DnC

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DnC

  1. 1. Surgical Abortion David Blair Toub, M.D. Dept. of Obstetrics and Gynecology Pennsylvania Hospital
  2. 2. Introduction <ul><li>1973: Roe v. Wade ; Trimester Approach </li></ul><ul><li>Number of Abortions Stable or Decreasing </li></ul><ul><li>~ 1/3 of Women 15-44 Undergo Abortion </li></ul><ul><li>Abortion 10-11x Safer than Continuing Pregnancy, 2x Safer than PCN Injection </li></ul><ul><li>91% 1st TM, 9% 2nd TM, .01% 3rd TM </li></ul><ul><li>1965: Illegal Ab = 17% of Maternal Deaths </li></ul>
  3. 3. Introduction <ul><li>Russia </li></ul><ul><li>Number of abortions: 1996 - 2 469 000 2000 - 1 962 000 </li></ul><ul><li>Number of mini-abortion: 1996 - 601 346 2000 - 493 942 </li></ul>
  4. 4. Patient Evaluation <ul><li>Counseling, ACA (in PA) </li></ul><ul><li>Pregnancy Test </li></ul><ul><li>History – LMP, Medical Risk Factors </li></ul><ul><li>PEx – Confirmation of Gestational Age </li></ul><ul><li>T+Rh, Hct </li></ul><ul><li>U/S – if Significant Discrepancy on Exam or Recent Vaginal Bleeding </li></ul>
  5. 5. Techniques <ul><li>≤ 14 Weeks: </li></ul><ul><li>– Suction Curettage </li></ul><ul><li>– Medical Abortion (≤ 56 days LMP) </li></ul><ul><li>14-24 Weeks and Beyond: </li></ul><ul><li>– Dilatation and Evacuation (D+E) </li></ul><ul><li>– Intact D+E (“D+X”) </li></ul><ul><li>– Labor Induction Methods (Prostaglandins) </li></ul><ul><li>– Amnioinfusion (HS, Urea, Prostaglandins) </li></ul>
  6. 6. Cervical Dilatation <ul><li>Mechanical: </li></ul><ul><li>– Done at Time of D+E </li></ul><ul><li>– Convenient for Patient </li></ul><ul><li>– May be Uncomfortable </li></ul><ul><li>– Increased Risk of Perforation (Compared with Osmotic Dilators) </li></ul>
  7. 7. Cervical Dilatation <ul><li>Osmotic Dilators (e.g. Laminaria) </li></ul><ul><li>– Increased Time, Inconvenience </li></ul><ul><li> – Less Pain, Decreases Perforation Risk </li></ul><ul><li>Examples: </li></ul><ul><li> – Laminaria japonicum, L. digitatum </li></ul><ul><li> – Dilapan </li></ul><ul><li> – Lamicel </li></ul>Synthetic
  8. 8. Suction Curettage <ul><li>Office, Clinic or Hospital Setting </li></ul><ul><li>Local (Paracervical Block) or IV Sedation </li></ul><ul><li>General Anaesthesia Increases Risk </li></ul><ul><li>Prophylactic Doxycycline Decreases Endometriitis Risk </li></ul><ul><li>Rigid or Osmotic Dilators Used </li></ul><ul><li>“ No-Touch” Technique </li></ul>
  9. 9. Dilatation & Evacuation <ul><li>Avoid Mechanical Dilatation if Feasible </li></ul><ul><li>Requires Additional Experience and Training </li></ul><ul><li>Safer than Amnioinfusion in Most Cases when Performed by Experienced Operator </li></ul><ul><li>Less Emotionally Traumatic for Most Patients (Compared With Labor Induction) </li></ul>
  10. 10. Additional 2nd / 3rd Trimester Methods <ul><li>Labor Induction </li></ul><ul><li>– PGE Vaginal Suppositories </li></ul><ul><li> – Amnioinfusion (Hypertonic Saline, Urea, Prostaglandins) </li></ul><ul><li> – Oxytocin </li></ul><ul><li>D+X </li></ul><ul><li>Hysterotomy (Outmoded – Should be Abandoned) </li></ul>
  11. 11. Complications <ul><li>Bleeding </li></ul><ul><li>Infection </li></ul><ul><li>Retained POC </li></ul><ul><li>“ Missed Abortion” </li></ul><ul><li>Perforation – low risk, high risk variants </li></ul><ul><li>Hematometra (“postabortal,” or “re-do” syndrome) </li></ul><ul><li>Undiagnosed Ectopic Pregnancy </li></ul>
  12. 12. Postabortion Management <ul><li>Bleeding May Occur for 2 Days –2 Weeks </li></ul><ul><li>Appropriate Contraception May Commence Immediately or Soon Thereafter </li></ul><ul><li>Significant Pain, Bleeding or Fevers Should Prompt Evaluation </li></ul><ul><li>Patients Should Follow-up in 2-4 Weeks (UCG May Still Be Positive) </li></ul><ul><li>If Tissue Sent for Histology – Check Report </li></ul>
  13. 13. Summary <ul><li>Surgical Abortion Is a Safe Procedure </li></ul><ul><li>Complications,While Infrequent, May Be Serious </li></ul><ul><li>Since Roe , There Has Been a Dramatic Reduction in Maternal Mortality From Illegal Abortion Procedures </li></ul><ul><li>The Need for Abortion May Be Reduced by Appropriate Contraception </li></ul>

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