1. Surgical Abortion David Blair Toub, M.D.
Dept. of Obstetrics and Gynecology
Pennsylvania Hospital

2. Introduction 1973: Roe v. Wade; Trimester Approach
Number of Abortions Stable or Decreasing
~ 1/3 of Women Undergo Abortion
Abortion 10-11x Safer than Continuing Pregnancy, 2x Safer than PCN Injection
91% 1st TM, 9% 2nd TM, .01% 3rd TM
1965: Illegal Ab = 17% of Maternal Deaths

3. Patient Evaluation Counseling, ACA (in PA) Pregnancy Test
History – LMP, Medical Risk Factors
PEx – Confirmation of Gestational Age
T+Rh, Hct
U/S – if Significant Discrepancy on Exam or Recent Vaginal Bleeding

4. Techniques ≤ 14 Weeks: – Suction Curettage
– Medical Abortion (≤ 56 days LMP)
14-24 Weeks and Beyond:
– Dilatation and Evacuation (D+E)
– Intact D+E (“D+X”)
– Labor Induction Methods (Prostaglandins)
– Amnioinfusion (HS, Urea, Prostaglandins)

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

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

7. Suction Curettage 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
“No-Touch” Technique

8. 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)

9. Additional 2nd / 3rd Trimester Methods
Labor Induction
– PGE Vaginal Suppositories
– Amnioinfusion (Hypertonic Saline, Urea, Prostaglandins)
– Oxytocin
D+X
Hysterotomy (Outmoded – Should be Abandoned)

10. Complications Bleeding Infection Retained POC “Missed Abortion”
Perforation – low risk, high risk variants
Hematometra (“postabortal,” or “re-do” syndrome)
Undiagnosed Ectopic Pregnancy

11. 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 (UCG May Still Be Positive)
If Tissue Sent for Histology – Check Report

12. Summary Surgical Abortion Is a Safe Procedure
Complications,While Infrequent, May Be Serious
Since Roe, There Has Been a Dramatic Reduction in Maternal Mortality From Illegal Abortion Procedures
The Need for Abortion May Be Reduced by Appropriate Contraception