Method for Induced Abortion
OBSTETRICS & GYNECOLOGY
Volume 104, Number 1, July 2004
R3 박영미
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First trimester abortion
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Vacuum curettage
Complications of vacuum curettage abortion
Medical abortion in the first trimester
Complications of early medical abortion
Second trimester abortion
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Dilation and evacuation
Complications of dilation and evacuation
Labor induction methods
Fetal death in utero
Selective fetal reduction
Methods for abortion in the first trimester
Vacuum curettage
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The most common method of abortion in the
United States
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Before 13 weeks : suction or vacuum curettage
After 13 weeks : dilation and evacuation (D&E)
Antibiotics
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Marked reduction in postabortal infection
Tetracycline, doxycycline, minocycline
: broad spectrum of antimicrobial effect
: oral absorption
Vacuum curettage
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Pain relief
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Paracervical block
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Nonsteroidal anti-inflammatory drugs
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10-20mL of 1% lidocaine
Deep injection into the cervical stroma at multiple site
Addition of 2-4 units of vasopressin to the anesthetic
solution
-> reduces blood loss
-> prevent postabortal uterine atony
Preoperative administration -> modest reduction in pain
Conscious sedation
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Intravenous midazolam 1-3mg and fentanyl 50-100ug
Vacuum curettage
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The necessary dilatation of the cervix
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Mechanical cervical dilation with tapered cervical
dilators
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Hygroscopic dilators – laminaria
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Reduces risk for perforation or cervical laceration
Prostaglandins – misoprostol
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400ug vaginal dose, 3-4 hours before procedure
Minimal side effects, little expense
Vacuum curettage
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For complete abortion and early diagnosis of ectopic
pregnancy
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Preoperative ultrasonography
Careful inspection of the aborted tissue
Follow up with serial hCG titer
Manual vacuum aspiration
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6mm flexible cannula and modifed 60ml syringe
Effective in pregnancies as early as 3 weeks
As safe and effective as electric vacuum through 10weeks of
pregnancy
Used to treat Incomplete spontaneous abortion in office or
emergency room
Complications of vacuum curettage
- Immediate complications 
Excessive bleeding
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Cause
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Incomplete abortion
Pregnancy of more advanced gestational age than
expected
Uterine atony
Low-lying implantation
Uterine injury
Management
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Misoprostol 1000ug, rectally or buccally
30ml balloon Foley catheter : inserted into the uterine
cavity, inflated with 50-60ml of sterile saline
Complications of vacuum curettage
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Persistent postabortal bleeding
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Cause
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Retained tissue or clot (hematometra)
Trauma
Management
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Prompt surgical intervention
: laparoscopy
: repeat vacuum curettage
Selective uterine artery embolization
Rarely, hysterectomy
Complications of vacuum curettage
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Uterine perforation
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Risk
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1 in 1000 first trimester abortion
Increases with gestational age, parous women
Perforations at the junction of the cervix and lower
uterine segment
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lacerate the ascending branch of the uterine artery within
the broad ligament
severe pain, broad ligament hematoma, intra-abdominal
bleeding
laparotomy to ligate the severed vessels and repair the
uterine injury
Complications of vacuum curettage
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Low cervical perforation
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Injure the descending branch of the uterine artery within
the cardinal ligaments
The bleeding is external, through the cervical canal
-> subside temporarily as the artery goes into spasm
-> no intra-abdominal bleeding
Management
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Hysterectomy
Arteriography and selective uterine artery embolization
Complications of vacuum curettage
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Hematometra
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Symptom & sign
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Lower abdominal pain
: increasing intensity in the hour after an abortion
Large, globular, tense uterus
Management
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Immediate re-evacuation
Pretreatment with ergot 0.1mg IM, the use of oxytocin
Addition of vasopressin to the paracervical anesthetic
Complications of vacuum curettage
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Early detection of ectopic pregnancy,
incomplete abortion
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Immediate fresh examination of the specimen
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If no chorionic tissue
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The gestational sac, chorionic villi are easily visualized
Frozen section : to rule out ectopic pregnancy
A few villi but no gestational sac
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Retained pregnancy tissue in the uterus
Complications of vacuum curettage
- Later complication 
Retained tissue or clot & early endometritis
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Symptom & sign
① No response to simple analgesics
② Excessive and prolonged bleeding
③ Severe pain or fever
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Management
① Broad spectrum oral antibiotics
② Vacuum evacuation in the clinic
Complications of vacuum curettage
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Advanced sepsis
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Symptom & sign
① generalized abdominal tenderness & guarding
② tachycardia
③ significant fever
④ prostration
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Management
① immediate hospital care
② prompt uterine evacuation
③ high dose combinations of antibiotics
④ intensive care for cardiovascular support with
fluid resuscitation, monitoring with central lines
Medical abortion in the first trimester
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Three highly effective regimens
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Mifeprostone (RU-486) + misoprostol
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Methortexate + misoprostol
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Misoprostol alone
Medical abortion in the first trimester
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Mifepristone + prostaglandin analogue
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The first highly effective means
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Mifeprostone
: analogue of norethindrone
: high affinity for progesterone receptors
-> act as a false transmitter and blocks natural
progesterone
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Effectiveness
: increased to approximately 95% by the addition of lowdose prostaglandin
Medical abortion in the first trimester
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The U.S FDA
: Mifepristone 600mg orally, followed by
misoprostol 400ug orally 2days later
: Use is limited to the first 49days of amenorrhea
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Evidence-based protocol
: Mifeprostone 200mg orally, followed by selfadministered vaginal misoprostol 800ug at home
: Vaginal misoprostol
-> lower peak serum level, more sustained blood level
-> administered at 24,48,72 hours after the mifeprisotne
(no difference in efficacy)
: The effective gestational age can be safely
extended from 49 to 63 days of amenorrhea
Medical abortion in the first trimester
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Methotrexate + misoprostol
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Regimen
: Methotrexate 50mg/m2 single intramuscular dose,
followed vaginal imsoprostol 800ug at 3-7days
: Expulsion of the gestational sac has not occurred
-> Misoprostol is repeated in 24hours
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Effectiveness
: 53% aborted after the first dose of misoprostol,
additional 15% after the second dose,
total of 92% by 35 days
Medical abortion in the first trimester
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Misoprostol alone
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Regimen
: Vaginal misoprostol 800ug initially, followed by
800ug at 24 hours, if needed
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Effectiveness
: Complete abortion rate : 92%
: As effective as mifepristone/misoprostol and
much less expensive
Medical abortion in the first trimester
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Vaginal ultrasonography after start of medical abortion
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Performed to ensure that the uterine cavity is empty
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Intact gestation with cardiac echoes 2weeks after start of
medication -> failed abortion
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Gestational sac is present but no fetal cardiac activity
-> wait for expulsion, take more misoprostol
-> have surgical evacuation
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If medical abortion fails, surgical termination is advisable
: possible risk for fetal malformation from misoprostol and
methotrexate
Complications of early medical abortion
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Persistent bleeding
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The duration of bleeding or spotting
: 9-16 days after mifeprisotne/ misoprostol
: up to 8% as long as 30 days
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Need for curettage is related to gestational age
( 200mg mifepristone + 800ug vaginal misoprostol )
: 2.1 % at 49 days or less
: 3.1% at 50-56 days
: 5.1% at 57-63 days
Complications of early medical abortion
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Hausknecht : the complications report
( November 2000 to May 2002, 80,000 women who received
mifepristone )
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Vacuum curettage for bleeding or for persistent
non-viable pregnancy
A death of a woman with a ruptured ectopic
pregnancy
Infection (0.013%)
Sepsis with adult respiratory distress syndrome
Coronary artery thrombosis
Second-trimester abortion
Dilation and Evacuation
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Dilation of the cervix
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Laminaria method
: Prevailed because of
① concerns about cervical injury for mechanical dilation
② the greater technical ease of second-trimester
procedures
: More laminaria are used as gestational age
① After 20 weeks -> 10 more laminaria
② 10-13 laminaria at 20-23 weeks
-> greater than 14mm by the next day
Dilation and Evacuation
: Method
① Initial set of 2-3 medium laminaria
② 4 or more new laminaria to the first set 6 hours later
③ Dilatations of 18 mm or more by the next day in 92%
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Misoprostol treatment
: Replace laminaria in the early second trimester
: method
①
②
③
④
600ug administered buccally
2-4 hours before procedure
At 14-16 weeks of gestation
Sufficient dilation to allow insertion of a 14mm vacuum
curette
Dilation and Evacuation
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Instrument technique
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At 13-15 weeks
: Readily evacuation with vacuum cannula of 12-14mm
-> Ovum forceps (as an adjunct)
: The surgeon may prefer to use forceps as the primary and
use the vacuum only the end of the procedure
Through 16 weeks
: The 16mm cannula system, vacuum curette alone
At 17 weeks and beyond
: Even large diameter aspiration system is not adequate by
itself
: Forceps evacuation ,the primary method and
vacuum, the secondary method
Dilation and Evacuation
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Decrease of blood loss
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Intravenous oxytocin
: 40 or more units per 1000mL
: During the procedure or begun after uterine
evacuation is completed
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Vasopressin
: Two to four units mixed with the local anesthetic
solution
: Diluted with 10-20mL sterile saline
: Injected into the cervix
Dilation and Evacuation
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The patients
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The obese patient
: Increased procedure difficulty, procedure time,
blood loss with increasing body mass index
: BMI greater than 30
-> 20% longer time for procedure
-> 40% more difficult by the operator
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Placenta previa
: Not a contraindication to laminaria with D&E
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Previous cesarean delivery
: Not increase perioperative risk of D&E
Dilation and Evacuation
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Intact D&E procedure
① 2 or more days of laminaria treatment to obtain
wide dilation of the cervix
② Assisted breech delivery of the trunk of the fetus,
under ultrasound guidance
③ The calvarium is decompressed
④ Delivered with the fetus otherwise intact
Dilation and Evacuation
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Combination D&E technique
① After multistage laminaria treatment over 2 or
more days
② 1.5-2.0mg of digoxin are injected into the fetus
under ultrasound guidance
③ The membranes are ruptured
④ Intravenous oxytocin is started (167mU/min)
⑤ Assisted delivery is performed after a few hours
Complications of dilation and evacuation
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The same as first-trimester surgical abortion
: no more frequent when laminaria are used
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Perforation
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0.32% for D&E at 13-20 weeks
: but, 0.05% with first-trimester vacuum curettage
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Lead to bowel injury and require laparotomy
: but, safely managed with laparoscopy with first trimester
Complications of dilation and evacuation
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Hemorrhage
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Caused by incomplete procedure, uterine atony,
trauma (as in the first trimester)
At the later gestational ages, risk for DIC increases
: 8 / 100,000 first trimester
: 191 / 100,000 second trimester
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Amniotic fluid embolism
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Rare and less frequent with vacuum curettage and
D&E than with labor induction technique
Must be considered when a patient exhibits
respiratory difficulty while undergoing an abortion
Labor induction methods
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Hypertonic solution
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Intra-amniotic hypertonic saline
: The first effective labor induction method for
second trimester abortion
: Hypertonic urea
: Potentially safer agent
–> intravascular injection would not be harmful
: Intra-amniotic dose of 80-90g is effective
: injection-to-abortion intervals are prolonged
Labor induction methods
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Intra-amniotic prostaglandin F²α
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Effective, but often required a second injection
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Associate with
: Transient fetal survival in some cases
: Significant gastrointestinal side effects
: Failure of the primary technique
: Risk for cervical rupture, in the primigravida
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Overnight treatment with laminaria tents reduced
: The mean time from instillation to abortion from
29 hours to 14 hours
: The need for second injections
Labor induction methods
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Systemic prostaglandins
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Three different prostaglandis
① Dinoprostone (prostaglandin E2)
② Carboprost tromethamine (Hemabate)
③ Misoprostol
Labor induction methods
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Dinoprostone
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20mg vaginal suppository every 3 hours
The mean time to abortion : 13.4 hours
90% aborting by 24 hours
Reducing the dinoprostone to 10mg at 6 hour intervals
combined with high-dose oxytocin
-> the same efficacy but fewer gastrointestinal side
effects
Carboprost tromethamine
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250ug every 2 hours intramuscular injection
The mean time to abortion : 15-17 hours
About 80% aborting by 24 hours
Labor induction methods
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Misoprostol
The ideal dose and interval is still under
investigation
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200ug vaginally every 12 hours
: Equally effective with dinoprostone 20mg every 3 hours
: Fewer side effects (vomiting, diarrhea, fever)
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200ug, 400ug, 600ug at 12 hour intervals
: Abortion by 48 hours to be 70.6%, 82%, 96%
: Vomiting, diarrhea, fever increased with the dose
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High doses and short intervals
: increase risk for uterine rupture
: 3 case of uterine rupture with previous cesarean delivery
Labor induction methods
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Mifepristone and prostaglandins
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Method
① Mifepristone is administered
② 3 days later the patient is hospitalized for
prostaglandin treatment
(gemeprost, misoprostol)
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Typical intervals from start of the prostaglandin to
abortion : 7-9 hours
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Recent studies use misoprostol more often
: low cost and high efficacy
Labor induction methods
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High dose oxytocin
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Method
① 50 units in 500mL of 5% dextrose and normal
saline given over 3 hour period
② After 1 hour rest
③ Oxytocin infusion is repeated, adding 50
additional units to the next 500mL infusuon,
continuing with 3 hour
④ And 1 hour of rest
⑤ Repeat until the patient aborts or a final solution
of 300 units of oxytocin in 500mL is reached
Labor induction methods
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Use of feticidal agents
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Feticidal agents
: reduces the induction to abortion interval and improve
efficacy
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Method
① 60mL of 23% saline solution
② Intra-amniotic urea
③ Ultrasound guided fetal intra-cardiac injection
of potassium chloride
④ 1.0-1.5mg of digoxin given
: ultrasound-directed intrafetal injection
: into the amniotic sac
Labor induction methods
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Hysterotomy and hysterectomy
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Little indication as the primary method for abortion
: because the risk of major complications and
death is greater than for any other technique
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The only need for hysterotomy in failed abortion
: uterine anomaly
Fetal death in utero
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Vaginal Prostaglandine E2
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Highly effective after fetal death
Producing fetal abortion in about 10 hours
Side effect : vomiting, diarrhea, fever
Beyond 24 weeks, the full dose of 20mg should not be used
-> uterine rupture
Misoprostol
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Increasingly used to manage fetal death
Vaginal 200ug at 12 hour intervals
Safe and effective in the second trimester
The dose should be reduced in the third trimester
 Initial dose of 25ug at 6 hour intervals
 Increasing to a maximum of 50ug at 6 hour intervals
Fetal death in utero
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Hemorrhage begun after abortion
-> DIC should be suspected
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If the uterus appears intact on manual exploration
① intramuscular carboprost, immediately
: stop the bleeding, even in the presence of DIC
: reduce the need for blood products
② misoprostol 1000ug rectally
: used successfully for postpartum hemorrhage
Selective fetal reduction
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Method
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Indication
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US guided intra-cardiac injection of potassium
Multiple pregnancy, to avoid the risk of extreme prematurity
for the surviving pregnancies
One anomalous fetus of multifetal gestation
Contraindication
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Monoamniotic twins
Twin-twin transfusion syndrome
-> embolic phenomena
-> infarction in the surviving twin
Selective fetal reduction
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Fetal loss
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Higher with higher starting numbers of gestations
① Starting number > 6 -> 15.4%
② Starting numbers =2 -> 6.2%
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Higher if more fetuses were left intact
① Finishing number = 3 -> 18.4%
② Finishing number = 1 -> 6.7%