The document provides information on medical and surgical abortion methods. It discusses medication abortion procedures using mifepristone and misoprostol up to 12 weeks gestation. For pregnancies between 12-24 weeks it recommends mifepristone followed by repeated doses of misoprostol. Surgical abortion techniques including manual vacuum aspiration are described, involving dilating the cervix, inserting a cannula to suction the uterine contents. Pain management and counseling requirements are also outlined.

1. Namus M.
Apr 22

2. Introduction
Medical methods
Surgical methods
Summary
References

3.  Among the 208 million women estimated to become pregnant
each year worldwide, 59 percent (or 123 million) experience a
planned or intended pregnancy leading to a birth or miscarriage or
a still birth.
 Surgical methods of abortion
 Use of transcervical procedures for terminating pregnancy,
including :
 vacuum aspiration,
 dilatation and curettage (D&C),
 dilatation and evacuation (D&E) and
 transabdominal procedures (hysterotomy and hysterectomy).
 Medication abortion
 Use of pharmacological drugs to terminate pregnancy.
 Sometimes the term “non-surgical abortion” is also used.

4.  .
MEDICAL TECHNIQUES
Intravenous oxytocin
Intra-amnionic hyperosmotic fluid
- 20% saline
- 30% urea
Prostaglandins E2, F2?, E1, and analogues
- Intra-amnionic injection
- Extraovular injection
- Vaginal insertion
- Parenteral injection
- Oral ingestion
Antiprogesterones (RU 486 [mifepristone] and epostane)
Methotrexate (intramuscular and oral)
Various combinations of the above

5.  .
SURGICAL TECHNIQUES
Cervical dilatation followed by uterine evacuation
- Curettage
- Vacuum aspiration (suction curettage)
- Dilatation and evacuation (D&E)
- Dilatation and extraction (D&X)
Menstrual aspiration
Laparotomy
- Hysterotomy
- Hysterectomy

6.  .

7.  .
MEDICATION ABORTION SURGICAL ABORTION
Usually avoids invasive procedure Invasive procedure
Usually avoids anesthesia Sedation used if desired
Requires two or more visits Usually requires one visit
Days to weeks to complete Complete in a predictable period
Available during early pregnancy Available during early pregnancy
High success rate (~95%)
High success rate (99%)
Bleeding moderate to heavy for a short
time
Bleeding commonly perceived as light
Requires surveillance to ensure
completion of abortion
Does not require surveillance in all cases

8. The first steps in providing abortion care are to:
establish that the woman is pregnant
estimate the duration of the pregnancy
confirm that the pregnancy is intrauterine
These are obtained by:
History
P/E
Targeted Investigations

9.  Past reproductive history
 LMP
 Breast tenderness/engorgement,
nausea & vomiting, fatigue,
changes in appetite, and increased
frequency of urination
 Previous ectopic pregnancy;
 any bleeding tendencies or
disorders;
 history of or presence of STIs;
 current use of medications;
 known allergies;
 Physical or cognitive
disabilities/mental illness
 Surgical history
 History of contraceptive use
 Alcohol, tobacco or drug use
 Ask for contraindication for
medication abortion use
 History of sexual violence
 Overall Psychological assesment

10. Vital Signs: Blood pressure, pulse and temperature
Confirm pregnancy and estimate its duration by a
bimanual pelvic and an abdominal examination
Signs of pregnancy include softening of the cervical
isthmus and softening and enlargement of the uterus.
The uterus is anteverted, retroverted or otherwise
positioned
Signs of STIs and other reproductive tract infections
Health conditions, such as anemia

11. Laboratory Tests:
 Obtaining such tests should not hinder or delay uterine
evacuation
 Hgb/ Hct
 Blood Group & Rh
US
 Is not routinely required for the provision of abortion
 Can help identify an intrauterine pregnancy and exclude an
ectopic one
 It may also help determine gestational age and diagnose
pathologies or non-viability of a pregnancy
 Some health-care providers find it helpful before or during

12. The provision of information is an essential part of
good-quality abortion services
Adequate relevant information and counseling from a
trained health-care professional
Information must be provided to each woman,
regardless of her age or circumstances, in a way that
she can understand, to allow her to make her own
decisions about whether to have an abortion and, if so,
what method to choose.

13. Information on abortion procedures
what will be done during & after
What & for how long is experienced
pain management available
risks and complications of the method
When to resume her normal activities
Follow-up care

14. If a choice of abortion methods is available, clear
information about
which methods are appropriate and
the advantages and disadvantages of each available
method.

15. Contraceptive information and services
Is an essential part of abortion care
GOAL: to begin the chosen method immediately following
abortion
This will increase the likelihood that she will continue its
correct and consistent use
Every woman should be informed that ovulation can
return as early as 2 weeks after abortion

16. A
Consent Form for Uterine Evacuation
After having consulted with my health service provider about my health condition, I, (name of client)
, hereby consent to a procedure for safe termination of pregnancy. I have been counseled and informed about the
alternative methods and about the possible side effects and outcomes of the procedure.
In the event of complications arising during the procedure, I request and authorize the responsible health service
provider to do whatever is necessary to protect my health and wellbeing.
I confirm that the information that I provided to my health service provider is accurate.
Signature ________________________________
Date _____________________________________

17. The most appropriate methods of abortion differ by the
duration of pregnancy .
The methods summarized are indicative rather than
prescriptive with regard to the time limits

18. A

19. Have been proved to be safe, effective & feasible
The most effective regimens rely on the anti-
progestogen, mifepristone.
Treatment regimens entail an initial dose of
mifepristone followed by administration of a synthetic
prostaglandin analogue
Gemeprost is similar to misoprostol, but it is more
expensive, requires refrigeration, and may only be
administered vaginally.

20. Up to
7 weeks*
Mifepristone 200
mg Oral
Wait 24-48 hours
Misoprostol 800
mcg Vaginal OR
Buccal OR
Sublingual
Misoprostol 400
mcg Oral
7-9 weeks* Mifepristone 200
mg Oral
Wait 24-48 hours
Misoprostol 800
mcg Vaginal OR
Buccal OR
Sublingual

21. 9 -12 weeks
(63 -84 days)
Mifepristone 200
mg Oral
Wait 36-48
hours
Misoprostol
800 mcg
Vaginal
Additional
Misoprostol 400
mcg Vaginal or
Sublingual
every 3 hours
for maximum of
4 further doses

22. >12 weeks
(63 -84 days)
Mifepristone 200
mg Oral Wait 36-48 hours
400 μg oral or 800
μg vaginal
misoprostol
followed
400 μg vaginal or
sublingual
misoprostol every 3
hours up to a
maximum of five
doses,
administered in a
health-care facility.

23.  200 mg mifepristone administered orally, followed after
36 to 48 hours by:
 400 μg oral or 800 μg vaginal misoprostol followed by
400 μg vaginal or sublingual misoprostol every 3 hours
up to a maximum of five doses, administered in a
health-care facility.
For pregnancies of gestational age greater than 24
weeks, 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

24. For pregnancies of gestational age up to 12 weeks (84
days)
 effectiveness of misoprostol alone is lower.
75–90% effective in completing abortion
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
For pregnancies of gestational age over 12 weeks (84
days)
 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

25. Up to 12 weeks
(up to 84 days)
Misoprostol 800
mcg
Vaginal or
Sublingual
REPEAT
Misoprostol every
3-12 hours for up
to 3 doses until
expulsion
Return for
confirmation of
completed
abortion in 7-14
days

26. Decrease rate of continuing pregnancy
Decrease time of expulsion
Fewer side effect
Improve complete abortion rate
Lower cost

27.  Up to 9 completed weeks since LNMP
 Mifeprestone PO 200 mg followed 48 hours later by
 Misoprostol 800 µg vaginally. Insert misoprostol deep into the
vagina or instruct the woman to do so by herself.
 After 12 till 24 weeks completed weeks since LMP
 Mifeprestone PO 200 mg followed 48 hours later by
 Misoprostol 400µg of oral misoprostol every 3 hours up to a maximum
of 5 doses if abortion does not occur.
 After 24 till 28 weeks completed weeks since LMP
 Mifeprestone PO 200 mg followed 48 hours later by
 Misoprostol 100µg of oral misoprostol every 3 hours up to a
maximum of 5 doses if abortion does not occur.

28. A

29. It is defined as the presence of gestational cardiac
activity on vaginal ultrasonography 2 weeks after the
initiation of mifepristone
 a retained sac 2 weeks after the administration of
mifepristone

30. Absence of pregnancy symptoms
History of bleeding, clots, cramps
Absence of signs of infection
Cervix: closed, not tender
Uterus: involutes, firm, not tender
Ultrasound: no growth/ viability

31. Excessive bleeding
 Soaking more than 2 thick pads/ hour for 2 consecutive hours
 Symptoms of anaemia or hypovolemia
Persistent fever:
 38˚C or higher or
 beginning more than 8 hours after taking misoprostol
No bleeding within 24 hours of taking misoprostol
Women with these warning signs should call or visit the
clinic.

32. Pre-Procedure Care:
The first steps in providing abortion care are to
establish that the woman is pregnant and, if she is, to
estimate the duration of the pregnancy.
Information & Counseling
Informed Consent
Cervical Preparations
Pain Manageement

33. The following groups of women need cervical
preparation regimens:
Nulliparous women and those aged 18 or below with
gestational duration of
more than nine weeks
All pregnant women at gestations more than 12 weeks
Cervical anomalies or previous surgery

34. Uses include:
 To make abortion procedure quicker and easier to
perform by reducing the
need for mechanical cervical dilatation.
To facilitate the procedure for inexperienced providers.

35. Methods:
Osmotic (hygroscopic) dilators
These devices, draw water from cervical tissues and
expand, gradually
dilating the cervix
Requires at least 4 hours to be effective
 Pharmacologic Agents
Misoprostol 400 micrograms (µg) vaginally or orally three
to four hours before
the procedure; or
 Mifepristone200 milligrams(mg) orally 36 hours before

36. .

37. Sources of pain
Psychological pain: anxiety, fear, apprehension
Cervical pain due to dilatation
Uterine cramping due to manipulation

38. Non-Pharmacological Methods for Relieving
Psychological Pain
- Gentle, respectful interaction and communication
- Verbal support and reassurance
- Gentle, smooth operative technique
- These supplement but do not substitute for drugs
 Pharmacological Means of Addressing Psychological
Pain
- Anxiolytics/sedatives: relieve anxiety
- Analgesics: relieve pain
- General anesthesia: for extreme cases

39. A

40. It is a method by which the contents of the uterus are
evacuated through a plastic or metal cannula that is
attached to a vacuum source.
Extremely effective (98 – 100 % of cases, at 12 weeks or
less) and very safe.
A. Manual Vacuum Aspiration (MVA)
B. Electric Vacuum Aspiration (EVA)
Specific safety benefits compared to sharp curettage
include
- reduced risk of infection
- reduced risk of cervical injury or uterine perforation
- reduced amount of cervical dilatation required
- decreased blood loss
- shortened hospital stay and reduced need for

41. . MVA
Inexpensive
Small
Portable
Quiet
Specimen likely
to be intact
May require
repeated reloading
of suction
EVA
More costly but longer
life
Bulky
Less portable
Noisy
Fragmentation of
specimen possible
Constant suction

42. It consists of manual
vacuum source (aspirator)
that produces suction and
holds tissues and blood
removed in uterine
evacuation procedures.
Cannulae are attached to
the aspirator to apply suction
and aspirate tissue from the

43. A

44. Intended for uterine aspiration or evacuation
Treatment of incomplete abortion uterine size to 12
weeks LMP
First-trimester abortion (menstrual regulation)
Endometrial biopsy
 Only contraindication: endometrial biopsy in cases of
suspected pregnancy

45.  1. Prepare instruments
 2. Prepare the woman
 3. Perform cervical antiseptic preparation
 4. Administer paracervical block
 5. Dilate cervix
 6. Insert cannula
 7. Suction uterine contents
 8. Inspect tissue
 9. Perform any concurrent procedures
 10. Process instruments

46. Disassembling the Aspirator
Assembling the MVA
Creating Vacuum (Charging)
Checking Vacuum Retention
Selection of Cannulae

47. Ensure pain medication is given at appropriate time
- Ask the woman to empty her bladder
- Put the patient in lithotomy position
- Ask for her permission to start
- Put on barriers and wash hands
- Perform a bimanual exam

48. Follow No-Touch
Technique
 Use antiseptic sponges
to clean cervix and os
and then, if desired,
vaginal walls
Do not retrace areas
previously cleaned

49. Recommended to
administer when
mechanical dilatation is
required
Usually 15 – 20 ml of 0.5
to 1 percent lidocaine
solution (< 200 mg)

50. To allow a cannula approximate to the uterine size
- Required in most but not all cases
- Cannula should fit snuggly in os to hold vacuum
- Use gentle operative technique
- Use progressively larger series of cannulae
- Can use mechanical dilators, laminaria, misoprostol

51. Gently apply traction to the
cervix
Rotate the cannula while
gently applying pressure
Insert cannula slowly until it
touches the fundus, draw
back
Alternatively, insert just past
internal os

52.  Attach charged aspirator
Release buttons to start suction
Gently rotate cannula 180 degrees
in each direction
Use “in and out” motion
Do not withdraw cannula opening
beyond external os

53. Gritty sensation
Frothy – bright red blood
No further conceptus material
aspirated
Uterus contracts as felt by
movement of cannula
Woman complaining of cramping
or pain

54. Empty contents of aspirator into container
Look for POC: villi and decidua should be visible
Amnion & chorion are
filmy and transparent;
Decidua is translucent.

55. Empty contents of aspirator into container
Look for POC: villi and decidua should be visible
Amnion & chorion are
filmy and transparent;
Decidua is translucent.

56. Such as IUD insertion or cervical tear repair

57. Proper handling and cleaning of the instrument used
and to make ready for the next procedure.

58.  Vagal Reaction
Incomplete evacuation
Uterine or cervical injury or perforation
Pelvic infection
acute hematometra

59. Physical monitoring
Pain management
Provision of antibiotics
Other health issues
Emotional monitoring and support
Contraceptive counseling
Follow-up care scheduled
Discharge instructions given

60. Performed first by dilating the cervix & evacuating the
product of conception
- Mechanically scraping out of the contents (sharp
curettage)
- Vacuum aspiration (suction curettage)
- Both
Before 14 weeks, D&C or vacuum aspiration should be
performed
After 16 weeks, dilatation & evacuation (D&E) is performed
- Wide cervical dilatation

61.  D&E is the generic term for suction curettage abortions at
>13 wks' gestation.
 D&E differs from suction curettage in two principal ways:
1.D&E requires wider cervical dilation, and
2.Physicians need forceps to evacuate more advanced pregnancies.
 It is the most common technique used for second-trimester pregnancy termination.
 The proportion of abortions performed by curettage techniques is inversely related to GA.

62.  Uterine perforation
Cervical laceration
Uterine bleeding due to large fetus and placenta

63.  Similar to Dilatation & Evacuation.
 Evacuation the intracranial content after the delivery of
fetal body
 Minimize uterine and cervical injury.
 Anti microbial prophylaxis recommended
 Generally performed for gestations of 24 weeks or later.

64.  Aspiration of endometrial cavity using a flexible cannula and
syringe within 1-3 weeks after failure to menstruate
 Several points at early stage of gestation
 Woman not being pregnant
 Implanted zygote may be missed by the curette
 Failure to recognize an ectopic pregnancy
 Infrequently, a uterus can be perforated

65. Abdominal hysterotomy or hysterectomy
 Indications
Significant uterine disease
Failure of medical induction during the 2nd trimester

66.  .