First-Trimester Procedures
Menstrual extraction—aspiration of endometrium through undilated cervix.
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- Performed for women who have not yet missed a menstrual period.
- 100% effective if implantation site is not missed.
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- Cervical trauma may occur and may lead to incompetent cervix.
- Hemorrhage.
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RU 486 (mifepristone)—a progesterone antagonist; taken up to 7 wk gestation (56 days LMP); taken orally.
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- Prevents implantation of fertilized egg.
- Most effective in early gestation, during luteal phase, within 10 days of first.
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- Slight nausea and fatigue during period of bleeding.
- Uterine aspiration may be needed if RU 486 does not work.
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Misoprostol—initiates uterine contractions; given intravaginally.
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- Softens cervix and aids in expelling products of conception.
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Uterine aspiration (vacuum or suction curettage)—cannula suction under local anesthesia, following cervical dilatation, usually with laminaria tent.
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- Relatively few complications—minimal bleeding, minimal discomfort.
- Outpatient basis.
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- Performed after one or two missed menstrual periods.
- Cervical or endometrial trauma possible.
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Surgical dilation and curettage (D & C)— cervix dilated with laminaria tents; endometrium scraped with metal curette or flexible aspiration tip, under local anesthesia (paracervical block).
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- After cervix is dilated, procedure takes about 15 min.
- Outpatient basis.
- Relatively few complications ( ≤ 1%)— bleeding like a heavy period, some cramping.
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- Performed after one or two missed periods.
- Possible but rare: cervical trauma, uterine perforation, infection, hemorrhage .
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Second-Trimester Procedures
Intraamniotic infusion between weeks 14 and 16; transabdominal extraction of 200 mL amniotic fluid and replacement with equal amount of hypertonic NaCl (20%); or 30% urea in D₅W.
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- Does not require laparotomy.
- Woman may ambulate until labor starts and during early labor.
- Abortion completed within 36-40 hr; 34 of fetuses are aborted in 24 hr.
- With urea: abortion usually occurs within 12 hr; complications less common or serious than with NaCl.
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- Complications increase proportionately with weeks of gestation.
- Risks—hypernatremia: tinnitus, tachycardia, and headache.
- Water intoxication: edema, oliguria (≤ 200 mL/8 hr), dyspnea, thirst, and restlessness
- Hemorrhage and possible disseminated intravascular coagulation (DIC); fever with sepsis.
- Woman experiences labor
- May require D & C.
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Instillation of 40-45 mg prostaglandin F₂, E₂
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- Labor is usually shorter than with hypertonic NaCl.
- Avoids complications of water intoxication and hypernatremia.
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- May cause vomiting, diarrhea, nausea.
- Fetus may be born alive.
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D & E (dilation and evacuation)— extends D & C and vacuum curettage up to 20 wk gestation.
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- Woman does not experience labor.
- Hospitalization is shortened.
- With a skilled operator, complication rate is lower than with intraamniotic injection methods.
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- Requires 3 d to dilate cervix; procedure done on third day.
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Second - and Third-Trimester Procedures
Hysterotomy—cesarean delivery
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- Available for gestations more than 14-16.
- Preferred method if woman wishes a tubal ligation or hysterectomy to follow.
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- After: major surgery complications—heir orrhage and infection possible.
- Fetus may be born alive, causing ethical, moral, religious, and legal problems.
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