Surgical termination

Surgical termination is performed in either a hospital setting or dedicated facility in a designated clinic. General anaesthetic is standard practice in the UK, although use of local anaesthetic, paracervical block, with or without sedation, is increasingly being offered. Vacuum aspiration is the standard procedure using a plastic cannula for aspiration with complete avoidance of using sharp instruments within the uterus, thereby minimizing the risk of uterine damage. Suction termination may be safer under local anaesthesia, but studies comparing the safety of local and general anaesthesia have been observational or only partially randomized.

Many clinicians avoid surgical termination under 7 weeks' gestation because of the risk of failure to remove the pregnancy. However, with the increased sensitivity of pregnancy tests, many women now present at very early gestations, shortly after a first period has been missed. For these women, it is not acceptable to defer the abortion until a suitable gestation for surgery and their preference might not necessarily be for medical termination or indeed, in certain circumstances, there could be contraindications to medical abortion. Suction terminations performed at less than 7 weeks' gestation are three times more likely to fail to remove the gestation sac than those performed between 7 and 12 weeks [19].

The 1990s saw renewed interested in MVA which had its origins back in the 1960s in relation to the practice of 'menstrual extraction'. MVA does take longer than electronic vacuum procedures, especially as the gestation increases towards 9 weeks. For MVA, uterine evacuation is accomplished using a 4, 5 or 6 mm flexible cannula attached to a 50 cc manual vacuum syringe. MVA had largely been abandoned after the legalization of abortion because of its failure rate, but modern protocols relying on human chorionic gonadodatrophin (hCG) assay, high-resolution ultrasound pre- and post-procedure and careful immediate tissue inspection are effective. Although the technique is well established in the USA, there is also renewed interested in introducing these early surgical abortion techniques in the UK. Creinin and Edwards report a continuing pregnancy rate of only 0.13% [32] but other series have reported 2.3% rates [33] and certainly, if conventional suction termination is the only method available within a service, the RCOG guideline group recommendation is to defer the procedure until the pregnancy has exceeded 7 weeks' gestation. It should be noted that there is no randomized trial evidence comparing MVA with medical termination at present.

Conventional suction termination is appropriate at 715 weeks' gestation although, possibly reflecting the skills and experience of practitioners, many units adopt medical abortion at gestations above 12-13 weeks.

Table 33.3 Cervical priming agents for surgical termination

* Misoprostol 400 [ig(2 x 200 \xg tablets) administered vaginally, either by the woman or clinician, 3 h prior to surgery

Gemeprost 1 mg vaginally, 3 h prior to surgery

Mifepristone 600 mg orally 36-48 h prior to surgery

*This regimen is unlicensed.

Cervical priming prior to surgical abortion reduces the complications of cervical injury, uterine perforation, haemorrhage and incomplete evacuation. Younger patient age is a risk factor for cervical damage and increasing gestation, particularly in multiparous women, is associated with uterine perforation. Mifepristone and the prostaglandin Ei analogues, gemeprost and misoprostol are effective cervical priming agents (Table 33.3). In the UK, gemeprost is the licensed preparation, although there is evidence that misoprostol is an effective lower cost alternative. Mifepristone has also been shown to be an effective priming agent [34]. Mifepristone has higher efficacy than gemeprost and misoprostol when given 48 h ahead of surgery, but mifepristone has the disadvantage of requiring administration 36-48 h ahead of the abortion and there could be problems with preoperative bleeding. Misopros-tol remains the most popular priming agent in the UK and the optimal time interval for administration is at least 3 h before surgery [35]. More recent work suggests that the sublingual route of administration is also effective for cervical priming, but is associated with an increased rate of gastrointestinal side effects.

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Getting Back Into Shape After The Pregnancy

Getting Back Into Shape After The Pregnancy

Once your pregnancy is over and done with, your baby is happily in your arms, and youre headed back home from the hospital, youll begin to realize that things have only just begun. Over the next few days, weeks, and months, youre going to increasingly notice that your entire life has changed in more ways than you could ever imagine.

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