5 times greater affinity for the
receptor than progesterone. By blocking progesterone, the hormone that
maintains pregnancy, abortion can be completed. Cervix is softened and
dilated; decidual necrosis and detachment of the pregnancy at the
endometrium and uterine contractions ensue. |
Adult Dose |
600 mg PO day 1 of medical
abortion regimen; doses as low as 200 mg reported as efficacious |
Pediatric Dose |
Not established |
Contraindications |
Documented
hypersensitivity; confirmed/suspected ectopic pregnancy; undiagnosed adnexal
mass; IUD in place; chronic adrenal failure; concurrent long-term
corticosteroid therapy; hemorrhagic disorders; concurrent anticoagulation
therapy; inherited porphyrias |
Interactions |
Not studied yet; possibly
ketoconazole, itraconazole, erythromycin, grapefruit juice; rifampin,
dexamethasone, St John's Wort, some anticonvulsants |
Pregnancy |
X - Contraindicated in
pregnancy |
Precautions |
Abdominal pain, uterine
cramping, nausea, vomiting, diarrhea |
Drug Category: Antimetabolites -- The
antimetabolite, methotrexate, has been used for over 15 years for the medical
treatment of early, unruptured ectopic pregnancies. Success rate for this
indication is greater than 90%. Adverse effects are minimal and regimens are
cost effective. This offers effective destruction of rapidly dividing placental
cells. This class of drug to be used for the medical termination of pregnancy,
although for complete expulsion, it usually has to be administered in
conjunction with prostaglandin.
Drug Name
¡@ |
Methotrexate (Folex PFS,
Rheumatrex) -- Antimetabolite that works by blocking enzyme dihydrofolate
reductase, thereby inhibiting folate production and, thus, DNA synthesis.
Primarily affects rapidly dividing cells first, such as trophoblast cells.
|
Adult Dose |
50 mg/m2 IM;
alternatively, 50 mg PO |
Pediatric Dose |
Not established |
Contraindications |
Documented
hypersensitivity; alcoholism; hepatic insufficiency; kidney disease;
inflammatory bowel disease; clotting disorder; documented immunodeficiency
syndromes; preexisting blood dyscrasias; bone marrow hypoplasia; leukopenia,
thrombocytopenia; significant anemia (Hct<30%) |
Interactions |
Oral aminoglycosides may
decrease absorption and blood levels of concurrent oral methotrexate (MTX);
charcoal lowers MTX levels; coadministration with etretinate may increase
hepatotoxicity of MTX; folic acid or its derivatives contained in some
vitamins may decrease response to MTX
Probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides, including
TMP-SMZ, can increase MTX plasma levels; may decrease phenytoin plasma
levels; may increase plasma levels of thiopurines
|
Pregnancy |
D - Unsafe in pregnancy
|
Precautions |
Nausea, vomiting, diarrhea,
hot flushes, headache, cramping, dizziness; toxic adverse effects on the
hematologic, renal, GI, pulmonary, and neurological systems |
Drug Category: Uterotonics -- The rapid and
complete emptying of the uterus usually provides a natural uterine contraction
process that successfully halts postabortion blood loss and eventually leads to
normal uterine blood loss and normal uterine involution back to the prepregnant
state. The uterotonic medications typically are used to enhance this process or
to halt immediate postabortion bleeding. In some cases, these drugs can be
potent enough inducers of uterine activity to lead to abortion without other
drugs or regimens.
Drug Name
¡@ |
Oxytocin (Pitocin) --
Produces rhythmic uterine contractions and can stimulate the gravid uterus
as well as vasopressive and antidiuretic effects. Can also control
postpartum bleeding or hemorrhage.
When used as in labor protocols, can induce second trimester abortion.
|
Adult Dose |
10 U IM after delivery
Alternatively, 10-40 U IV in 1000 mL of IV fluid at rate high enough to
control uterine atony
|
Pediatric Dose |
>12 years: Administer as in
adults |
Contraindications |
Documented
hypersensitivity; cardiac arrhythmias with tachycardia |
Interactions |
Pressor effect of
sympathomimetics may increase when used concomitantly with oxytocic drugs,
causing postpartum hypertension |
Pregnancy |
X - Contraindicated in
pregnancy |
Precautions |
Overstimulated uterus can
be hazardous; hypertonic contractions can occur in a patient whose uterus is
hypersensitive to oxytocin, regardless of whether it was administered
appropriately; oxytocin has intrinsic antidiuretic effect that, when
administered by continuous infusion and patient is receiving fluids by
mouth, can cause water intoxication |
Drug Category: Ergot Alkaloids -- Also in the
category of uterotonics and almost exclusively used for treatment of postabortal
bleeding, atony, or hemorrhage.
Drug Name
¡@ |
Methylergonovine (Methergine)
-- Acts directly on uterine smooth muscle, causing a sustained tetanic
uterotonic effect that reduces uterine bleeding and shortens third stage of
labor. Administer IM during puerperium, delivery of placenta, or after
delivering anterior shoulder. Also may be administered IV, over no less than
60 sec, but should not be administered routinely because it may provoke
hypertension or a cerebrovascular accident. Monitor BP closely when
administering IV. |
Adult Dose |
0.2 mg PO tid/qid for 2-7 d
Alternatively, 0.2 mg IM/IV repeat q2-4h prn
|
Pediatric Dose |
<12 years: Not established
>12 years: Administer as in adults
|
Contraindications |
Documented
hypersensitivity; glaucoma; Tourette syndrome; anxiety; hypertension |
Interactions |
Concurrent administration
of methylergonovine with vasoconstrictors or other ergot alkaloids may
produce additive effect |
Pregnancy |
C - Safety for use during
pregnancy has not been established. |
Precautions |
Caution in sepsis,
obliterative vascular disease, or hepatic or renal insufficiency |
Drug Name
¡@ |
Carboprost tromethamine (Hemabate)
-- Prostaglandin similar to F2-alpha (dinoprost) but has longer duration and
produces myometrial contractions that induce hemostasis at placentation
site, which reduces postpartum bleeding. |
Adult Dose |
250 mcg IM; repeat at 15-90
min intervals to maximum dose of 2 mg |
Pediatric Dose |
Not established |
Contraindications |
Documented
hypersensitivity; pelvic inflammatory disease |
Interactions |
Increases toxicity of
oxytocic agents |
Pregnancy |
X - Contraindicated in
pregnancy |
Precautions |
Caution in cardiovascular
disease, asthma, hypotension or hypertension, adrenal disease, diabetes,
renal or hepatic disease, a compromised uteri, or jaundice; do not inject IV
(may induce hypertension and bronchospasm) |
Drug Category: Sedatives -- During surgical
abortion, relaxation techniques and local anesthetic is typically all that is
required to adequate pain relief. In some patients, the use of intravenous,
oral, or sublingual sedatives can enhance this effect.
Drug Name
¡@ |
Midazolam (Versed) --
Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring
acute and/or short-term sedation. Also useful for its amnestic effects. |
Adult Dose |
0.5-2 mg IV over 2 min;
repeat q2-3min prn; total IV dose generally 2.5-5 mg |
Pediatric Dose |
>12 years: 0.5 mg IV over 2
min; repeat q3-4min prn |
Contraindications |
Documented
hypersensitivity; preexisting hypotension; narrow-angle glaucoma;
sensitivity to propylene glycol (diluent) |
Interactions |
Sedative effects of
midazolam may be antagonized by theophyllines; narcotics and erythromycin
may accentuate sedative effects of midazolam due to decreased clearance |
Pregnancy |
D - Unsafe in pregnancy
|
Precautions |
Caution in congestive heart
failure, pulmonary disease, renal impairment, and hepatic failure; Romazicon
is a benzodiazepine antagonist used to reverse the effects of versed
(0.2-0.3 mg IV, may wear off faster than the versed itself) |
Drug Category: Antiemetics -- Antiemetics are
not typically necessary unless patients already have pre-existing nausea and
vomiting of pregnancy or have nausea and vomiting in reaction to general
anesthesia.
Drug Name
¡@ |
Prochlorperazine (Compazine)
-- May relieve nausea and vomiting by blocking postsynaptic mesolimbic
dopamine receptors through anticholinergic effects and depressing reticular
activating system. |
Adult Dose |
5-10 mg PO/IM tid/qid; not
to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid
|
Pediatric Dose |
2.5 mg PO/PR q8h or 5 mg
q12h prn; not to exceed 15 mg/d
IV dosing is not recommended for children
0.1-0.15 mg/kg/dose IM and change to PO as soon as possible
|
Contraindications |
Documented
hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe
liver or cardiac disease |
Interactions |
Coadministration with other
CNS depressants or anticonvulsants may cause additive effects; with
epinephrine, may cause hypotension |
Pregnancy |
C - Safety for use during
pregnancy has not been established. |
Precautions |
Drug-induced Parkinson
syndrome or pseudoparkinsonism occurs quite frequently; akathisia is most
common extrapyramidal reaction in elderly; lowers seizure threshold; caution
with history of seizures |
Drug Name
¡@ |
Promethazine (Phenergan) --
Antidopaminergic agent effective in treating emesis. Blocks postsynaptic
mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem
reticular system. |
Adult Dose |
12.5-25 mg PO/IV/IM/PR q4h
prn |
Pediatric Dose |
0.25-1.0 mg/kg PO/IV/IM/PR
4-6 times/d prn |
Contraindications |
Documented
hypersensitivity; narrow-angle glaucoma |
Interactions |
May have additive effects
when used concurrently with other CNS depressants or anticonvulsants;
coadministration with epinephrine may cause hypotension |
Pregnancy |
C - Safety for use during
pregnancy has not been established. |
Precautions |
Caution in cardiovascular
disease, impaired liver function, seizures, sleep apnea, and asthma; avoid
accidental intra-arterial injections |
Drug Category: Antibiotics -- Most antibiotics
are used prophylactically to prevent postoperative endometritis. Some
institutions have used dosages that would cover CT and GC because patients are
often unavailable for contact after an abortion (lack of providers means many
travel very far to receive their abortion).
Drug Name
¡@ |
Doxycycline (Vibramycin) --
Inhibits protein synthesis and thus bacterial growth by binding to 30S and
possibly 50S ribosomal subunits of susceptible bacteria. Prophylaxis of
postabortion infections. If contraindicated, use erythromycin or ampicillin.
Suspected cervicitis for chlamydia. |
Adult Dose |
New ACOG recommendations
recommend 100 mg PO 1 h prior to abortion, then 200 mg PO postabortion; this
regimen may produce nausea and vomiting
100 mg PO bid for 1-3 d postabortion
|
Pediatric Dose |
2-5 mg/kg/d in 1-2 divided
doses; not to exceed 200 mg/d, not generally applicable |
Contraindications |
Documented
hypersensitivity; severe hepatic dysfunction |
Interactions |
Bioavailability decreases
with antacids containing aluminum, calcium, magnesium, iron, or bismuth
subsalicylate; tetracyclines can increase hypoprothrombinemic effects of
anticoagulants; tetracyclines can decrease effects of oral contraceptives,
causing breakthrough bleeding and increased risk of pregnancy |
Pregnancy |
D - Unsafe in pregnancy
|
Precautions |
Photosensitivity may occur
with prolonged exposure to sunlight or tanning equipment; reduce dose in
renal impairment; consider drug serum level determinations in prolonged
therapy; tetracycline use during tooth development (last one-half of
pregnancy through age 8 y) can cause permanent discoloration of teeth;
Fanconilike syndrome may occur with outdated tetracyclines |
Drug Name
¡@ |
Erythromycin (E-Mycin, Ery-tab,
Eryc, Erythrocin) -- Inhibits bacterial growth, possibly by blocking
dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein
synthesis to arrest. For treatment of staphylococcal and streptococcal
infections. Prophylaxis of postabortion infections. Use if doxycycline is
contraindicated. |
Adult Dose |
333 mg PO tid for 3-7 d;
alternatively 500 mg PO bid for 3-7 d |
Pediatric Dose |
30-50 mg/kg/d (15-25
mg/lb/d) PO divided q6-8h |
Contraindications |
Documented
hypersensitivity; hepatic impairment; concomitant use of astemizole,
cisapride, pimozide, terfenadine |
Interactions |
Coadministration may
increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine;
may potentiate anticoagulant effects of warfarin; coadministration with
lovastatin and simvastatin, increases risk of rhabdomyolysis |
Pregnancy |
B - Usually safe but
benefits must outweigh the risks. |
Precautions |
Caution in liver disease;
estolate formulation may cause cholestatic jaundice; GI adverse effects are
common (administer doses pc); discontinue use if nausea, vomiting, malaise,
abdominal colic, or fever occur; pseudomembranous colitis |
Drug Category: Immune globulins -- Pregnancies
past 5 weeks of gestation may have an established fetal blood system and Rh
sensitization can occur without administration. Typically, no preadministration
antibody screens are performed in this patient population.
Drug Name
¡@ |
Rh0(D) immune
globulin (RhoGAM) -- Given to Rh(-) mothers to avoid sensitization to Rh(+)
fetal blood. |
Adult Dose |
<12 wk gestation: 50 mcg (minidose)
>12 wk gestation: 300 mcg
Administered up to 72 h postabortion
|
Pediatric Dose |
Adolescent: Administer as
in adults |
Contraindications |
Documented hypersensitivity
|
Interactions |
None |
Pregnancy |
C - Safety for use during
pregnancy has not been established. |
Precautions |
Anaphylactic shock; fever;
do not administer live virus vaccine within 3 mo |
Drug Name
¡@ |
Metronidazole (Flagyl) --
Recommended as an alternative for endometritis prophylaxis. |
Adult Dose |
500 mg tid for 7d
postabortion when allergic to doxycycline; stat when treating suspected
bacterial vaginosis prior to abortion. |
Pediatric Dose |
Not established |
Contraindications |
Documented hypersensitivity
|
Interactions |
May increase toxicity of
anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of
metronidazole; disulfiram reaction may occur with orally ingested ethanol
|
Pregnancy |
B - Usually safe but
benefits must outweigh the risks. |
Precautions |
Adjust dose in hepatic
disease; monitor for seizures and development of peripheral neuropathy |
|
FOLLOW-UP |
¡@ |
Further Inpatient Care:
¡@
- Termination of pregnancy never requires inpatient treatment. If the
patient has a medical condition that requires hospitalization, then that
condition's indications for hospitalization should be followed.
- Patients that must have their termination performed by hysterotomy or
hysterectomy are hospitalized according to the needs of their operation.
- Patients with a medical complication of pregnancy termination, such as a
perforation, are cared for according to the treatment necessary.
- For the patient who has a fundal perforation, with an instrument that is
not connected to suction, patient observation may be indicated but usually is
not necessary.
- Patients with perforations suspicious of bowel injury may need exploratory
surgery via laparoscopy (if the physician is an extremely experienced
laparoscopist) or an exploratory laparotomy. If these procedures are used,
hospitalization may be required for 1-3 days to manage the usual postoperative
course.
- Antibiotic prophylaxis is recommended for any additional surgery with
broad-spectrum antibiotic coverage administered over at least 24 hours.
Further Outpatient Care:
¡@
- Postoperative care of a patient after surgical abortion
- Observe patients for a half an hour, checking for abdominal pain,
unusual bleeding, and observing vital signs.
- Anti-D immunoglobulin should be administered on the day of the procedure
to patients who are Rh-negative.
- Patients selecting immediate intrauterine device (IUD) insertion, depot-medroxyprogesterone
acetate (DMPA), or Norplant may begin their contraceptive this day as well.
¡@
- Postoperative appointments are usually 1-3 weeks after the procedure and
are important to ensure timely involution, confirm the pregnancy termination
has been completed, evaluate the patient for medical complications, offer
continuing contraceptive care, and evaluate psychological status.
- Postoperatively, patients should be given instructions to contact their
providers if they have severe pain, run a fever of 100.4ºF or higher, or soak
through more than 4-5 pads per hour or more than 12 pads in 24 hours. The
first 24 hours, a nonaspirin analgesic, such as acetaminophen, is
recommended, and after that time, patients can switch to a nonsteroidal
anti-inflammatory drug (NSAID), such as ibuprofen or naproxen.
¡@
- Provide patients with emergency contact numbers and instructions
regarding where to present if they have an emergency and cannot reach the
provider.
- Patients may bleed very little, if at all, if they were very early in
gestation, but the most common bleeding pattern is to have bleeding the day
of the procedure, then not much until the fifth postoperative day when
heavier cramping and clotting occurs.
¡@
- Patients should not use tampons for 5 days and should not have
intercourse until bleeding has stopped for a week or they have been cleared
by their provider at their postoperative visit.
- With antibiotic use as prophylaxis, postabortion infection rates in most
population groups should be less than 1-2%. Antibiotic use for the procedure
usually is limited to the day of the procedure or a 2-3 day course. The
antibiotics used are typically broad spectrum, and most centers use
doxycycline 100 mg bid, with erythromycin for those who are allergic. If
bacterial vaginosis is discovered, then the use of Flagyl 500 mg bid or
Cleocin 300 mg bid PO is selected. Some providers with caseloads of patients
who come from far distances and are difficult to locate postoperatively may
select to administer longer antibiotic courses to cover the event of a
positive CT or GC test coming back after the patient has left the facility
and either cannot be or does not want to be contacted.
¡@
- Most oral contraceptive pills can be started the day of the procedure or
the following Sunday. IUDs can be inserted that day or with the next
menstrual period. DMPA shots can be given that day or up to 5 days later.
- Patients who have had their pregnancies terminated need a postoperative
evaluation in 1-3 weeks. Women should be offered a contact number for any
questions, and episodes of unusual pain or bleeding should be cause for an
early postoperative visit.
- Uterine perforation: If the patient had a fundal perforation with no
suction applied, then observation for a few hours and evaluation of hemoglobin
levels is standard of care.
- Evaluation of acute abdominal pain postabortion: Suspect acute hematometra,
retained products of conception, pelvic infection, or perforation with or
without bowel involvement.
In/Out Patient Meds:
¡@
- Long-term steroid contraception
Deterrence/Prevention:
¡@
- Effective contraception is the only reasonable strategy toward abortion
prevention. Since the introduction of the long-acting steroid contraceptives,
abortion rates in the US have steadily declined.
Complications:
¡@
- Uterine hemorrhage
¡@
- Hemorrhage has been defined in a variety of ways; the need for
transfusion is exceedingly rare. If uterine hemorrhage rates include
hemorrhage immediately postabortion, uterine atony rates of hemorrhage are
as low as 5%. Initial hemorrhage should be evaluated by ensuring complete
uterine evacuation.
¡@
- The next steps are typically medical: the use of intramuscular
Methergine 0.2 mg, the use of intravenous Pitocin drips with 10-20 mIU/L
running at 100-200 cc. Hemabate also is helpful.
¡@
- In the past, uterine packing has been used, but this can be accomplished
effectively with the intrauterine inflation of a Foley balloon. Five cc
balloons can be inflated with 30 cc, or 30 cc balloons can be inflated with
up to almost 100 cc of sterile saline. The inflation should correlate with
uterine size.
¡@
- Uterine artery embolization can be used if placenta accreta is
encountered, but very few of these procedures have been performed, and
statistical success rates are impossible to evaluate.
- Uterine perforation
¡@
- Perforation rates have been estimated to occur in 1 per 250 cases. They
usually are fundal and recognized by the provider at the time of the
procedure. In a study by Pridmore of 13,907 women who underwent outpatient
termination of pregnancy, the perforation rate was 0.05%, and in the second
trimester, procedures from 13-20 weeks, the perforation rate was 0.32%.
¡@
- Risk factors for perforation are previous terminations of pregnancy,
lower segment cesarean sections, and loop electrosurgical excision
procedures (LEEPs) of the cervix. The common denominator is thought to be
scarring of the internal cervical os.
¡@
- Fundal perforations only require observation. If the extent of the
perforation cannot be determined, if the patient is medically unstable, if
the suction was applied at the time of the perforation, or if bowel or fat
content was obtained by forceps at the time of a perforation, surgical
evaluation of the patient is necessary. The surgical evaluation may be
performed by an experienced laparoscopist or by laparotomy.
- Retained products of conception
¡@
- Evaluation of the obtained products of conception at the time of
abortion and postabortion uterine scanning have reduced the retained
products of conception rate to less than 1% of cases, and in one series
reported by Hakim, Tovell, and Burnhill of 170,000 cases, only 0.5%
incidence occurred in the first trimester. In cases of second trimester
abortions, retained tissue rates are even lower with rates of 0.2% according
to Peterson and 0.5% according to Kafrissen et al.
¡@
- Cases of delayed bleeding even after a normal cycle have been reported.
Dilatation and curettage or hysteroscopy are necessary if bleeding is
brisker or if the amount of tissue is determined by sonography to warrant
more extensive procedures. Endometrial color flow can be helpful in
determining retained tissue.
- Endometritis and pelvic inflammatory disease
¡@
- Infections postabortion are rare, occurring in fewer than 1% of cases.
These usually are due to preexisting infections, such as bacterial vaginosis,
cervicitis or salpingitis, or a failure of antibiotic prophylaxis.
- The usual criteria for the diagnosis of pelvic inflammatory disease (PID)
should be used.
- Coexistent ectopic pregnancy
¡@
- Residual positive HCG titers are not uncommon, and clinicians need to be
vigilant in their evaluation of persistent positive pregnancy tests in order
to avoid missing an ectopic pregnancy.
¡@
- Pelvic ultrasonography is the most helpful tool. Presence of significant
tenderness on postoperative exam, a history of continued pain, and
increasing or plateauing HCG titers should make a clinician suspicious.
Coexistent interactive and extrauterine pregnancies are observed only in
extremely rare cases.
- Asherman syndrome
¡@
- Postabortion uterine synechiae (or adhesions) that can obliterate part
or all of the endometrial cavity have been reported. This is thought to be
more likely secondary to endometritis than the instrumentation of the
uterus, but sharp curetting after the abortion procedure should be avoided
to avoid denuding the basal layer of the endometrium.
¡@
- The diagnosis is made by hysteroscopy or hysterosalpingogram in a
patient who presents with postabortion amenorrhea.
- Few long-term sequelae of abortions have been documented. Although a
syndrome of posttraumatic stress has been reported, the literature has not
been able to separate the stressors of the patient's social situation that
lead to the abortion from the abortion procedure itself.
¡@
- Initial studies seemed to indicate a greater risk of elective
termination than that of term birth. Most of these data have been refuted.
In the Iowa Women's Health Study, women aged 55-64 years had their health
records of the state linked with the national Cancer Institute's
Surveillance, Epidemiology and End Results Program (SEER). Only 1.8% of the
women in this study reported induced abortion, which is lower than other age
groups will be as they reach that age, but the relative risk of breast
cancer for those with prior induced abortion was 1.1%. These results must be
reevaluated over time.
¡@
- One recent article reported a slightly greater incidence of adenomyosis
postabortion. A study by Zhou of 15,727 women who had induced abortions
compared with 46,026 women who did not have induced abortions showed an
increased risk in preterm and postterm pregnancy after induced abortion.
Another study by Hendricks showed that both induced abortion and prior
cesarean section increased the risk of placenta previa. In women with 3
prior cesarean sections, the relative risk was 2.4 and the risk of having 2
or more previous abortions was 2.1.
¡@
- In another study by Eras, abortion was suggested as a protective factor
against the development of preeclampsia in a subsequent pregnancy in women
with no prior deliveries.
- Psychologic consequences of abortion
¡@
- Generally, the psychological health of the abortion patient parallels
her psychologic health prior to seeking an abortion. If the woman needed to
have the abortion in secrecy, then long-term psychologic sequelae, such as
intrusive thoughts, are more common.
¡@
- Many studies actually have demonstrated improved psychological
well-being after abortion. For the studies that have shown this, the
improvement in psychological health is suspected to be more reflective of
the patient dealing with the social issues that led her to select abortion
to begin with.
¡@
- Sometimes, confusion over normal emotions, such as sadness and grief
versus psychological illnesses (eg, depression), seems to occur. The most
common feeling experienced after an abortion is that of relief and
confidence in the decision. Few women may experience feelings of grief and
guilt postabortion, and these feelings usually pass within days to weeks in
most cases and do not lead to psychological sequelae. One study demonstrated
that the risk for serious psychiatric illness postabortion was 1%, whereas
with live birth it was 10%. Few studies on these data exist, partly because
studies performed earlier gave no indication for psychiatric sequelae so no
new findings have been researched. Considering that over 1.5 million
abortions are performed in the US each year, if an epidemic of psychiatric
sequelae due to the procedure occurred, it would be observed by now.
¡@
- Many confounding factors are involved in a women's emotional status
during the time of her abortion. Relationships, religion, age, social
support, and previous psychological stability all play a part.
¡@
- An entire new set of circumstances and feelings exist in cases of rape
and incest. These are often psychologically complex situations and unique to
each case.
- Providers can help women through abortions by presenting options and
explaining the procedures. Counseling with a trained professional occurs
before the abortion. This is a good time to identify factors that might lead
to a patient having difficult feelings after the abortion. Some factors are
low self-esteem, preexisting or past psychological illness, lack of
emotional support, and past childhood sexual abuse. The counselor can then
confront these issues before the procedure and help the patient assess
specific needs and improve coping strategies.
Prognosis:
¡@
- Fertility is not impaired. Prognosis is excellent.
Patient Education:
¡@
- Give patients information about abortion and how to care for themselves
postabortion.
- Educate patients about birth control options, and discuss when to start
birth control postabortion.
|
MISCELLANEOUS |
¡@ |
- ¡@
- Most young adolescents have parental or family involvement in their
decision to have an abortion. Adolescents who are older, especially those
living independently, often do not. In spite of ample scientific evidence
that the majority of teens seek parental involvement and widespread legal
concern that individuals who do not seek parental involvement may be at
risk physically or emotionally, a barrage of legislation mandates that all
minors seek parental consents or that the parents be notified in advance
of a minor child having an abortion.
¡@
- The laws that have enabled this to occur legally are backed in the
Supreme Court. By 1999, 38 states had such laws, and 29 states enforce
their laws. Currently only Connecticut, Maine, and the District of
Columbia have laws that affirm the rights of a minor to seek her own
abortion. As a result, abortion providers in states that do not require
parental consent for minors have begun to see adolescents that may travel
hundreds of miles to seek an abortion.
- ¡@
- Mandatory waiting periods
- Mandatory waiting periods mandate by law that the woman seeking to
terminate a pregnancy must first, in person, receive specific information
about the pregnancy and pregnancy alternatives.
- In spite of the fact that these laws typically only mandate a short
24-hour waiting period, they have the effect of increasing the percentage
of second trimester abortions in states with these laws.
Special Concerns:
¡@
- Advances in neonatal medicine with improved fetal survival very early
in gestation have fueled the abortion debate in the past 2 decades,
overshadowing the continued cultural debate on beginning of life.
- Recently, the progress in using fetal tissue, fetal stem cells, or
even discarded embryos for research and medical treatments has kept the
debate both vocal and contentious. These therapies may be indicated in the
treatment of diabetes, Parkinson disease, kidney disease, and cartilage
diseases, among others.
- Current national regulations prohibit most fetal tissue research, but
the National Institute of Health (NIH) revealed late in the year 2000 that
it will allow stem cell research.
- Many world cultures place a premium on male children, and reports of
selective abortion of female fetuses have continued to surface.
- Most abortion providers are obstetricians and gynecologists. However,
providers from a variety of backgrounds (family practitioners, nurses) can
be taught to perform abortions safely. Physicians generally are receptive
to the concept of legal abortions being available in the US. Epidemiologic
research shows those most receptive tend to be non-Catholic and trained in
a residency program where abortion observation was a requirement.
- Keeping abortions safe, legal, and rare are the goals of abortion
providers.
- As providers have decreased in number, women are traveling farther to
obtain abortions, presenting later in pregnancy, and are unable to obtain
services if they are poor and live in most rural areas.
- Posttraumatic stress has been reported in abortion workers exposed to
violent abortion protests at their clinics.
- ¡@
|
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|
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