Summary

This chapter addresses, in brief, the clinical management of women before, during and after their abortion. Providing clinical care for women undergoing abortion is described in greater detail in the WHO document Clinical practice handbook for safe abortion care.

The evidence base for the following recommendations are available as GRADE (Grading of Recommendations Assessment, Development and Evaluation) tables and accessible online. Details of the GRADE methodology are presented in the Methods section of this document (pages 10–11). GRADE tables are available from: http://apps.who.int/iris/bit-stream/10665/75840/1/WHO_RHR_12.10_eng.pdf) - date accessed 14 February 2013.

2.1. Pre-abortion care

The first steps in providing abortion care are to establish that the woman is indeed pregnant and, if so, to estimate the duration of the pregnancy and confirm that the pregnancy is intrauterine. The risks associated with induced abortion, though small when abortion is properly performed, increase with the duration of pregnancy (1, 2). Determination of the length of pregnancy is a critical factor in selecting the most appropriate abortion method, and determines the content of the information and counselling to be given to women prior to abortion. Every health-service-delivery point should have staff who are trained and competent to take the woman's medical history and perform a bimanual pelvic and an abdominal examination to accurately assess pregnancy and its duration. Health-care centres that are not staffed and equipped to provide induced abortion must be able to refer women promptly to the nearest services with minimal delay. Staff should also be competent to offer counselling to help the woman consider her options if needed (see Section 2.1.8).

2.2. Methods of abortion

Pre-procedure considerations

2.2.1. Cervical preparation

Cervical preparation (or priming) using osmotic dilators, such as laminaria, or pharmacological agents is commonly used before some first-trimester surgical abortions because it may make the abortion procedure quicker and easier to perform by reducing the need for mechanical cervical dilatation (29, 30). Cervical preparation before surgical abortion is especially beneficial for women with cervical anomalies or previous surgery, adolescents and those with advanced pregnancies, all of whom have a higher risk of cervical injury or uterine perforation that may cause haemorrhage (31, 32). It may also facilitate the abortion procedure for inexperienced providers. However, cervical preparation has disadvantages, including additional discomfort for the woman, and the extra cost and time required to administer it effectively. It is therefore recommended for all women with durations of pregnancy over 12–14 weeks (29, 30, 33), although its use may be considered for women at any gestational age, in particular those at high risk for cervical injury or uterine perforation.

Cervical preparation using osmotic dilators requires at least 4 hours to be effective. In first-trimester surgical abortion, research suggests that administration of 400 μg misoprostol either vaginally 3–4 hours or sublingually 2–3 hours prior to the procedure is effective in preparing the cervix (29). Another effective pharmacological regimen is 200 mg mifepristone taken orally 36 hours before a vacuum aspiration procedure (29, 34). For cervical priming prior to D&E, misoprostol is inferior to overnight dilatation with laminaria. Unlike laminaria, misoprostol used alone for cervical preparation has not been studied after 20 weeks' gestation. Misoprostol use in combination with overnight osmotic dilators does not have any additional benefit in cervical dilatation before 19 weeks of gestation (30).

2.2.2. Pain management

Most women report some degree of pain with abortion. The factors associated with pain during surgical abortion with local anaesthesia have been evaluated in several observational studies. The degree of the pain varies with the age of the woman, parity, history of dysmenorrhoea and the anxiety level or fearfulness of the woman (35–37). Prior vaginal delivery and greater experience of the provider have been found to be associated with less pain during abortion (35, 38). The relationship between pain and gestational age as well as the amount of cervical dilatation required for the abortion have shown conflicting results (35, 36, 38), although a shorter procedure time has been associated with less pain (35).

Providing adequate pain management does not require a large investment in drugs, equipment or training. Neglecting this important element needlessly increases women's anxiety and discomfort, thereby seriously compromising the quality of care and potentially increasing the difficulty of performing the procedure.

Counselling and sympathetic treatment may reduce women's fears and perceptions of pain, as has been reported for women treated for incomplete abortion (39). Non-pharmacological relaxation techniques can result in shorter procedure times and decreased need for pain medications (40, 41), and listening to music may decrease procedural pain (37). The person performing the procedure, and other staff present, should be friendly and reassuring. Where feasible, and if the woman wishes, it may also be helpful for a supportive person, such as the woman's husband or partner, a family member or friend, to remain with her during the procedure. However, non-pharmacological approaches should not be seen as a replacement for pharmacological pain alleviation.

2.2.2.1. Medication for pain

Medication for pain management should always be offered for both medical and surgical methods of abortion, and provided without delay to women who desire it. Three types of drugs, either singly or in combination, are used to manage pain during abortion: analgesics, which alleviate the sensation of pain; tranquillizers, which reduce anxiety; and anaesthetics, which decrease physical sensation during surgical abortion. In most cases of surgical abortion, analgesics, local anaesthesia and/or mild sedation supplemented by verbal reassurance, are sufficient. Most of these drugs are comparatively inexpensive.

Non-narcotic analgesics included on the WHO Model list of essential medicines, such as non-steroidal anti-inflammatory agents like ibuprofen, reduce pain, including uterine cramping, associated with both surgical and medical methods of abortion (42, 43). Paracetamol was found, in randomized controlled trials, to be ineffective to relieve post-procedural pain following surgical abortion (44–46) and was similarly ineffective at reducing pain during medical abortion (47); therefore, the use of paracetamol is not recommended to decrease pain during abortion.

For surgical abortion, preoperative administration of tranquillizers, such as diazepam, can reduce fear and induce relaxation, making the procedure easier for both the woman and the provider. Such drugs can cause amnesia, which some women may want, but they may also induce drowsiness and delay ambulation (37). Supplemental use of narcotic analgesics may also be appropriate, though the possibility of complications such as respiratory depression means that resuscitation capability and narcotic-reversal agents must be available.

2.2.2.2. Anaesthesia

Where mechanical cervical dilatation is required for surgical abortion, a paracervical block using a local anaesthetic, such as rapidly acting lidocaine, injected beneath the cervical mucosa around the cervix, is commonly used. Advantages of using local rather than general anaesthesia include a reduction in procedural risks and complications, a faster recovery time, and a greater sense of control for the woman, who remains conscious and able to communicate with the provider. Injection of local anaesthetic must be done skilfully, to avoid intravenous introduction of the drug. The use of local anaesthesia with vacuum aspiration is safe; however, the degree to which it decreases pain has not been well studied, despite its common use (37).

General anaesthesia is not routinely recommended for abortion procedures, and increases the clinical risks (1, 48–50). It has been associated with higher rates of haemorrhage than local anaesthesia (1, 2). Use of general anaesthesia increases costs for both the health-care facility and the woman, particularly as some hospital policies unnecessarily require women who receive it to stay overnight. Nevertheless, as it is the most effective method of pain control, some women prefer general anaesthesia, and its use may also be preferable from the provider's perspective during difficult procedures. Any facility that offers general anaesthesia must have the specialized equipment and staff to administer it and to handle any complications.

2.2.3. Induction of pre-procedure fetal demise

When using medical methods of abortion after 20 weeks' gestation, inducing pre-procedure fetal demise should be considered. Modern medical methods, such as combination regimens of mifepristone and misoprostol or misoprostol alone, are not directly feticidal; the incidence of transient fetal survival after expulsion is related to increasing gestational age and decreasing interval to abortion (51, 52). Commonly used pre-procedure regimens to effect fetal demise include (53):

• Injection of potassium chloride (KCl) through the fetal umbilical cord or into the fetal cardiac chambers, which is highly effective but requires expertise for precise, safe injection and time to observe cardiac cessation on ultrasound.
• Intra-amniotic or intrafetal injection of digoxin. Digoxin has a higher failure rate than KCl to cause intrauterine fetal demise; however, it is technically easier to use, does not require ultrasound if administered intra-amniotically, and has demonstrated safety (maternal serum levels remain at or below therapeutic digoxin levels) (51). Digoxin requires time for fetal absorption; therefore, it is commonly administered the day before induction of abortion with misoprostol (33, 54).

2.2.4. Surgical methods of abortion

2.2.4.1. Vacuum aspiration

The recommended surgical technique for abortion up to gestational age less than 15 weeks is vacuum aspiration (57). The high efficacy of vacuum aspiration has been well established in several randomized controlled trials. Complete abortion rates between 95% and 100% are reported (55, 56). Electric and manual vacuum technologies appear to be equally effective; however, the use of manual vacuum aspiration is associated with less pain in pregnancies under 9 weeks' gestation and with more procedural difficulty over 9 weeks' gestation (57). Vacuum aspiration under 14 weeks' gestation is more effective and associated with fewer minor complications than medical abortion (56, 58).

Vacuum aspiration involves evacuation of the contents of the uterus through a plastic or metal cannula, attached to a vacuum source. Electric vacuum aspiration (EVA) employs an electric vacuum pump. With manual vacuum aspiration (MVA), the vacuum is created using a hand-held, hand-activated, plastic 60 ml aspirator (also called a syringe). Available aspirators accommodate different sizes of plastic cannulae, ranging from 4 mm to 16 mm in diameter. For each procedure, the appropriately sized cannula should be chosen based on the gestational age and the amount of cervical dilatation present; generally, the diameter of the cannula corresponds to the gestational age in weeks. Some cannulae and most aspirators are reusable after being cleaned and high-level disinfected or sterilized. Foot-operated mechanical pumps are also available.

Depending on the duration of pregnancy, abortion with vacuum aspiration takes from 3 to 10 minutes to complete and can be performed on an outpatient basis, using analgesics and/or local anaesthesia. The completion of abortion is verified by examination of the aspirated tissue. In very early pregnancy, the cannula may be inserted without prior dilatation of the cervix. Usually, however, dilatation using mechanical or osmotic dilators, or pharmacological agents such as misoprostol or mifepristone, is required before insertion of the cannula (see Section 2.2.1). Generally, vacuum-aspiration procedures can be safely completed without intrauterine use of curettes or other instruments. No data suggest that use of curettage after vacuum aspiration decreases the risk of retained products (59).

Most women who have a first-trimester abortion with local anaesthesia feel well enough to leave the health-care facility after observation for about 30 minutes in a recovery room. Longer recovery periods are generally needed for abortions performed later in pregnancy and when sedation or general anaesthesia has been used.

Vacuum aspiration is a very safe procedure. A study of 170 000 first-trimester abortions conducted in New York City by vacuum aspiration reported that less than 0.1% of the women experienced serious complications requiring hospitalization (60). Though rare, complications with vacuum aspiration can include pelvic infection, excessive bleeding, cervical injury, incomplete evacuation, uterine perforation, anaesthetic complications and ongoing pregnancy (1, 2). Abdominal cramping and menstrual-like bleeding occur with any abortion procedure.

2.2.4.2. Dilatation and curettage

D&C involves dilating the cervix with mechanical dilators or pharmacological agents and using sharp metal curettes to scrape the walls of the uterus.

D&C is less safe than vacuum aspiration (61) and considerably more painful for women (62). Therefore, vacuum aspiration should replace D&C. The rates of major complications of D&C are two to three times higher than those of vacuum aspiration (3). Randomized controlled trials comparing D&C with vacuum aspiration found that, for up to 10 weeks since the LMP, vacuum aspiration is quicker and associated with less blood loss than D&C (63, 64).

Where it is still practised, all possible efforts should be made to replace D&C with vacuum aspiration, to improve the safety and quality of care for women. Where no abortion services are currently offered, vacuum aspiration should be introduced rather than D&C. At sites where vacuum aspiration has yet to be introduced, managers must ensure that proper pain-management protocols are followed, and that D&C procedures are performed by well-trained staff under adequate supervision.

2.2.4.3. Dilatation and evacuation

D&E is used after 12–14 weeks of pregnancy. It is the safest and most effective surgical technique for later abortion, where skilled, experienced providers are available (3). D&E requires preparation of the cervix using osmotic dilators or pharmacological agents (see Section 2.1) and evacuating the uterus using EVA with 12–16 mm diameter cannulae and long forceps. Depending on the duration of pregnancy, preparation to achieve adequate cervical dilatation can require from 2 hours to 2 days. Many providers find the use of ultrasound helpful during D&E procedures, but its use is not essential (65).

A randomized controlled trial comparing D&E with intra-amniotic instillation of prostaglandin PGF_2α found D&E to be faster, safer and more acceptable, at least up to 18 weeks of pregnancy (66). D&E has been compared to the use of mifepristone with repeated doses of misoprostol in one small trial, where it was found to be associated with less pain and fewer adverse events (67). Like any medical procedure, providers need the requisite training, equipment and skills to safely perform D&E (68).

A D&E procedure can usually be performed on an outpatient basis with a paracervical block and non-steroidal anti-inflammatory analgesics or conscious sedation. General anaesthesia is not required and can increase risk (see Section 2.2.2.2). A D&E procedure usually takes no more than 30 minutes to perform. Clinic staff and women undergoing the procedure should expect more postoperative vaginal bleeding than after a first-trimester abortion. Staff should also be trained to provide counselling and information specific to second-trimester abortion.

2.2.4.4. Other surgical methods of abortion for use in later pregnancy

Major surgical operations should not be used as primary methods of abortion. Hysterotomy has no role in contemporary abortion practice, since its morbidity, mortality and cost are markedly higher than those of D&E or medical methods of abortion. Similarly, hysterectomy should not be used except for women with conditions that would warrant the operation independently (19).

2.2.4.5. Tissue examination following surgical abortion

After surgical methods of abortion, immediate examination of the products of conception is important to exclude the possibility of ectopic pregnancy and assess whether the abortion is likely to be complete. With vacuum aspiration, beginning around 6 weeks of pregnancy, trained providers can visually identify the products of conception, specifically chorionic villi and the gestational sac (59). If the aspirate does not contain products of conception, ectopic pregnancy should be suspected and the woman should undergo further evaluation (see Section 2.1.6). In addition, providers should be alert to tissue appearances suggestive of molar pregnancy, particularly in countries where molar pregnancy is common. If the contents of the aspirate contain less tissue than expected, the possibility of incomplete abortion and treatment with re-aspiration should be considered. Routine examination of the products of conception by a pathology laboratory is not necessary when trained providers perform routine tissue examination.

2.2.5. Medical methods of abortion

(see Box 2.1)

BOX 2.1

Dosages and routes of administration for mifepristone followed by misoprostol. 200 mg mifepristone administered orally. Administration of misoprostol is recommended 1 to 2 days (24–48 hours) following ingestion of mifepristone.

Medical methods of abortion have been proved to be safe and effective (4, 19, 24, 69–71). The most effective regimens rely on the antiprogestogen, mifepristone, which binds to progesterone receptors, inhibiting the action of progesterone and hence interfering with the continuation of pregnancy. Treatment regimens entail an initial dose of mifepristone followed by administration of a synthetic prostaglandin analogue, generally misoprostol, which enhances uterine contractions and aids in expelling the products of conception (72). Gemeprost is a prostaglandin analogue similar to misoprostol, but it is more expensive, requires refrigeration, and may only be administered vaginally (12). Thus, although gemeprost demonstrates similar efficacy as misoprostol, misoprostol is the prostaglandin analogue of choice for abortion-related care (73). A number of other prostaglandins that were used in the past, such as sulprostone and prostaglandin F_2α, are no longer used because of their adverse side-effects or relative lack of efficacy (74).

The effects of medical methods of abortion are similar to those associated with spontaneous abortion and include uterine cramping and prolonged menstrual-like bleeding. Bleeding occurs for 9 days on average but can last up to 45 days in rare cases (75).

Side-effects include nausea, vomiting and diarrhoea. Contraindications to the use of mifepristone and a prostaglandin analogue include chronic or acute adrenal or hepatic failure, inherited porphyria, and allergy to any of the drugs used. Mifepristone is not an effective treatment for ectopic pregnancy; suspicion of ectopic pregnancy demands further investigation and, if confirmed, immediate treatment (11). Caution and clinical judgement are required for women using corticosteroids long term, and for those who have bleeding disorders, severe anaemia, pre-existing heart disease or cardiovascular risk factors (12).

Medical methods of abortion have proved acceptable in many settings, including low-resource settings (76–78). The medications are increasingly available globally, and the combination of mifepristone and misoprostol for medical abortion is now included on the WHO model list of essential medicines (73, 79). As these medications become increasingly available, programme managers should be aware of what is required to introduce medical methods of abortion into existing health services (see Chapter 3).

2.2.5.1. Mifepristone and prostaglandin analogue

For pregnancies of gestational age up to 9 weeks (63 days)

Mifepristone with misoprostol has been proven highly effective, safe and acceptable for abortions occurring up to 9 weeks since the LMP. Efficacy rates up to 98% are reported (70, 80). Approximately 2–5% of women treated with the combination of mifepristone and misoprostol will require surgical intervention to resolve an incomplete abortion, terminate a continuing pregnancy, or control bleeding (81).

The original protocols for the use of mifepristone recommended an oral dose of 600 mg mifepristone followed by 1 mg of vaginal gemeprost after 36–48 hours. However, several studies have established that 200 mg of mifepristone is the dosage of choice, since it is as effective as 600 mg, and reduces costs when followed by a suitable prostaglandin analogue (4, 81–83). Some studies have indicated that mifepristone can be given as five or six divided doses of 25 mg over 3 days, for a total dose of 125–150 mg (84), a regimen widely used in the People's Republic of China. However, for service delivery and patient convenience, the single dose of mifepristone is recommended. A 50 mg dose of mifepristone is less effective than 200 mg, when given in combination with gemeprost (85). One trial reported that mifepristone, 100 mg, when combined with 800 μg of misoprostol given vaginally, was as effective as 200 mg; however, efficacy in both arms of this study was lower than expected (86).

Misoprostol is an effective prostaglandin analogue that is considerably less expensive than gemeprost, and does not require refrigeration. It is therefore the prostaglandin analogue of choice. An oral dose of 200 mg mifepristone followed by 800 μg misoprostol administered vaginally, sublingually or buccally is an effective medical abortion regimen (4). When compared to vaginal administration, sublingual misoprostol appears to be associated with higher rates of gastrointestinal side-effects, and buccal administration appears to be associated with higher rates of diarrhoea (4). Vaginal misoprostol is more effective and better tolerated than misoprostol given orally (87). Misoprostol given orally at a dose of 400 μg should be restricted to pregnancies up to 7 weeks' (49 days') gestation, given its higher failure rate when given orally as pregnancy progresses (12, 81).

Some protocols require that women take both mifepristone and a prostaglandin analogue under clinical supervision, involving a second visit to the healthcare facility one or two days after receiving mifepristone, to take the prostaglandin analogue. Home use of misoprostol is a safe option for women (80, 88). Increasingly, after receiving the mifepristone in the clinic, women receive misoprostol for self-administration at home within 24–48 hours following the mifepristone. Nevertheless, some women may prefer clinic use (89). Women using misoprostol at home may leave the facility shortly after taking the mifepristone. They must be told what to expect with regard to vaginal bleeding and expulsion of products of conception following use of misoprostol, and how to recognize complications and whom to contact if they should occur. Explaining that the misoprostol dose should be taken as planned regardless of whether bleeding occurs following mifepristone is important for the few women who experience such bleeding.

Following administration of the misoprostol, up to 90% of women will expel the products of conception over the following 4–6 hours. Most women are likely to require medication for cramping pain during this period of time (see Section 2.2.2.1).

In the case of a failed abortion where pregnancy is ongoing, re-administration of misoprostol or surgical abortion should be offered to the woman (12). Women with incomplete abortions can generally be observed unless vaginal bleeding is heavy, or they may be offered re-administration of misoprostol or surgical completion of their abortion. Facilities offering medical methods of abortion must be able to ensure provision of vacuum aspiration, if needed. Such provision can be available on-site or through an arrangement with another facility that performs vacuum aspiration. In all cases, health-care providers must ensure that the woman can reach such services in case of an emergency.

Women are more likely to be satisfied with the procedure if they have realistic expectations about the abortion process (90). Hence, they need complete information about what is to be expected with, and the possible side-effects of, medical methods of abortion. Health-care workers should ensure that women understand the importance of complying with the protocol, especially for drugs that are self-administered, and that they know how to recognize, and what to do in case of, complications.

For pregnancies of gestational age from 9 to 12 weeks (63–84 days)

Limited data suggest that during this period the most effective medical regimen is mifepristone 200 mg orally followed 36–48 hours later by misoprostol 800 μg vaginally, administered in a health-care facility. A maximum of four further doses of misoprostol 400 μg may be administered at three-hourly intervals, vaginally or sublingually (27, 28). Regimens during this period of pregnancy and the setting in which they can be administered are the subject of ongoing research.

For pregnancies of gestational age over 12 weeks (>84 days)

A regimen of oral mifepristone, 200 mg, followed by repeated doses of misoprostol is safe and highly effective when administered in a health-care facility (3, 91). An oral dose of 200 mg mifepristone followed 36–48 hours later by an initial dose of misoprostol, either 400 μg orally or 800 μg vaginally, with further doses of 400 μg of vaginal or sublingual misoprostol every 3 hours, up to four further doses is highly effective (91). For pregnancies beyond 24 weeks' gestation, the dose of misoprostol should be reduced, due to the greater sensitivity of the uterus to prostaglandins, but the lack of clinical studies precludes specific dosing recommendations.

A vaginally administered dose of 1 mg gemeprost used after 200 mg mifepristone, and repeated if necessary every 6 hours up to four doses can also be used effectively (92). The treatment with gemeprost may continue with 1 mg gemeprost every 3 hours for four additional doses if necessary (93, 94).

2.2.5.2. Misoprostol alone

For pregnancies of gestational age up to 12 weeks (84 days)

Misoprostol alone has also been studied for medical abortion in terms of effectiveness and safety. The effectiveness of misoprostol alone is lower, the time to complete abortion is prolonged, and the abortion process is more painful and associated with higher rates of gastrointestinal side-effects than when misoprostol is combined with mifepristone (4, 95). Because of misoprostol's wide availability and low cost, and since in some settings its broader use has been reported to contribute to a decrease in complications from unsafe abortion (96), the use of misoprostol alone appears to be common where mifepristone is unavailable.

The recommended misoprostol regimens are 800 μg administered vaginally or sublingually, and repeated at intervals no less than 3 hours but no more than 12 hours for up to three doses. This regimen is 75–90% effective in completing abortion. Sublingual administration is less effective than vaginal administration unless it is given every 3 hours, but this regimen has high rates of gastrointestinal side-effects (4, 96, 97). Oral administration is not recommended due to its low efficacy.

For pregnancies of gestational age over 12 weeks (84 days)

Misoprostol is effective in inducing abortion after 12 weeks of pregnancy, although the time to complete abortion is not as short as when it is used in combination with mifepristone. The recommended regimen is 400 μg of vaginal or sublingual misoprostol every 3 hours for up to five doses (91, 98). Particularly for nulliparous women, vaginal administration of misoprostol is more effective than sublingual dosing. For pregnancies beyond 24 weeks' gestation, the dose of misoprostol should be reduced due to the greater sensitivity of the uterus to prostaglandins; however, the lack of clinical studies precludes dosing recommendations.

Vaginal administration of gemeprost alone is registered for termination of second-trimester pregnancy in several countries. The recommended dose is 1 mg, which is given every 3 hours up to five times during the first day and repeated the next day if necessary. With this treatment, 80% and 95% of women will abort within 24 and 48 hours, respectively (99).

2.2.5.3. Other medical abortion agents

Methotrexate, which is a cytotoxic drug used to treat certain types of cancer, rheumatoid arthritis, psoriasis and some other conditions, has been used in combination with misoprostol as a medical method for early abortion (pregnancies of gestational age up to 7 weeks) in some countries where mifepristone has not been available. When combined with misoprostol, it is effective: a number of studies report an overall success rate of greater than 90% with 50 mg of methotrexate orally or intramuscularly, followed by 800 μg vaginal misoprostol 3–7 days later (4). However, a WHO toxicology panel recommended against the use of methotrexate for inducing abortion, based on concerns of teratogenicity if the pregnancy was not successfully aborted (100). Although the actual risks are as yet unknown, limb defects and skull and facial abnormalities in pregnancies that continued after failed attempts to induce abortion with methotrexate have been reported (101–103). It is therefore recommended that services wishing to introduce medical methods of abortion use combination regimens of mifepristone and misoprostol.

Other agents are used to stimulate uterine contractions and induce abortion after 12 weeks, but available data regarding their safety are limited. These agents include hypertonic saline, or hyperosmolar urea, injected intra-amniotically; ethacridine lactate administered intra- or extra-amniotically; prostaglandin analogues administered parenterally or intra- or extra-amniotically; and oxytocin injected intravenously or intramuscularly (91, 104). These methods and routes of administration, however, are invasive and likely to be less safe, and the time to complete abortion is longer when compared to the use of methods such as combined mifepristone and misoprostol.

2.2.6. Managing abortion complications

When abortion is performed by appropriately trained personnel under modern medical conditions, complications are impressively rare and the risk of death is negligible (in contrast to unsafe abortion, see Chapter 1). Nevertheless, every service-delivery site at each level of the health system should be equipped and have personnel trained to recognize abortion complications and to provide, or refer women for, prompt care, 24 hours a day (104). The facilities and skills required to manage most abortion complications are similar to those needed to care for women who have had a spontaneous abortion (miscarriage).

2.2.6.1. Ongoing pregnancy

Failed abortion with ongoing pregnancy can occur in women who have undergone either surgical or medical methods of abortion, although it is more common after medical procedures. Women with continuing symptoms of pregnancy or clinical signs of failed abortion should be offered a uterine evacuation procedure as expeditiously as possible (19).

2.2.6.2. Incomplete abortion

Incomplete abortion is uncommon following vacuum aspiration when the abortion is performed by a skilled provider. It is more common with medical methods of abortion (56). Common symptoms include vaginal bleeding and abdominal pain, and signs of infection may be present. Incomplete abortion should also be suspected if, upon visual examination, the tissue aspirated during surgical abortion is not compatible with the estimated duration of pregnancy. Staff at every health-care facility should be trained and equipped to treat incomplete abortion by emptying the uterus, paying attention to the possibility of haemorrhage, which might cause anaemia, or infection, which would necessitate antibiotic treatment.

Incomplete abortion may be treated using either vacuum aspiration or misoprostol. Vacuum aspiration is recommended over D&C for uterine evacuation, as it is associated with less blood loss, less pain and shorter procedure times (105). Incomplete abortion may also be treated using misoprostol: no differences were demonstrated in rates of complete abortion or of adverse events between uterine aspiration or misoprostol for women with incomplete spontaneous abortion (miscarriage) with uterine size up to 13 weeks' gestation, although there were more unplanned surgical interventions with misoprostol use (106). The recommended misoprostol dose and route of administration for this indication is either 600 μg oral or 400 μg sublingual (106, 107). The presence of bleeding may decrease misoprostol absorption when the drug is administered vaginally (108); thus, a non-vaginal route is generally preferable, although vaginal administration of 400–800 μg has been used effectively (106). Incomplete spontaneous abortions may also be managed expectantly, for women who are clinically stable and wish to avoid medical or surgical treatment, but the process takes more time (106). The decision about management of incomplete abortion should be based upon the clinical condition of the woman and her preference for treatment.

2.2.6.3. Haemorrhage

Haemorrhage can result from retained products of conception, trauma or damage to the cervix, coagulopathy or, rarely, uterine perforation. Depending on the cause of the haemorrhage, appropriate treatment may include re-evacuation of the uterus and administration of uterotonic drugs to stop the bleeding, intravenous fluid replacement, and, in severe cases, blood transfusion, replacement of clotting factors, laparoscopy or exploratory laparotomy. Because of the low incidence of haemorrhage using vacuum aspiration, oxytocic drugs are not routinely needed, although they may be indicated with D&E. Prolonged menstrual-like bleeding is an expected effect of medical methods of abortion. On average, vaginal bleeding gradually diminishes over about 2 weeks after medical abortion but, in individual cases, bleeding and spotting may persist for up to 45 days; such bleeding is rarely heavy enough to constitute an emergency. Surgical evacuation may be performed on the woman's request, or in cases where the bleeding is heavy or prolonged, causes anaemia, or there is evidence of infection. However, every service-delivery site must be able to stabilize and treat or refer women with haemorrhage immediately (19).

2.2.6.4. Infection

Infection rarely occurs following properly performed abortions. The genital tract, however, is more susceptible to ascending infection when the cervix is dilated after abortion or childbirth. Common signs and symptoms of infection include fever or chills, foul-smelling vaginal or cervical discharge, abdominal or pelvic pain, prolonged vaginal bleeding or spotting, uterine tenderness, and/or an elevated white blood cell count. When infection is diagnosed, health-care staff should administer antibiotics and, if retained products of conception are a likely cause of the infection, re-evacuate the uterus. Women with severe infections may require hospitalization. As discussed in Section 2.1.5, prophylactic provision of antibiotics for women undergoing surgical abortion has been found to reduce the risk of post-abortion infection (9) and they should be provided where possible.

There are few data on the incidence of clinically significant pelvic infection after medical abortion, but it occurs rarely and possibly less frequently than after vacuum aspiration. Many of the symptoms of pelvic infection, such as pain, are rather nonspecific and hence precise diagnosis is difficult. Women with pelvic pain, abdominal or adnexal tenderness, vaginal discharge, and fever should be treated with broad-spectrum antibiotics.

Rare cases of anaerobic infection without fever have been reported from Canada and the USA, following medical abortion (10, 12, 109). No such cases have been reported elsewhere. In these cases, women had little or no fever; variable nausea, vomiting, weakness and some abdominal pain; rapid deterioration within hours or days; tachycardia and refractory hypotension; multiple effusions; elevated haematocrit; and elevated leukocyte count and neutrophilia. All women had Clostridium-related toxic shock. Reported cases have also occurred outside of abortion care, such as during the postpartum period following a normal delivery (110). There is no evidence that prophylactic antibiotic treatment during medical abortion would eliminate these rare fatal cases of serious infection; therefore, prophylactic provision of antibiotics for women undergoing medical abortion is not recommended.

2.2.6.5. Uterine perforation

Uterine perforation usually goes undetected and resolves without the need for intervention. A study of more than 700 women undergoing concurrent first-trimester abortion and laparoscopic sterilization found that 12 out of the 14 uterine perforations were so small that they would not have been recognized had laparoscopy not been performed (111). When uterine perforation is suspected, observation and antibiotic treatment may be all that is necessary. When available and necessary, laparoscopy is the investigative method of choice. If the laparoscopy examination and/or the status of the patient give rise to any suspicion of damage to the bowel, blood vessels or other structures, a laparotomy to repair the damaged structures may be needed.

2.2.6.6. Anaesthesia-related complications

Local anaesthesia is safer than general anaesthesia, both for vacuum aspiration in the first trimester and for D&E in the second trimester (1, 49, 50). Where general anaesthesia is used, staff must be skilled in management of seizures and cardiorespiratory resuscitation. Narcotic-reversal agents should always be readily available in settings where narcotics are used.

2.2.6.7. Uterine rupture

Uterine rupture is a rare complication. It is associated with later gestational ages and uterine scar, but has also been reported in women without these risk factors. In a meta-analysis, the risk of uterine rupture in women with a prior caesarean delivery having a misoprostol-induced abortion in the second trimester was found to be 0.28% (112).

2.2.6.8. Long-term sequelae

The vast majority of women who have a properly performed induced abortion will not suffer any long-term effects on their general or reproductive health (113–115). In modern times, the risk of death from a safe, induced abortion is lower than from an injection of penicillin (116) or carrying a pregnancy to term (1).

Research shows no association between safely induced first-trimester abortion and adverse outcomes in subsequent pregnancies (117). Although second-trimester abortions have not been studied as extensively, there is no evidence of an increased risk of adverse outcomes in subsequent pregnancies (114, 118). Sound epidemiological data show no increased risk of breast cancer for women following spontaneous or induced abortion (119, 120). Negative psychological sequelae occur in a very small number of women and appear to be the continuation of preexisting conditions, rather than being a result of the experience of induced abortion (121, 122).

2.2.6.9. Other complications

Following unsafe abortion, various other complications may occur that result from the manner or method of provoking the abortion. Examples are poisoning, abdominal trauma, or the presence of foreign bodies in the genital tract, among others. Women with these complications should be stabilized and treated or referred for appropriate treatment, in addition to managing any abortion-related complications (see Sections 2.2.6.1–2.2.6.6) and receiving appropriate post-procedure care (see Section 2.3).

2.2.7. Other issues related to abortion procedures

2.2.7.1. Infection prevention and control

Since abortion procedures and care involve contact with blood and other body fluids, all clinical and support staff in all facilities that provide these services should understand and apply standard precautions for infection prevention and control, for both their own protection and that of their patients.

Standard precautions are simple infection-control practices to be used in the care of all patients, at all times, to reduce the risk of transmission of blood-borne infections. They include: hand-washing with soap and water before and after all procedures; use of protective barriers such as gloves, gowns, aprons, masks, and goggles to avoid direct contact with blood and other body fluids; safe disposal of waste contaminated with blood or other body fluids; proper handling of soiled linen; careful handling and disposal of “sharps”; and proper disinfection of instruments and other contaminated equipment (123).

Hand-washing and use of protective barriers

All staff should wash their hands thoroughly before and after coming into contact with the woman, as well as immediately following any contact with blood, body fluids or mucous membranes (124). High-level disinfected or sterile gloves should be worn and replaced between contacts with different patients and between vaginal (or rectal) examinations of the same woman. After completing the care of one woman and removing gloves, the health-care provider should always wash their hands, as gloves may have undetected holes in them (124). The use of auxiliary supplies, such as sterile booties, does not make a significant difference in infection rates, although it increases costs.

Cleaning

Detergents and hot water are adequate for the routine cleaning of floors, beds, toilets, walls, and rubber draw sheets. Following spillage of body fluids, heavy-duty rubber gloves should be worn and as much body fluid as possible removed with an absorbent material. This can then be discarded in a leak-proof container and later incinerated or buried in a deep pit. The area of spillage should be cleaned with a chlorine-based disinfectant and then thoroughly washed with hot soap and water.

All soiled linen should be handled as little as possible, bagged at the point of collection and not sorted or rinsed in patient-care areas. If possible, linen with large amounts of body fluid should be transported in leak-proof bags. If leak-proof bags are not available, the linen should be folded with the soiled parts inside, and handled carefully, wearing gloves.

Safe disposal of waste contaminated with body fluids

Solid waste that is contaminated with blood, body fluids, laboratory specimens or body tissue should be treated as clinical waste, and disposed of properly and in accordance with local regulations (123). Liquid waste, such as blood or other body fluids, should be poured down a drain connected to an adequately treated sewer or pit latrine.

Safe handling and disposal of “sharps”

The greatest hazard of HIV transmission in healthcare settings is through skin puncture with contaminated needles or “sharps”. This also applies to transmission of hepatitis B and C. Most “sharps” injuries involving such transmission are through deep injuries with hollow-bore needles. Such injuries frequently occur when needles are recapped, cleaned, disposed of, or inappropriately discarded. Although recapping needles is to be avoided whenever possible (124), sometimes recapping is necessary. When this is the case, a single-handed scooping method should be used. Puncture-resistant disposal containers must be available and readily accessible for the disposal of “sharps”. These can be burned in a closed incinerator or buried in a deep pit. Added precautions to prevent “sharps” injuries include wearing gloves, having an adequate light source when treating women, placing “sharps” containers directly at the point of use, never discarding “sharps” in general waste, and keeping “sharps” out of the reach of children. Whenever possible, needle holders should be used when suturing.

Safe cleaning of equipment after use

Immediately after use, all reusable surgical instruments used in abortion should be sent for cleaning and sterilization. Medical equipment and supplies intended for single use should not be reused (124). Where central services for instrument processing are not available, or in resource-poor settings, the following procedures are recommended.

The most important step to ensure proper final decontamination of instruments is physical cleaning (123). Instruments should be kept wet until cleaning. Letting the devices dry may make it difficult to completely remove all contaminants. A disinfectant such as a 0.5% chlorine solution can be used. Aspirators must be disassembled before cleaning and further processing. Detachable adaptors must be removed from cannulae.

Caution: aspirators, cannulae and adaptors are not safe to handle with bare hands until cleaned.

After soaking, wash all surfaces thoroughly in running water and detergent. Detergent is preferable to soap, which can leave a residue. All instruments should then be sterilized (preferred) or disinfected with a high-level disinfectant (where sterilization is not possible or feasible). Sterilization kills all microorganisms, including bacterial endospores such as those that cause tetanus and gas-gangrene. High-level disinfection (HLD) destroys all microorganisms including hepatitis and HIV but does not reliably kill bacterial endospores.

Sterilization is best achieved with pressurized steam (autoclave) or multi-hour (>5 hours) soaks in fresh glutaraldehyde solution (125). HLD can be achieved by shorter soaks in glutaraldehyde or bleach (sodium hypochlorite) solutions (125). The use of phenol or antiseptics will not achieve HLD. Instruments that were cold-processed (soaked in solutions) must be thoroughly rinsed after processing. Instruments that were subjected to HLD may be rinsed in boiled water; instruments that were sterilized should be rinsed in sterile water (see Table 2.1 for instrument-processing details).

Table 2.1

Instrument processing.

Some manufacturers produce aspirators and cannulae made of high-grade plastics that are engineered to be sterilized in an autoclave, while other plastic instruments will crack and melt when exposed to high heat for sterilization. Health-care workers should always refer to the instructions for use of all items being disinfected, to ensure they are using the appropriate form of disinfection. Additionally, the manufacturers' instructions for all products used in the disinfection process should be followed.

2.3. Post-abortion care and follow-up

Following an induced or spontaneous abortion, women should receive appropriate post-abortion care. For those women whose abortions were performed unsafely, post-abortion care is used as a strategy to attenuate the morbidity and mortality associated with complications, including uterine aspiration for incomplete abortion (see Section 2.2.6.2); offer of contraception to prevent future unintended pregnancies; and linking women with other needed services in the community. Following safe, induced abortion, post-abortion care may not require a follow-up visit if the woman has adequate information about when to seek care for complications and has received any needed supplies or information to meet her contraceptive needs.

All women should receive contraceptive information and be offered counselling for and methods of post-abortion contraception, including emergency contraception, before leaving the health-care facility. All methods of contraception, including IUDs and hormonal contraceptives, can be initiated immediately following surgical or medical abortion, as long as attention is paid to each woman's health profile and the limitations associated with certain methods (see Annex 6). There are a few methods that should not be started immediately following an abortion: the contraceptive diaphragm and cervical cap should not be used until about 6 weeks after a second-trimester abortion, and fertility-awareness-based methods should only be started after the resumption of regular menses (127). IUDs placed immediately post-abortion offer better protection against unintended pregnancy than postponing insertion (128–130). Although it is safe, there is a higher risk of expulsion of IUDs if inserted at the time of a second-trimester abortion (131). For medical abortion, hormonal contraceptives can be started by the woman after taking the first pill of a medical abortion regimen, but confirmation that the abortion is complete should precede insertion of an IUD or sterilization. Additionally, special attention should be given when women request sterilization, to ensure their choice is not unduly influenced by the nature of the moment.

Abortion-service-delivery sites should be able to provide a woman's contraceptive method of choice in the facility. If the contraceptive method chosen by the woman cannot be provided on-site (e.g. sterilization is rarely offered at primary-care level), the woman should be given information about where and how she can obtain it, and be offered an interim method. For those methods not available on-site, the abortion facility should develop a direct referral system to ensure women are able to obtain their chosen contraceptive method. All women should be informed about emergency contraception, and consideration should be given to providing it to them to be kept at home for future use, particularly for women who choose condoms as their primary method of contraception and those who choose not to start using a routine contraceptive method immediately.

Providers should discuss prevention of STIs, including HIV, and the importance of condom use with women who choose methods other than condoms for contraception (127). Information about infection prevention should be particularly emphasized for individuals who may be at increased risk, and in areas of known high prevalence of HIV and other STIs. HIV counselling and testing should be available in the facility, or by referral to other facilities. Dual protection, or the use of one method such as condoms, or a combination of methods, to protect against both pregnancy and STIs should be promoted.

Women undergoing abortion should receive clear, simple, oral and written instructions about how to care for themselves after leaving the health-care facility, and how to recognize complications that require medical attention. These instructions should include: abstaining from sexual intercourse and from placing anything in the vagina until bleeding stops; the availability of contraception, including emergency contraception, to avoid a pregnancy (fertility may return as soon as 2 weeks following abortion); and the need to return to the health-care facility in case of increasing pelvic pain, heavy bleeding or fever (19). During the time it takes for a medical abortion to be completed, women should be able to contact, at any time, a physician or other health-care worker who can answer questions and provide support.

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