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  • 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 15-44 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. Introduction
    • Russia
    • Number of abortions: 1996 - 2 469 000 2000 - 1 962 000
    • Number of mini-abortion: 1996 - 601 346 2000 - 493 942
  • 4. 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
  • 5. 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)
  • 6. Cervical Dilatation
    • Mechanical:
    • – Done at Time of D+E
    • – Convenient for Patient
    • – May be Uncomfortable
    • – Increased Risk of Perforation (Compared with Osmotic Dilators)
  • 7. Cervical Dilatation
    • Osmotic Dilators (e.g. Laminaria)
    • – Increased Time, Inconvenience
    • – Less Pain, Decreases Perforation Risk
    • Examples:
    • – Laminaria japonicum, L. digitatum
    • – Dilapan
    • – Lamicel
    Synthetic
  • 8. 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
  • 9. Dilatation & 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)
  • 10. Additional 2nd / 3rd Trimester Methods
    • Labor Induction
    • – PGE Vaginal Suppositories
    • – Amnioinfusion (Hypertonic Saline, Urea, Prostaglandins)
    • – Oxytocin
    • D+X
    • Hysterotomy (Outmoded – Should be Abandoned)
  • 11. Complications
    • Bleeding
    • Infection
    • Retained POC
    • “ Missed Abortion”
    • Perforation – low risk, high risk variants
    • Hematometra (“postabortal,” or “re-do” syndrome)
    • Undiagnosed Ectopic Pregnancy
  • 12. 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
  • 13. 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