HOW TO TREAT 25
ausdoc . com . au 6 DECEMBER 2024
HOW TO TREAT 25
a plastic or metal cannula attached to a vacuum source . The aspiration may be with a portable , hand-held , manual vacuum aspiration ( MVA ) or with electric vacuum aspiration ( EVA ) using an electric pump . Both procedures require cervical dilation . The three options for pain relief during early surgical abortion are local anaesthetic ( paracervical block ) plus NSAIDs ; procedural sedation with local anaesthesia ( paracervical block ) plus NSAIDs ; and deep sedation or general anaesthesia plus NSAIDs .
Vacuum aspiration is effective and safe , with success rates above 98 % and major complication rates below 1 %. 31 Complications include incomplete evacuation , cervical or uterine injury ( such as perforation or tearing ), anaesthetic complications , infection , haemorrhage , haematometra and failed abortion .
Discuss the risks and side effects with the patient before the procedure .
Cervical priming
RANZCOG recommends cervical priming with misoprostol before surgical abortion . 16 This reduces both the need for additional cervical dilatation and the risk of incomplete abortion compared with placebo . 32 Note that misoprostol is associated with nausea and abdominal pain / cramping .
Antibiotic prophylaxis
Prescribe antibiotic prophylaxis per local policy for all women before surgical abortion . The Therapeutic Guidelines recommendations appear in box 7 . 27
Electric and manual vacuum aspiration
Electric vacuum aspiration is the most common method in Australia . The procedure is usually performed under sedation or general anaesthetic . The cervix is dilatated and a rigid or flexible cannula inserted to the top of the uterine cavity . Suction is applied as the operator moves the catheter across the top and sides of the cavity . The products of conception are removed into the pump ’ s receptacle ( see figure 7 ). The procedure takes about 10 minutes .
Manual vacuum evacuation , under local anaesthesia or very light sedation , can be performed up until 12 weeks ’ gestation . The cervix is gently dilated to approximately 7mm and a soft flexible plastic catheter inserted to the fundus . A syringe is used to generate suction to remove the products of conception . Bleeding stops once the uterus is emptied . This procedure generally requires less cervical dilation than EVA and is equally safe and efficacious . 33 The
Table 3 . Complications and risks of abortion Complication / risk Medical abortion Surgical abortion
Continuing pregnancy |
1 – 2 in 100 |
1 in 1000 |
|
|
Higher in pregnancies < 7 weeks |
Need for further intervention to complete the procedure
Table 4 . Management options for RPOC Management Advantages Disadvantages Expectant management
Medical management with misoprostol 800μg ( 4 x 200μg tablets ) buccal followed by a repeat dose of 400μg ( 2 x 200μg tablets ) four hours later if required .
Requires analgesia and anti-emetics Surgical
operator usually examines the tissue under the microscope to confirm the presence of multiple white chorionic villi . This confirms pregnancy tissue has been removed from the uterine cavity and rules out an ectopic pregnancy .
Individualise analgesia based on patient preference , clinical need , clinician capabilities , local policies and / or contextual factors . 14
< 14 weeks : 70 in 1000 > 14 weeks : 13 in 100
Allows for spontaneous passage of RPOC Avoids potential surgical and anaesthetic risks
Avoids potential surgical and anaesthetic risks with the option for treatment at home if desired and suitable
Leads to rapid resolution of bleeding and pain
POST ABORTION CONTRACEPTION
PROVISION of information on effective reversible contraception after abortion is key to integrated abortion care . Ovulation , on average , occurs three weeks after an abortion , but possibly as early as eight days , and around half of women resume sexual
34 , 35 activity within two weeks . Immediate provision of highly
< 14 weeks : 35 in 1000 > 14 weeks : 3 in 100
Infection * Less than 1 in 100 Less than 1 in 100
Severe bleeding requiring transfusion < 20 weeks : less than 1 in 1000 > 20 weeks : 4 in 1000
Cervical injury from dilation and manipulation ** – 1 in 100 Uterine perforation – 1 – 4 in 1000 Uterine rupture
Less than 1 in 1000 for second-trimester medical abortions ***
< 20 weeks : less than 1 in 1000 > 20 weeks : 4 in 1000
* Upper genital tract infection of varying degrees of severity is unlikely but may occur after abortion and is usually associated with pre-existing infection . Infection after surgical abortion is reduced with use of prophylactic antibiotics . ** Cervical injury is less likely if cervical preparation is undertaken in line with best practice . *** The presence of a uterine scar ( eg , following a previous caesarean ) is a risk factor . RANZCOG guidelines state use of medical abortion can be up to 10 weeks or 70 days . 14
Source : RCOG 2022 24 Reproduced from : Royal College of Obstetricians and Gynaecologists . Best practice in abortion care . London : RCOG , March 2022 , with the permission of the college .
Figure 6 . Retained products of conception .
–
Bleeding and pain may continue for several weeks The timeframe for resolution is unpredictable
Bleeding and pain may continue for days or weeks and the timeframe for resolution is unpredictable Side effects of misoprostol include nausea , vomiting , diarrhoea and chills
Side effects of surgery include anaesthetic risk , risk of uterine perforation , infection and scarring
effective contraception reduces the risk of a repeat unintended pregnancy . 35-38
Discussing the reversible but most effective methods , such as implants and intrauterine devices , is encouraged , but take care not to pressure women to make a choice . 39
The UK Faculty of Sexual and Reproductive Healthcare recommendations appear in table 5 . 39
Box 7 . Before surgical abortion
• Investigate patients for bacterial vaginosis and STIs and treat appropriately to prevent postprocedural infective complications , ideally complete treatment before the procedure .
• Antibiotic prophylaxis is not indicated if the patient has been investigated and treated appropriately for an STI or bacterial vaginosis before the procedure .
• In those not appropriately investigated before surgical termination use : — Doxycycline 100mg orally ,
60 minutes before the procedure , then 200mg orally , 90 minutes after the procedure . OR
— Doxycycline 400mg orally , with food , 10-12 hours before the procedure .
— An alternative regimen is :
• Metronidazole 2g orally , within 120 minutes before the procedure . PLUS Azithromycin 1g orally , within 120 minutes before the procedure for those at higher risk of infection .
• Those at higher risk include : — Aged 20 or younger . — Three or more sexual partners in the past 12 months .
— A history of pelvic inflammatory disease or an STI in the past 10 years . — Clinical evidence of cervicitis . — A sexual partner who has other partners , a history of STI , or current or recent STI symptoms .
• Some centres use a single preoperative dose of azithromycin ( as monotherapy ) for prophylaxis for surgical termination of pregnancy ; there are few published data on this approach .
Source : Therapeutic Guidelines 2023 27
CHALLENGES
DESPITE recent changes in abortion decriminalisation ( see figure 1 ), there is a huge disparity in access to abortion , with great swathes of rural and remote Australia considered abortion deserts . 40 Young women in regional and remote areas are more likely to carry an unintended pregnancy to term compared with women in metropolitan areas . 1 , 2
Medicare rebates for both medical and surgical abortions and associated complications are low , and not all public hospitals have clear pathways for these patients . A woman turned away from her GP or public hospital may feel disempowered PAGE 27
Figure 7 . Vacuum aspiration .