Presentation on theme: "Surgical Abortion Paula Bednarek, MD, MPH Assistant Professor Dept of Obstetrics and Gynecology Oregon Health & Science University."— Presentation transcript:
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 –Highest rate of teen pregnancy in world –Half of pregnancies unintended
Teenage pregnancy is more common in the United States than in most other industrialized countries
Half of all pregnancies in the United States each year are unintended Pregnancies (6.3 million) Unintended pregnancies Intended pregnancies
Rate of Abortion by Age Group Source: Jones et al., % of women in the USA will have an abortion at some time in their life
Abortions by Gestational Age (Weeks Since Last Menstrual Period) Source: Henshaw adjustments to Strauss et al., 2004 (2001 data) Weeks % of Abortions
The small proportion of women who do not use contraceptives... Women at risk of unintended pregnancy (42 million) Women experiencing unintended pregnancies (3 million)... account for roughly half of all unintended pregnancies
Any contraceptive method is better than none,... % of users becoming pregnant within one year... but choice of method makes a difference
ABORTION Legal Aspects Abortion is protected by the U. S. Supreme Court decision Roe v. Wade decided in Decision made in privacy with a women and her physician. Based on the principle of maternal rights superseding the rights of the fetus.
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.
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
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.
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 seaweed Laminaria japonicum. –Dilapan (Synthetic sponge cervical dilator) –Mifepristone??
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.
MANUAL VACUUM ASPIRATION Technique: 1.Speculum to visualize cervix 2.Cleanse with antiseptic, paracervical block 3.Dilate as necessary to allow insertion of the cannula 4.Insert cannula to fundus 5.Create suction with syringe and perform curettage. 6.Take care to not lose the vacuum by pulling the cannula through the cervical os before an adequate amount of tissue has been obtained
MANUAL VACUUM ASPIRATION Technique (cont’d): 7.Continue curettage until uterus feels empty 8.Expel syringe contents into dish to inspect tissue 9.Careful inspection of tissue. 10.If products of conception not seen, follow ‑ up ultrasound to confirm completion
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
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
Complications of Surgical Abortion Risk of complications increases with increasing gestational age Reporting of all complications required to state health department
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 laparotomy is usually indicated.
Incomplete abortion Defined as a need to have another suction procedure to complete the abortion Incidence is approximately 1 in 250 abortions
Infection The incidence of infection is about 1 in 200. Almost always successfully treated as an outpatient.
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 weeks1 in 500,000 Between 13 and 15 weeks1 in 60,000 After 20 weeks 1 in 11,000 Risk to persons who participate in: Motorcycling1 in 1,000 Automobile driving1 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
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.
20 Million Unsafe Abortions Occur Each Year
Almost All Abortion-Related Deaths Occur in Developing Countries Deaths per 100,000 unsafe abortions, 2003
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.
Mortality trends for abortion
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.
Abortion Is Safer the Earlier in Pregnancy It Is Performed Deaths per 100,000 abortions Gestation at abortion
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.
Reasons for Abortions After 16 Weeks Since Last Menstrual Period Woman did not realize she was pregnant71% Difficulty making arrangements for abortion48% Afraid to tell parents or partner33% Needed time to make decision24% 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% Other11% Source: Torres and Forrest, 1988 (1987 data)
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”)
2nd Trimester Abortion Complications n Hemorrhage è Uterine Atony è Placental Abnormalities è Disseminated Intravascular Coagulopathy n Uterine Injury è Tears of the Cervical Os è Perforation è Uterine Rupture è Asherman Syndrome n Amniotic Fluid Embolism n Infection
Hemorrhage in 2nd Trimester Abortion n Definition: > 250 or 500cc, or needing transfusion n Increasing risk with gestational age n Risk Factors: è maternal age è parity è prior cesarean delivery è fibroids è history of postabortion or postpartum bleeding
Uterine Atony in 2nd Trimester Abortion n Prevention è Vasopressin in paracervical block è Methergine IM n Treatment è Manual uterine compression è Oxytocin IV or IM è Methergine IM è Hemabate IM è Misoprostol 600 ug intravaginally or rectally è Volume expansion, transfusion as needed