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First Trimester Abortions — Surgical
Gestational age, as determined by the number of days since the first day of the last menstrual period, is used to determine the medically appropriate abortion method. In pregnancies with a gestational age of 63 days or less, a medication abortion, rather than a surgical abortion, is possible — see the heading, “Medical abortions (up to 9 weeks, or 63 days)” below. For pregnancies of a gestational age beyond 63 days, the following surgical methods are utilized.
- Manual Vacuum Aspiration – MVA (Up to 10 weeks)
- Dilation and Evacuation – D&E (6 – 13 weeks)
Both methods use suction to remove the fetus and other products of conception from the uterus (womb). For very early surgical abortions, a manual suction device may be used. Otherwise, machine-operated suction is used.
Late in the first trimester, the cervix or neck of the uterus must first be opened in order to accomplish the abortion. The cervix may be softened the day before using medication placed in the vagina and/or stretched slowly using thin rods made of seaweed inserted in the cervix. The day of the procedure metal rods may be needed to further stretch the cervix. Usually, the cervix needs to be opened no more than 1/4″-1/2″ in the first trimester. This can be painful, much like menstrual cramps, so local anesthesia is used.
Once the cervix has been adequately dilated, the fetus is removed by inserting a hollow plastic tube called a “vacurette” and applying suction. Generally, the plastic tube is moved in and out, or is rotated to enhance the suction force at the tip of the vacurette. This is sometimes followed by scraping the walls of the uterus with a loop-like tool, called a curette, to ensure that no fetal tissue or parts are left behind that might cause subsequent problems.
Second Trimester Abortions — Surgical
Dilation and Evacuation – D&E (13 – 24 weeks)
Abortion performed in the middle months of pregnancy is a significantly different procedure from the first trimester. The procedures used require greater time and skill and entail somewhat greater risk. The essential difference is that the cervix must be dilated to increasing diameters as the fetus grows. The extent to which the cervix can be safely dilated with dilators varies, dependent upon the woman’s cervix. Most experienced physicians will avoid the use of mechanical dilators beyond the 14th week of pregnancy; some will avoid them after the 10th week. As a general rule, the method of choice for dilating the cervix beyond the 12th week involves the use of osmotic dilators. Osmotic dilators made of seaweed absorb water and expand once placed inside the cervix. They are inserted a day or two before the abortion and/or oral or vaginal medications are given to further soften the cervix (this will cause cramping). After the cervix is stretched the uterine contents are suctioned out. Any remaining fetal or placenta parts are removed with forceps. Sharp curettage and or the suction machine may be used to remove any remaining tissue or blood clots to prevent infection or bleeding. This type of abortion is performed under sedation combined with local anesthesia.
* After 24 weeks of pregnancy, abortions are usually performed only for serious health reasons.
Possible Complications Following Surgical Abortions:
- Incomplete abortion
- Heavy bleeding
- Damage to the uterus or nearby internal structures
- Cervical tears
- Continued pregnancy
- Complications from general anesthesia
- RH sensitization
Medical Abortions (up to 9 weeks, or 63 days)
Currently, the two drugs used for early non surgical abortions are Mifepristone (formerly known as RU- 486) and Misoprostol. In this procedure Mifepristone is taken first and Misoprostol is taken in a follow-up visit.
The medication first given is Mifepristone. Mifepristone was developed and tested specifically as an abortion-inducing agent. Mifepristone is taken orally, and works by blocking the hormone progesterone that is necessary to sustain pregnancy. Without progesterone, the lining of the uterus breaks down, the cervix softens, and bleeding begins and the embryo dies.
After two days if the abortion hasn’t occured, a second drug, Misoprostol, is administered. Misoprostol acts on the uterus to create contractions and bleeding, similar to those of a spontaneous abortion or “miscarriage.” When taken after abortion-inducing drugs, it causes the uterus to expel the fetus. The contractions usually occur 2 to 4 hours after insertion of the suppositories. Heavy bleeding is expected at times, followed by severe abdominal cramps. Generally, cramping will be milder after the fetus has been expelled. The fetus and fetal tissue may be expelled at an unexpected time or place.
For most women who take the Mifepristone regimen, the abortion will be complete within four hours of taking Misoprostol. For others, bleeding begins in 24 hours. The whole process can take 9-16 days.
A follow-up appointment is necessary to make sure that the abortion is complete and that there is no risk of infection. If the abortion was not complete, a surgical abortion must be performed to ensure that all the fetal tissue has been removed. U.S. trials of Mifepristone indicate that 2 in 25 women will have to follow up their medical abortion with a surgical abortion (Spitz, Irving, et al., New England Journal of Medicine, 1998).