Surgical Abortion: A Comprehensive Clinical Overview

Definition and Overview

• First trimester (≤13 weeks): Vacuum curettage (suction aspiration) — manual (MVA) or electric pump
• Second trimester (14–24 weeks): Dilation and evacuation (D&E)

First-Trimester Surgical Abortion

Vacuum Curettage

1. Pre-procedure: Confirm gestational age (ideally with ultrasound). Administer antibiotic prophylaxis — a single dose of doxycycline is safe and effective (taken the night before or day of procedure).
2. Analgesia: Non-steroidal anti-inflammatory drugs (e.g., ibuprofen 800 mg) + anxiolytic (e.g., diazepam 10 mg) given pre-operatively. Local anesthetic (paracervical block with 1% lidocaine ± epinephrine) is administered at the cervicovaginal junction.
3. Positioning: Dorsal lithotomy. Bimanual exam to assess uterine size and position. Speculum placed; cervix cleansed with antiseptic (e.g., Betadine).
4. Tenaculum: A single-tooth tenaculum applied to the anterior or posterior cervical lip to stabilize the cervix and straighten the endocervical canal.
5. Cervical dilation: Achieved by:
   • Metal or plastic graduated dilators (e.g., Denniston dilators) — inserted progressively, feeling for a slight "pop" as each passes the internal os
   • Osmotic dilators (laminaria) placed hours before
   • Misoprostol 400 µg vaginally or buccally 3–4 hours before procedure
   • Cannula size typically matches gestational age in mm (e.g., 8–9 mm cannula for 9-week gestation)
6. Aspiration:
   • Insert cannula (5–12 mm diameter plastic) into uterine cavity using no-touch technique
   • Apply suction (55–75 mmHg); rotate in multiple directions
   • Endpoint: uterus feels smaller; "gritty" sensation on the cannula; no more tissue visible in tubing

Manual Vacuum Aspiration (MVA)

• Usable in office/clinic settings without powered equipment
• Quieter
• Lower cost

1. Prepare the syringe: push valve buttons down and forward; pull plunger back until arms snap over the barrel edge — this creates the vacuum reservoir.
2. Attach the cannula to the syringe; insert into the cervical os.
3. Release the valve to apply suction; rotate and move the cannula to aspirate tissue.
4. Continue until no further tissue is seen and the cavity feels empty.

Electric Suction Curettage

• Suction pressure of 55–75 mmHg or greater is required
• Technique is otherwise identical to MVA

Tissue Inspection

• Identify chorionic villi (feathery, float in water)
• Confirm gestational sac is present
• Tissue is sent to pathology to rule out ectopic pregnancy or trophoblastic disease
• If no villi are seen, ectopic pregnancy must be excluded urgently

Second-Trimester Surgical Abortion

Dilation and Evacuation (D&E)

1. Cervical preparation (essential at this gestational age):
   • Osmotic dilators (laminaria or Dilapan) placed 1–2 days prior — they absorb moisture and gradually expand, softening and dilating the cervix
   • Misoprostol (prostaglandin analog) ± mifepristone may be used as adjuncts
2. Surgical evacuation:
   • Suction curettage for smaller fetal parts
   • Grasping forceps (e.g., Bierer, Sopher forceps) to remove larger fetal parts
   • Ultrasound guidance is recommended throughout
3. Completion: Curettage to ensure uterine cavity is empty; inspect all tissue

• Fewer complications overall
• Less pain reported
• May be considered less emotionally challenging
• More cost-effective

Rh Status

Complications

First-Trimester Aspiration Complications (per 34,755 procedures)

Specific Complications

• Risk ~0.01% in first trimester; higher with later gestations, prior uterine surgery (e.g., cesarean section), or inexperienced operator
• Lateral perforations are more dangerous (risk of vascular injury)
• Small midline perforations may be managed conservatively with observation

• Can be due to uterine atony, retained products, perforation, or cervical laceration
• Managed with uterotonic agents (oxytocin, misoprostol, methylergonovine), curettage if retained tissue, or surgical intervention

• Presenting features: fever, uterine tenderness, purulent discharge
• Prevention: routine perioperative doxycycline
• Treatment: broad-spectrum antibiotics; re-evacuation if retained tissue

• Most common major complication
• Diagnosed by ultrasound; treated with repeat aspiration

• Can occur during dilation, especially with forceful or hurried technique
• Minor lacerations often managed with pressure or a single suture

• Blood accumulation in the uterine cavity due to cervical spasm
• Presents with severe cramping and minimal external bleeding shortly after procedure
• Treated by re-evacuation

• Intrauterine adhesions as a long-term complication, more common after infection or aggressive curettage
• Can result in hypomenorrhea, amenorrhea, or infertility

Contraindications

• Uncorrected coagulopathy (correct before procedure)
• Severe medical illness requiring stabilization
• Undiagnosed pelvic infection (treat before procedure when possible)
• Lack of confirmation of intrauterine location (must rule out ectopic pregnancy first)

Pre-Procedure Requirements

• Confirm intrauterine pregnancy (ultrasound)
• Determine gestational age accurately
• Informed consent (all options discussed)
• CBC, Rh blood type
• Antibiotic prophylaxis (doxycycline single dose)
• Paracervical block ± systemic analgesia/sedation

Comparison: Surgical vs. Medical Abortion (First Trimester)

Psychological Outcomes

Summary