John Spencer

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    Day case surgical abortion in late second trimester

    John A D Spencer, Senior Clinical Consultant, Marie Stopes International, London, United Kingdom

    A review of the management of all surgical abortions with a gestation between 19 and 23 weeks was undertaken during 2009 by prospective collection of data. All were day-cases, admitted subsequent to clinical assessment, blood tests, and consent. Cases not suitable for general anaesthesia in our centres were referred for hospital management.  Cervical preparation was by intracervical Dilapan rods (a hygroscopic dilator) and vaginal Misoprostol.  Dilatation and Evacuation was performed after waiting at least four hours.

    Of a total of 770 cases in two London centres data were collected on 726 (94%). Three of the four doctors performed 94% (37%, 37% and 20%) of cases respectively. The number of cases each month varied between 50 and 84 and there were no significant differences between the two centres. Cervical preparation began before 1100 hours in 95% of cases.

    The age range of clients was 14 to 46 years (96% were between 15 and 39). 38% were multiparous (parity 1-4) of which 17% had a history of one or more caesarean sections. 95 % experienced noticeable abdominal cramps during the cervical preparation interval but only a small minority requested analgesia. The incidence of diorrhoea was 5% and vomiting 3%. One client began bleeding sufficient to require transfer to hospital before surgery.

    Analysis of the treatment patterns showed that the dose of Misoprostol administered was influenced by age (more if younger), gestation (more if 22 or 23 weeks) and parity (less if multiparous). Most clients had 3 Dilapan rods inserted through the internal cervical os and difficulty were noted in only a few nulliparae. The preparation interval was significantly longer if the gestation was 22 or 23 weeks, and if a higher dose of misoprostol was given. Multipara had a shorter preparation interval.

    The cervical dilatation found prior to commencing Dilatation and Evacuation was significantly greater after the higher dose of misoprostol, with higher gestations, in multiparae. The procedure duration was longer with higher gestations, and was shorter if the cervical dilatation was greater and in multiparae. Metal (Pratts) double-ended cervical dilators were rarely (less than 5%) required. Recovery was uneventful in all cases not already transferred to hospital, and all clients were discharged within 2 hours.

    There were only four serious complications which required transfer to the local hospital. The case of haemorrhage from a low-lying placenta had a placenta accreta related to a previous caesarean scar and required subtotal hysterectomy. Three cases had a laceration of the internal cervix or lower uterus,

    directly related to surgery, and were successfully managed with an intrauterine balloon and suturing.

    Table to summarise treatment and outcomes by gestation

     

    19 wks

    20 wks

    21 wks

    22 wks

    23 wks

    n  (%) of study group

    120 (17)

    193 (26)

    161 (22)

    139 (19)

    113(16)

    Mean age for each gestation

    23

    24

    25

    25

    24

    Intracervical Dilapan  x 3 (%)

    99

    99

    96

    96

    75

    Intracervical Dilapan  x 4 (%)

    0

    0

    2

    3

    24

    Misoprostol 600 mcg PV (%)

    97

    97

    91

    53

    55

    Misoprostol 800 mcg PV (%)

    2

    1

    7

    46

    44

    Cervical preparation for 4-6 hrs (%)

    93

    91

    91

    78

    91

    Cervix pre-op Cx dilat  >18mm (%)

    67

    79

    81

    86

    88

    Procedure duration  <20 min (%)

    99

    97

    87

    81

    71