Surgical termination of pregnancy

Dr.Z Allameh MD

SUCTION CURETTAGE

     Suction curettage is the most commonly used method of pregnancy termination in the United States.

The procedure is usually performed between the 7th and 13th menstrual weeks.

suction procedures performed after the 13th gestational week are termed dilatation and extraction (D&E). According to the Centers for Disease Control, over 96 percent of abortions in the United States in 2001 were performed by suction curettage or D&E .

The procedure does not require hospitalization except in women with medical or surgical disorders that place them at higher surgical risk.

Cervical Dilatation

In pregnancies 7 to 13 weeks, the endocervical canal can either be dilated  manually or  osmotic dilators or  prostaglandins can be used to gradually dilate the cervix .

Cervical Dilatation

 Mechanical: – Done at Time of D+E – Convenient for Patient – May be Uncomfortable – Increased Risk of Perforation (Compared with Osmotic Dilators)

Cervical Dilatation

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

Suction Curettage

 First trimester suction curettage is the safest method for surgical pregnancy termination.  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

Minisuction Introduced in 1972 by Karman and Potts

Uterine evacuation

  – – – – Uterine evacuation is an integral part of obstetric and gynecologic care, not only for elective pregnancy termination , but also in the management of spontaneous abortion intrauterine fetal demise retained products of conception gestational trophoblastic neoplasia The choice of technique for uterine evacuation depends more upon uterine volume and operator experience than the underlying indication for the procedure.

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)

Additional 2nd / 3rd Trimester Methods

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

second trimester pregnancy termination:

 There are three general methods of second trimester pregnancy termination:  Dilatation and extraction  Administration of systemic abortifacients  Intrauterine instillation of abortifacients

SYSTEMIC ABORTIFACIENTS

  (eg, prostaglandin E2, intramuscularly ( misoprostol ) are usually given intravaginally; rarely, they are given carboprost tromethamine ).

Fetacidal agents are recommended in conjunction with these procedures to avoid the possibility of transient fetal survival. Options include intraamniotic instillation of saline (60 mL of a 23 percent solution), intracardiac injection of about 5 mEq potassium chloride , or injection of 1 to 1.5 mg digoxin into the fetus or amniotic sac [ 16 ].

Prostaglandin E2

     suppositories (20 mg) can be used for second trimester pregnancy termination.

A suppository is placed in the posterior fornix at 3 to 5 hour intervals until abortion occurs . The dose may be adjusted downward to 5 mg based upon a more advanced gestational age (more sensitive to prostaglandins). Patients are often premedicated with acetaminophen , compazine which invariably occur.

, and diphenoxylate to minimize fever, nausea, vomiting, and diarrhea, The mean time to abortion is 13.4 hours and 90 percent of women abort by 24 hours.

 Intravenous oxytocin may be used concomitantly with PGE2 to hasten delivery, but poses additional risks of hyperstimulation and uterine rupture Therefore, we recommend oxytocin not be administered until at least . two hours after the last dose of PG.

Misoprostol

 PGE1 analog misoprostol :  (200 to 600 mcg per vaginam every 12 hours or 400 mcg every 3 to 6 hours [up to five doses])  leads to contractions and successful abortion in 70 to 100 percent of cases .

 Higher doses of misoprostol are associated with increased rates of side effects and complications (eg, fever, nausea, vomiting, diarrhea, uterine rupture).

Misoprostol with mifepristone

  Induction of contractions is more effective with a combined mifepristone misoprostol .

The mean time to abortion ranges from 6 to 9 hours. Completion of abortion within 24 hours occurs in 90 to 97 percent of patients. Analgesic requirements are also lower  Misoprostol vaginally .

can be administered orally or An example of an effective regimen is to four doses).

mifepristone (200 mg) administered 36 to 48 hours before misoprostol (800 mcg per vaginam followed by 400 mcg orally or intravaginally every 3 hours up

Carboprost tromethamine

 a prostaglandin similar to PGF2 alpha except for the addition of a methyl group at the C-15 position. This substitution produces a longer duration of activity. The dose for inducing second trimester abortion is 250 mcg intramuscularly to start, 250 mcg at 1.5 to 3.5 hour intervals depending on uterine response; a 500 mcg dose may be given if uterine response is not adequate after several 250 mcg doses; the maximum total dose administered should not exceed 12 mg. The mean time to abortion is 15 to 17 hours and 80 percent of women abort within 24 hours [ 31 ].

High-dose oxytocin

   Oxytocin at high doses can also be used as an abortifacient and is associated with less fever and fewer gastrointestinal side effects than prostaglandins.

The initial dose is 50 U in 500 mL of 5 percent dextrose/normal saline over three hours .

After an hour of rest, the infusion is repeated using 60 U of oxytocin. This regimen is continued up to a maximum of 300 U oxytocin in 500 mL solution (ie, 1667 mU/min).

INTRAUTERINE INSTILLATION OF ABORTIFACIENT AGENTS

The two major agents employed are:  

PGF2 alpha hypertonic saline

Saline infusion

    hypertonic saline has the advantage of causing fetal death, but the duration of the procedure can be long.

Osmotic dilators should be placed at least 12 hours prior to the procedure to facilitate cervical dilatation and shorten the infusion to abortion time. This is important to intramyometrial avoid intravascular infusion of the hypertonic saline, which can result in life-threatening hypernatremia , myometrial necrosis , or DIC .

or Two hundred milliliters of 20 percent saline solution (40 grams) are infused by gravity and the needle removed.

Prostaglandin F2 alpha infusion

     PGF2 alpha has the advantage of speed, but the fetus may be born alive and maternal side effects (eg, vomiting, diarrhea, incomplete abortion) are common he procedure is the same except 2.5 to 5 mg PGF2 alpha is infused as a test dose, followed by 17.5 to 35 mg if the test dose is tolerated. One-quarter of women will require a second injection to maintain labor and complete the procedure. Alternatively, carboprost tromethamine (2 mg) can be instilled

Complications

 Bleeding  Infection  Retained POC  “Missed Abortion”  Perforation – low risk, high risk variants  Hematometra  Undiagnosed Ectopic Pregnancy

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 (HCG May Still Be Positive)  If Tissue Sent for Histology – Check Report