GUIDELINESGuidelines for first-trimester abortion have been published by the WHO,the National Abortion Federation, the Society of Family Planning,and the Royal College of Obstetricians and Gynaecologists.
The recommendations in this article are generally concordant with these guidelines.
CONCLUSIONS AND RECOMMENDATIONSThe patient described in the vignette, with a pregnancy at 9 weeks of gestation, should be offered the choice of a medical or surgical abortion. Both are safe with respect to short- and long-term sequelae. Medical abortion is associated with more pain and bleeding and a higher risk of incomplete abortion, whereas the risk of rare complications requiring major surgery is higher after surgical approaches. Antibiotic prophylaxis has well-established benefits in suction curettage and may also be useful in medical abortion, although this is less certain. The patient can be reassured that the best evidence indicates no long-term psychological harm, impairment of future fertility, or increased risk of breast cancer associated with abortion. The insertion of an IUD at the time of the abortion should be recommended to prevent another unintended pregnancy.
Medical AbortionMedical abortion has evolved considerably since mifepristone was first licensed for use in Europe in the early 1990s. Whereas initial results with mifepristone alone were disappointing, effectiveness improved dramatically when a prostaglandin or prostaglandin analogue was administered 1 or 2 days after mifepristone. Today, the most commonly used prostaglandin is the prostaglandin E analogue misoprostol; its advantages include stability at room temperature (which facilitates short-term storage), possible administration by several routes (vaginal, buccal, sublingual, and oral), and low cost. Misoprostol (and other prostaglandin analogues) can be used alone as abortifacients but are less effective than mifepristone plus misoprostol. Similarly, in areas where mifepristone is still unavailable, such as Canada, methotrexate followed by misoprostol can be used, although this regimen is not as effective as the mifepristone–misoprostol regimen.
Initially, misoprostol at a dose of 400 μg was administered orally, and this continues to be the preferred route of administration in France, although in the United Kingdom and United States, vaginal administration of misoprostol at a dose of 400 to 800 μg was shown to be more effective, particularly at gestational ages of more than 7 weeks. If needed, the administration of a second dose of misoprostol, either vaginally or orally according to the amount of vaginal bleeding, further increased the likelihood of complete abortion.Alternative routes of misoprostol administration, including sublingualand buccal, have been shown to be as effective as vaginal administration, although side effects of prostaglandin, which are mainly gastrointestinal, are more frequent. However, many women prefer the convenience of these approaches, which do not involve vaginal administration of tablets.
The Food and Drug Administration–approved dose of mifepristone is 600 mg, but in a randomized trial, the effectiveness of a 200-mg dose was similar to that of a 600-mg dose for medical abortion at all gestational ages. An initial vaginal dose of 800 μg of misoprostol is widely used; although a lower dose may be sufficient in many women and is associated with fewer side effects, there is no effective way to predict which women will require the higher dose.
Some studies have indicated that the interval between administration of these two medications can be reduced to 24 hours or less, but most clinics wait 24 to 48 hours after mifepristone administration to administer misoprostol. Once medications have been administered, abortion can be completed at home. The safety and efficacy of medical abortion completed at home are similar to the safety and efficacy of medical abortion in the clinic, although ready access to emergency facilities is still required. This is now the usual approach to medical abortion in the United States and is increasingly common in Europe.
Surgical ApproachesSince the 1970s, suction curettage, also known as vacuum aspiration, has been the standard method of abortion in the United States, where more than 80% of abortions in the first trimester are performed surgically. Vacuum aspiration is a safe procedure that is associated with low rates (<1%) of serious complications (e.g., uterine perforation) and of retained products of conception. Preparation with misoprostol is an effective means of softening and dilating the cervix. Whether this approach reduces morbidity is not yet established, although the use of osmotic dilators (Laminaria digitata or L. japonica) has been associated with significantly lower rates of uterine perforation and cervical injury, as compared with no cervical preparation. Given the rarity of these complications, cervical preparation is not routinely performed before vacuum aspiration, although a recently updated guideline recommends such preparation in all women who are undergoing abortion.
Local anesthesia (usually with lidocaine) is customary for vacuum aspiration in the United States, since large case series suggest that hemorrhage, cervical injury, and uterine perforation occur more frequently when general anesthesia is used. Either electric or manual vacuum aspiration can be used, the latter with the use of a syringe with a valve and plunger that lock when the vacuum is created. The two techniques appear to have similar effectiveness and acceptability, although manual vacuum aspiration is preferentially used at earlier gestational ages, since the bulkier uterine contents after 9 weeks limit its efficacy. The uterine contents are aspirated with either a rigid or a flexible plastic cannula; the two types of cannulae have similar efficacy. Although a sharp metal curette has been used to check the completeness of the operation, there are no data to provide support for this practice. The aspirated tissue should be immediately inspected to confirm the presence of the trophoblast and to minimize the chance of an undetected ectopic pregnancy.
Deep sedation (with the use of a tranquilizer, narcotic, or both) or general anesthesia is used less often for first-trimester procedures than for second-trimester procedures. Oral analgesics, such as nonsteroidal antiinflammatory drugs, are commonly administered before the procedure. A paracervical block is widely used. Data are lacking to provide support for this practice, although less pain is reported with a paracervical block that is combined with intravenous sedation than with intravenous sedation alone.A supportive environment, including frequent explanation and reassurance by the medical and nursing staff, is known to decrease the perception of pain and the need for analgesia.
Comparison of Medical and Surgical AbortionMost abortion providers offer both medical and surgical options for abortion at up to 9 weeks of gestation. Few randomized trials have compared the two approaches.Trials in the United States and the United Kingdom (involving abortions at up to 13 weeks of gestation) showed that women found medical abortion less acceptable than surgical abortion. An earlier trial in Scotland showed equal rates of acceptability for medical and surgical abortion at up to 50 days of gestation, with a lower rate of acceptability for medical abortion at 50 to 63 days of gestation.A subsequent randomized trial comparing the two procedures late in the first trimester showed that women undergoing medical abortion were significantly, albeit modestly, less likely to say they would opt for the same method again (70% vs. 79%).
These results may be explained by the observations that in the trials comparing medical with surgical abortion, medical abortion resulted in more pain, more prolonged bleeding (up to 2 weeks after administration of misoprostol), and a slightly higher failure rate. At approximately 9 weeks of gestation, 2 to 5% of women undergoing medical abortion will require a repeat procedure to complete emptying of the uterus, as compared with 1% of women undergoing surgical evacuation. A registry-based study from Finland involving more than 4000 women likewise indicated that bleeding and incomplete abortion were more common with medical than with surgical abortion, although it also showed higher rates of rare complications requiring major surgery after surgical approaches;rates of infection and other serious complications were similar. Hemorrhage requiring blood transfusion is rare (occurring in 0.1% of women) after both medical and surgical abortion.
Although women value having a choice in the method of abortion, the factors that determine an individual woman's decision are not always clear. Some women prefer surgical methods that are simple, quick, and associated with a low risk of complications or failure. Others may favor medical methods because they do not involve surgical instrumentation and may appear to be more natural (i.e., more like a miscarriage).
Assessment before AbortionOnce the woman's choice to proceed with an abortion has been clearly established and written informed consent has been obtained, there is no need for further delay, which may only increase the risk of complications. Counseling should be offered only if the woman requests it or there is a perceived need for it. The blood-group rhesus type should be determined and Rh immune globulin should be administered in Rh-negative women. Cytologic screening of the cervix and screening for sexually transmitted diseases should be offered as appropriate. Ultrasonographic examination of the uterus is common, but it is not required routinely before a first-trimester abortion is performed.
Prevention of InfectionAntibiotic prophylaxis at the time of abortion significantly reduces the likelihood of infection after vacuum aspiration. A randomized, controlled trial showed that prophylaxis was more effective and less expensive than a screen-and-treat approach for chlamydia, gonorrhea, and bacterial vaginosis. Doxycycline is widely used, and the best evidence provides support for only a single dose for 24 hours of coverage, although some clinicians prefer presumptive treatment of chlamydia with doxycycline (usually at a dose of 200 mg daily for 7 days); a single 1-g dose of azithromycin can be used instead, but it is more expensive. In the United Kingdom, metronidazole is administered in addition to doxycycline or azithromycin at the time of either medical or surgical abortion, but there are no data to provide support for this routine practice.
Data from randomized, controlled trials of antibiotic prophylaxis with medical abortion are lacking. However, a large before-and-after study of clinics providing medical abortion showed a marked decline (93%) in the rate of serious infections after implementation of routine antibiotic prophylaxis and a change in the route of misoprostol administration from vaginal to buccal. It is increasingly common for antibiotic prophylaxis to be used at the time of abortion, whether medical or surgical.
Subsequent Health and Reproductive Risks.
Vibha - The Family Hospital follows all International guideline to carry out safe and legal abortion services in India