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Surgical Abortion

Surgical Abortion. Paula Bednarek, MD, MPH Assistant Professor Dept of Obstetrics and Gynecology Oregon Health & Science University. SCOPE OF THE PROBLEM. Worldwide: 100 million sex acts per day 175 million pregnancies per year 75 million unintended pregnancies per year United States

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Surgical Abortion

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  1. Surgical Abortion Paula Bednarek, MD, MPH Assistant Professor Dept of Obstetrics and Gynecology Oregon Health & Science University

  2. SCOPE OF THE PROBLEM • Worldwide: • 100 million sex acts per day • 175 million pregnancies per year • 75 million unintended pregnancies per year • United States • Highest rate of teen pregnancy in world • Half of pregnancies unintended

  3. Teenage pregnancy is more common in the United States than in most other industrialized countries

  4. Half of all pregnancies in the United States each year are unintended Intended pregnancies Unintended pregnancies Pregnancies (6.3 million)

  5. Rate of Abortion by Age Group 43% of women in the USA will have an abortion at some time in their life Source: Jones et al., 2002

  6. Abortions by Gestational Age(Weeks Since Last Menstrual Period) % of Abortions Weeks Source: Henshaw adjustments to Strauss et al., 2004 (2001 data)

  7. . . . account for roughly half of all unintended pregnancies The small proportion of women who do not use contraceptives . . . Women at risk of unintended pregnancy (42 million) Women experiencing unintended pregnancies (3 million)

  8. Any contraceptive method is better than none, . . . . . . but choice of method makes a difference % of users becoming pregnant within one year

  9. ABORTIONLegal Aspects • Abortion is protected by the U. S. Supreme Court decision Roe v. Wade decided in 1973. • Decision made in privacy with a women and her physician. • Based on the principle of maternal rights superseding the rights of the fetus.

  10. ABORTION • Viability = gestational age at which a fetus will survive outside of the womb albeit with artificial support. • Physicians have an ethical responsibility to provide information and appropriate referral for abortion or contraceptive services that a patient might request.

  11. ABORTION Technique • Discussion of the alternatives. Informed consent. Careful pelvic exam. • Ultrasound assessment of gestational age. Not yet the standard of care. Most large volume providers include as part of the abortion package. • Procedure depends on gestational age (stated from the first day of the last menstrual period) • Same technique used for managing unsuccessful pregnancies

  12. Suction abortion technique: <14 weeks gestational age • Anesthetic choices: • Paracervical block with local anesthetic. Oral or IV sedation may be used in addition. • General anesthetic used in more difficult 1st trimester procedures • Dilation of the cervix to allow passage of a suction cannula into the uterine cavity.

  13. Suction abortion technique: <14 weeks gestational age • Direct dilation with dilator <12-14 weeks • Laminaria for pregnancies >12-14 weeks gestation. Absorb moisture and swell to dilate the cervix. Misoprostol also effective. • Sterilized pieces of the seaweedLaminariajaponicum. • Dilapan (Synthetic sponge cervical dilator) • Mifepristone??

  14. Suction abortion technique: <14 weeks gestational age • Size of canulas in mm diameter used equals the gestational age in weeks • Suction is applied with an electric pump and the pregnancy is removed from the uterus. • Suctioning continues until uterus feels empty • Tissue carefully inspected to assure that the entire pregnancy has been removed.

  15. MANUAL VACUUM ASPIRATION Technique: • Speculum to visualize cervix • Cleanse with antiseptic, paracervical block • Dilate as necessary to allow insertion of the cannula • Insert cannula to fundus • Create suction with syringe and perform curettage. • Take care to not lose the vacuum by pulling the cannula through the cervical os before an adequate amount of tissue has been obtained

  16. MANUAL VACUUM ASPIRATION Technique (cont’d): • Continue curettage until uterus feels empty • Expel syringe contents into dish to inspect tissue • Careful inspection of tissue. • If products of conception not seen, follow‑up ultrasound to confirm completion

  17. MANUAL VACUUM ASPIRATION Advantages: • Earlier procedures require less cervical dilation, less bleeding and less cramping • Less noisy than suction machine • Less time for patient with pregnancy side effects • Electricity not needed • Re‑usable syringes

  18. MANUAL VACUUM ASPIRATION Disadvantages: • Slightly more difficult technique? • Need more than one aspiration for greater gestaional age pregnancies • Inability to find products of conception raises question of failure of the technique or ectopic pregnancy

  19. Complications of Surgical Abortion • Risk of complications increases with increasing gestational age • Reporting of all complications required to state health department

  20. Perforation of the uterus • Approximately 1 in 1000 first trimester suction abortions • Managed by observation in the hospital or clinic • Risk of bowel injury or significant internal bleeding is <1%. • Approximately 1 in 300 D&E's. • Immediate laparoscopy or laparotomyis usually indicated.

  21. Incomplete abortion • Defined as a need to have another suction procedure to complete the abortion • Incidence is approximately 1 in 250 abortions

  22. Infection • The incidence of infection is about 1 in 200. • Almost always successfully treated as an outpatient.

  23. Abortion Risks in Perspective Chance of death Risk from terminating pregnancy: per year: Before 9 weeks 1 in 1,000,000 Between 9 and 10 weeks 1 in 500,000 Between 13 and 15 weeks 1 in 60,000 After 20 weeks 1 in 11,000 Risk to persons who participate in: Motorcycling 1 in 1,000 Automobile driving 1 in 5,900 Power-boating 1 in 5,900 Playing football 1 in 25,000 Risk to women aged 15–44 from: Having sexual intercourse (PID) 1 in 50,000 Using tampons 1 in 350,000 Source: Bartlett et al., 2004 (1988–1997 data); Contraceptive Technology, 2005

  24. International Perspective on Abortion • A very small proportion of abortions worldwide take place in the United States. • Most unsafe abortions occur in countries where abortion is illegal.

  25. 20 Million Unsafe AbortionsOccur Each Year

  26. Almost All Abortion-Related Deaths Occur in Developing Countries Deaths per 100,000 unsafe abortions, 2003

  27. Complications of Unsafe Abortion • An estimated five million women are hospitalized each year for treatment of abortion-related complications, such as hemorrhage and sepsis. • Complications from unsafe abortion procedures account for 13% of maternal deaths, or 67,000 per year. • Approximately 220,000 children worldwide lose their mothers every year because of abortion-related deaths.

  28. Mortality trends for abortion

  29. Long-Term Safety of Abortion • First trimester abortions pose virtually no risk of • Infertility • Ectopic pregnancy • Miscarriage • Birth defect • Preterm delivery or low birth weight • Abortion is not associated with breast cancer. • Abortion does not pose a hazard to women’s mental health.

  30. Abortion Is Safer the Earlier in Pregnancy It Is Performed Deaths per 100,000 abortions Gestation at abortion

  31. Obstacles to Obtaining Abortion Services • Although most women obtain abortions early in pregnancy, some women face substantial obstacles to access. • Nearly four in 10 women of reproductive age receive coverage under Medicaid, yet 32 states allow Medicaid funding for abortion only in cases of rape, incest or life endangerment. • Lacking insurance coverage, poor women often require time to find the money to pay for an abortion, if they are able to at all. • Legal requirements such as parental consent for minors or waiting periods are likely to cause further delays, increasing the risk of complications.

  32. Reasons for Abortions After 16 Weeks Since Last Menstrual Period Woman did not realize she was pregnant 71% Difficulty making arrangements for abortion 48% Afraid to tell parents or partner 33% Needed time to make decision 24% Hoped relationship would change 8% Pressure not to have abortion 8% Something changed during pregnancy 6% Didn’t know timing was important 6% Didn’t know she could get an abortion 5% Fetal abnormality diagnosed late 2% Other 11% Source: Torres and Forrest, 1988 (1987 data)

  33. Dilation and Evacuation (D & E) • >14 weeks gestational age • Fetus and placenta extracted through the cervix. • Anesthetic choices: Same as <14 weeks gestational age suction procedures. • This is not the procedure used in intact dilation and extraction (“partial birth abortions”)

  34. Hemorrhage • Uterine Atony • Placental Abnormalities • Disseminated Intravascular Coagulopathy • Uterine Injury • Tears of the Cervical Os • Perforation • Uterine Rupture • Asherman Syndrome • Amniotic Fluid Embolism • Infection 2nd Trimester Abortion Complications

  35. Hemorrhage in 2nd Trimester Abortion • Definition: > 250 or 500cc, or needing transfusion • Increasing risk with gestational age • Risk Factors: • maternal age • parity • prior cesarean delivery • fibroids • history of postabortion or postpartum bleeding

  36. Prevention • Vasopressin in paracervicalblock • Methergine IM • Treatment • Manual uterine compression • Oxytocin IV or IM • Methergine IM • HemabateIM • Misoprostol 600 ugintravaginally or rectally • Volume expansion, transfusion as needed Uterine Atony in 2nd Trimester Abortion

  37. Questions?

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