Surgical Abortion

1
Surgical Abortion

• David Blair Toub, M.D.
• Dept. of Obstetrics and Gynecology
• Pennsylvania Hospital

2
Introduction

• 1973 Roe v. Wade Trimester Approach
• Number of Abortions Stable or Decreasing
• 1/3 of Women 15-44 Undergo Abortion
• Abortion 10-11x Safer than Continuing Pregnancy,
  2x Safer than PCN Injection
• 91 1st TM, 9 2nd TM, .01 3rd TM
• 1965 Illegal Ab 17 of Maternal Deaths

3
Patient Evaluation

• Counseling, ACA (in PA)
• Pregnancy Test
• History LMP, Medical Risk Factors
• PEx Confirmation of Gestational Age
• TRh, Hct
• U/S if Significant Discrepancy on Exam or
  Recent Vaginal Bleeding

4
Techniques

• 14 Weeks
• Suction Curettage
• Medical Abortion ( 56 days LMP)
• 14-24 Weeks and Beyond
• Dilatation and Evacuation (DE)
• Intact DE (DX)
• Labor Induction Methods (Prostaglandins)
• Amnioinfusion (HS, Urea, Prostaglandins)

5
Cervical Dilatation

• Mechanical
• Done at Time of DE
• Convenient for Patient
• May be Uncomfortable
• Increased Risk of Perforation (Compared
  with Osmotic Dilators)

6
Cervical Dilatation

• Osmotic Dilators (e.g. Laminaria)
• Increased Time, Inconvenience
• Less Pain, Decreases Perforation Risk
• Examples
• Laminaria japonicum, L. digitatum
• Dilapan
• Lamicel

Synthetic
7
Suction Curettage

• Office, Clinic or Hospital Setting
• Local (Paracervical Block) or IV Sedation
• General Anaesthesia Increases Risk
• Prophylactic Doxycycline Decreases Endometriitis
  Risk
• Rigid or Osmotic Dilators Used
• No-Touch Technique

8
Dilatation and Evacuation

• Avoid Mechanical Dilatation if Feasible
• Requires Additional Experience and Training
• Safer than Amnioinfusion in Most Cases when
  Performed by Experienced Operator
• Less Emotionally Traumatic for Most Patients
  (Compared With Labor Induction)

9
Additional 2nd / 3rd Trimester Methods

• Labor Induction
• PGE Vaginal Suppositories
• Amnioinfusion (Hypertonic Saline, Urea,
  Prostaglandins)
• Oxytocin
• DX
• Hysterotomy (Outmoded Should be Abandoned)

10
Complications

• Bleeding
• Infection
• Retained POC
• Missed Abortion
• Perforation low risk, high risk variants
• Hematometra (postabortal, or re-do syndrome)
• Undiagnosed Ectopic Pregnancy

11
Postabortion Management

• Bleeding May Occur for 2 Days 2 Weeks
• Appropriate Contraception May Commence
  Immediately or Soon Thereafter
• Significant Pain, Bleeding or Fevers Should
  Prompt Evaluation
• Patients Should Follow-up in 2-4 Weeks (UCG May
  Still Be Positive)
• If Tissue Sent for Histology Check Report

12
Summary

• Surgical Abortion Is a Safe Procedure
• Complications,While Infrequent, May Be Serious
• Since Roe, There Has Been a Dramatic Reduction in
  Maternal Mortality From Illegal Abortion
  Procedures
• The Need for Abortion May Be Reduced by
  Appropriate Contraception