Pregnancy Termination: First-Trimester Suction Aspiration

CHAPTER 127 Pregnancy Termination


First-Trimester Suction Aspiration



Lawrence Leeman, Emily Godfrey


First-trimester surgical termination of pregnancy (suction aspiration) is one of the safest surgical procedures performed in the United States, with 1.2 million procedures performed each year. By the time a woman reaches 45 years of age, approximately one in three will have had an abortion. About half of these are performed at 8 weeks or less in gestational age, and 88% are completed in the first trimester of pregnancy. Although abortion has been legal in all 50 states since the 1973 Roe v. Wade Supreme Court decision, many states have imposed laws such as parental consent for minors, mandatory waiting periods, and compulsory state-directed counseling that may limit availability of the procedure or discourage a woman from having an abortion. Therefore, clinicians performing abortion must be aware of any state and local restrictions that govern it.


Virtually all first-trimester surgical abortions are accomplished with vacuum aspiration. This chapter contains specific information about uterine aspiration using manual vacuum aspiration (MVA) and electric suction abortion in the first trimester. The most commonly used MVA device is a 60-mL syringe with locking valves and a plunger that provides identical suction pressure (26 inches of mercury) as an electric pump until the cylinder reaches approximately 80% capacity. The aspirator can be quickly emptied and reused if more capacity is needed. It is small, portable, and quiet and thus very practical for a variety of settings, including offices, emergency departments, and hospital-based locations. Although there is still some suction sound, there is no mechanical noise. When MVA and electric suction have been compared in studies, some patients prefer MVA because the sound of electrical suction can be disquieting. Clinicians may prefer MVA for aspiration at early gestational ages because it causes less disruption of the gestational sac, the presence of which confirms a successful aspiration procedure. Electrical suction may be preferred for later first-trimester gestational ages because of the larger amounts of products of conception (POC) and the need for repeat passes if MVA is used.


The suction technique described in this chapter for first-trimester abortion can also be used for surgical completion of spontaneous abortion, including missed and incomplete abortion. Many institutions use operating room settings for completion of spontaneous abortion. In most circumstances, however, spontaneous abortion treatment can be integrated into outpatient settings. Expectant management to await spontaneous passage of the POC and medical management with misoprostol are also safe options. The highest patient satisfaction is achieved when patients can make their own choice of a management plan. The relative and absolute contraindications to first-trimester abortion would also apply to treatment of spontaneous abortion.



Anatomy


Anatomic variations can increase the likelihood of complications occurring during uterine aspiration. A vaginal septum may interfere with visualizing and accessing the cervix. Cervical stenosis may occur and can be caused by prior surgical procedures including loop electrical excision, cryotherapy, and cold knife cone biopsy. Dilation may be more difficult in nulliparous teenagers because of a tight cervical os, particularly at early gestational ages. Mullerian anomalies including uterus didelphys, bicornuate uterus (Fig. 127-1), and an intrauterine septum may interfere with successful uterine aspiration. Intraoperative ultrasonography can facilitate the procedure. Adnexal masses or uterine fibroids may result in inaccurate gestational age dating; fibroids can interfere with cervical dilation.


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Figure 127-1 Ultrasonographic scan of bicornuate uterus with gestational sac in the right horn.



Indications



• Elective abortion up to 12 weeks’ estimated gestational age

• Treatment of early pregnancy failure or spontaneous abortion for uterine sizes up to 12 weeks

• Postabortal hematometra

• Backup for medical abortion (mifepristone/misoprostol or methotrexate/misoprostol; see Chapter 128, Pregnancy Termination: Medication Abortion)


Contraindications


Medical contraindications are rare. It is important for clinicians to be aware that some clinical scenarios require stabilization before abortion or that the procedure be performed in a hospital setting.



Absolute


Absolute contraindications to first-trimester abortion in an outpatient setting include the following:


• Hemodynamic instability

• Active pelvic infection


Relative


Relative contraindications include the following:


• Uncontrolled hypertension

• Uncontrolled diabetes

• Molar pregnancy (based on gestational age)

• Coagulopathy


Equipment and Supplies



• Medium Graves speculum (size and type varies based on patient habitus).

• Single-tooth or atraumatic tenaculum.

• Syringe with 22- to 27-gauge, 3-inch spinal needle, or 22- to 27-gauge needle on 3-inch needle extender.

• Anesthetic agent for cervical block (e.g., 0.5% or 1% lidocaine with epinephrine or vasopressin).

• Rigid cervical dilators for mechanical dilation: Pratt, Hegar, or Denniston (see Chapter 136, Cervical Stenosis and Cervical Dilation).

• Osmotic dilators: Sterilized seaweed stem (Laminaria japonicum) available in a variety of sizes (2 to 10 mm); when used, they should be inserted into the cervical os 6 to 18 hours before the procedure (see Chapter 136, Cervical Stenosis and Cervical Dilation).

• Cervical softening agents: misoprostol (prostaglandin E1 analog), available in 200-µg dose.

• Povidone–iodine or other antiseptic solution or sterile water.

• Ring forceps.

• 4 × 4 gauze pads.

• Manual vacuum syringe (Ipas MVA Plus; Fig. 127-2).

• Disposable suction cannulas, which come in a variety of sizes or flexibility, including flexible, semiflexible, or rigid (curved and straight; see Fig. 127-2). It is essential that the clinician identify which cannula produces adequate seal and suction with the type of MVA device that is being used.

• Suction machine with tubing as an alternative to MVA syringe (Fig. 127-3).

• Metal bowl for POC (if using MVA)

• Medium-sharp uterine curette

• Formalin jar (POC may be sent to pathology; however, many physicians performing aspiration abortion examine their own POC)

• Intravenous solutions, tubing, and oxytocics (for treatment of excessive bleeding)

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Figure 127-2 Ipas Plus syringe with flexible plastic cannulas for manual vacuum aspiration.


(From ARHP [Association of Reproductive Health Professionals]: www.arhp.org.)


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Figure 127-3 Berkeley Synevac vacuum curettage machine.



Precautions


With the availability of portable office ultrasonography, pregnancies can be detected at very early gestational ages. In the past, women were frequently asked to defer pregnancy termination until they were at least 7 weeks’ gestation, when a change of uterine size can be detected on physical examination and cervical softening occurs naturally. Now that these pregnancies can be verified earlier with ultrasonography and cervical softening agents are available, women can routinely be offered uterine aspiration or medical abortion as soon as a gestational sac is identified on transvaginal ultrasonography. Women who present for a first-trimester abortion with a positive urine pregnancy test in whom ultrasonography cannot confirm an intrauterine pregnancy can pose a management dilemma. In these cases, an algorithm has been suggested by Creinin and Edwards (Fig. 127-4). Outpatient uterine aspiration under local analgesia with a cervical block works well for most women. Some women, including those with a history of anxiety disorder, substance abuse, or poor tolerance to gynecologic examinations may be best cared for in clinical sites where conscious sedation or general anesthesia is provided. These patients should be identified during options counseling and offered referral to a clinic that can offer a greater range of anesthetic options.


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Figure 127-4 Algorithm for early surgical abortion. hCG, human chorionic gonadotropin. *Discriminatory zone. †The timing of follow-up serum quantitative hCG test or ultrasonography (or both) may vary according to patient’s risk factors for ectopic pregnancy.


(Adapted from Creinin MD, Edwards J: Early abortion: Surgical and medical options. Curr Probl Obstet Gynecol Fertil 20:1–32, 1997.)



Preprocedure Patient Education


It would be impossible provide a full discussion of counseling here, but several techniques and general principles can be outlined.


1 Explore the patient’s feelings. This may be done by asking nonjudgmental and open-ended questions as well as through active listening. The clinician should empathize and help the patient reflect on her own feelings. Ambivalence should be acknowledged and discussed.

2 Explore options. The patient’s options regarding her pregnancy include terminating or continuing the pregnancy. If she chooses to continue the pregnancy, she has the additional option of parenting or making an adoption plan. The risks, advantages, and disadvantages of each option should be explored in the context of the woman’s particular life situation. If she chooses pregnancy termination, appropriate options based on gestational age should be discussed.

3 Making decisions. Strategies for decision making and the need for any additional counseling may be explored. The patient should be encouraged to seek advice from others she trusts: partner, parents, siblings, friends, teachers, or spiritual counselors. It is imperative that a timetable for decision making be established based on the gestational age.

4 Screening for special problems. Extreme anxiety, ambivalence, drug or alcohol use, medical problems, or psychological problems may require special and individualized measures.

5 Informed consent. The risks of the procedure must be reviewed and any questions answered. The patient’s ability to give informed consent must be reviewed with regard to her age, mental status, and any possibility of coercion. A support person may be present during any procedure.

6 Postprocedure issues. These include the need for any additional counseling, contraception, follow-up visits, and reporting any complications. Emerging evidence indicates that increasing use of contraceptive implants and intrauterine devices (IUDs) could reduce repeat pregnancy among adolescent mothers and repeat abortions among women seeking induced abortion. IUDs can be inserted immediately after a first-trimester surgical abortion.


Procedure


Before starting the procedure, the following steps must be completed:


1 Pregnancy must be confirmed. A home pregnancy test may not have been performed correctly, and therefore it is best to confirm a pregnancy with an in-office urine pregnancy test or ultrasonography demonstrating an intrauterine pregnancy.

2 Gestational age must be determined. This can be accomplished by correlating weeks from the last normal menstrual period with a pelvic examination to size the uterus. Abnormal bleeding in pregnancy, contraception use, menstrual irregularities, and poor recall of dates, denial, and even the possibility of falsification may hinder a clinician in calculating an accurate gestational age from historical data. A pelvic examination to size the uterus requires practice and may be complicated when a patient is obese or uncooperative, has uterine fibroids or adnexal masses, or has a retroverted uterus. As a rough guideline, up to the sixth week of pregnancy, the uterus is the size of a plum in nulliparous women and the size of a pear in parous women. By 8 to 9 weeks the uterus is the size of a small orange but is softer and often asymmetrically enlarged. By 10 weeks the uterus is the size of a medium orange. By 12 weeks the uterus is as large as a grapefruit and becomes palpable suprapubically in thin or normal-weight women. A retroverted uterus will pop forward out of the pelvis between 12 and 13 weeks. By 15 or 16 weeks the uterus is the size of a cantaloupe. Ultrasonographic examination is highly accurate in dating a pregnancy, regardless of historical data or results of the physical examination. Ultrasonography also sheds light on several important complications of pregnancy such as first-trimester fetal demise, ectopic pregnancy, and gestational trophoblastic disease or molar pregnancy. Many clinicians routinely perform a dating ultrasonographic examination before planning abortion by uterine aspiration. Ultrasonography can also be useful during or after the procedure to confirm completion of the procedure. Intraoperative ultrasonographic guidance is recommended for women with uterine anomalies or fibroids. It can also be used if the clinician has difficulty with dilation or uterine aspiration.

3 Perform a hematocrit or hemoglobin if there is a history or clinical suspicion of anemia.

4 Optional testing, depending on patient risk factors, the nature of the practice, and financial considerations, includes wet prep, Papanicolaou smear, gonorrhea and chlamydia screening, and blood tests for syphilis and human immunodeficiency virus.

5 Determine Rh factor status (mandatory). Rh-negative women who have been pregnant less than 13 weeks should receive a 50-µg dose of D immunoglobulin (MICRhoGAM 50 µg) within 48 hours of the procedure. It is ideally given during the procedure or immediately after. Some give the MICRhoGAM injection intracervically at the anterior lip where the cervical block was placed.

6 Premedication is recommended 30 to 60 minutes before the procedure with a nonsteroidal anti-inflammatory medication such as ibuprofen 600 to 800 mg orally. Diazepam (5 or 10 mg) or an oral narcotic may be given an hour before the procedure in selected cases.

7 Establishment of an intravenous (IV) line generally is unnecessary in an outpatient setting. Oxytocin, methylergonovine (Methergine), and other injectable drugs must be readily available should an unexpected hemorrhage occur. They can be administered intramuscularly when an IV line is not in place.

8 Conscious sedation may be offered. It is important that clinicians be aware of the rules and regulations regarding conscious sedation at their institutions before instituting this level of care. A simple and effective regimen is midazolam (Versed) given IV at the rate of 1 mg/min up to 5 mg, accompanied by fentanyl 50 to 100 µg IV. The patient should be monitored for respiratory depression with a pulse oximeter and frequent vital signs, and a crash cart should be available (see Chapter 2, Procedural Sedation and Analgesia).

9 Atropine 0.4 mg may be given IV or subcutaneously in patients with a history of a vagal reaction to prior cervical manipulations (e.g., bradycardia, fainting/loss of consciousness, diaphoresis, nausea).

10 Prophylactic antibiotics are a standard of care. A common regimen is doxycycline 100 mg twice daily for 3 days. Metronidazole (500 mg orally, twice daily for 2 days) is an option if the patient is allergic to doxycycline. Special consideration must be given to women with active infections, cardiac defects, prostheses, and other high-risk conditions (see Chapter 221, Antibiotic Prophylaxis).


Initial Steps



1 Position the patient in the dorsal lithotomy position using stirrups. The patient should have her buttocks at or slightly beyond the edge of the table.

2 If not already done, assess the shape, size, and position of the uterus by performing a bimanual examination.

3 Remove osmotic dilators, if placed previously.

4 After inserting the speculum, cleanse the cervix with sterile water or other antiseptic solution such as povidone–iodine.


Paracervical Block



1 Paracervical block (see Chapter 173, Paracervical Block, for additional information) is a simple, safe, and effective means of providing local anesthesia for abortion in the office setting (Fig. 127-5). The technique can vary, including the site of injection, type of anesthetic, and quantity of solution injected. Most clinicians limit the total amount of 1% lidocaine injected to 20 mL (or 0.5% lidocaine to 40 mL) to avoid lidocaine toxicity.

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Figure 127-5 Paracervical block technique. “X” marks the locations where submucosal injections can be made. Ten milliliters of local anesthetic (1% lidocaine or 2% chloroprocaine) are injected with a 22-gauge needle into four sites at the 3, 5, 7, and 9 o’clock positions. (Some clinicians prefer to inject in the 4 and 8 o’clock positions only.) Ideally, the injection should be given submucosally, near the junction of the cervix and vagina. The injection should be superficial enough to raise a bleb or wheal under the mucosa. Because the area is vascular, care must be taken not to inject the anesthetic directly into a vessel. The tenaculum may be used to elevate the cervix and hold it to either side for better exposure of the injection sites.



Cervical Preparation


The cervix may be dilated mechanically with plastic or metal dilators, or with the assistance of preprocedural prostaglandins such as misoprostol. Prostaglandins cause softening and dilation of the cervix as well as some uterine cramping. Misoprostol is the prostaglandin of choice because it is inexpensive, stable at room temperature, and effective in a variety of dosing routes, and has been shown to be effective in first-trimester abortion. Several studies show that misoprostol, given vaginally, is more effective than given orally; buccal and sublingual dosing have also been documented as effective, but they both have more unwanted side effects than the vaginal route. Studies examining various doses found that 400 µg (vaginal or sublingual) is most effective and that higher doses were not necessary. Although not well studied, 400 µg by the buccal route is a commonly used alternative. Optimal dosing occurs when misoprostol is given 2 to 4 hours before the procedure; however, administration as late as 1 hour before the procedure can be helpful with cervical softening. Patients commonly experience some cramping and bleeding before the actual surgical procedure with this drug.


Laminaria is an option for dilation but it is less popular because it requires two visits to the office (Fig. 127-6). Some clinicians routinely use misoprostol for all women undergoing uterine aspiration in the outpatient setting regardless of gestational age. Other providers prefer laminaria for primiparous women over 10 to 12 weeks and multiparous women with an estimated gestational age of 12 weeks or greater. The Society of Family Planning guidelines for first-trimester abortion state that cervical ripening be considered for all adolescents and is recommended for any women at 12 to 14 weeks or if an initial attempt at dilation has been unsuccessful.


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Figure 127-6 A, Insertion of the laminaria. B, Immediately after insertion. C, Twelve to 24 hours after insertion.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Pregnancy Termination: First-Trimester Suction Aspiration

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