226. Pregnancy Termination

Question 1

1st trimester surgical evacuation

• methods (2, pros/cons)
• how to know when procedure is complete
• pain mgmt

Answer 1

Most common type of evacuation
Methods: Mechanical dilation or pre-op PG to dilate
1. Electric Vacuum Aspirator: electric pump for suction with plastic/metal cannula, quick, efficient, makes noise
2. Manual Vacuum Aspirator: locking valve, portable, reusable, equivalent to electric but QUIET

Procedure complete when ID PoC: electric = look for frond-like tissue (embryonic tissue)
Manual aspirator = more intact gestational sac

Pain: almost everyone gets lidocaine paracervical block (helps with pain, dilation, cervical manipulation)
- 58% local anesthetic, 32% local/IV, 10% general anesthetic but most dont need it

Question 2

1st semester medication abortion

• names of meds and mechanisms
• contraindications
• rare SE
• follow up

Answer 2

1. MIFEPRISTONE: induce decidual necrosis via endogenous PG production, form gap junctions in myometrium, cervical dilation, high sensitivity to exogenous PGs later (ABORTIFACENT)
2. MISOPROSTOL: PG analogue = stim uterine contractions (EXPULSION AGENT)

Usually take misoprostol 24-48 hrs later out of office

CI: ectopic pregnancy, IUD in use, long term CS use, hemorrhagic disorders, concurrent anticoagulant use, chronic adrenal failure, allergy to PGs

Rare SE: heavy bleeding with dizziness, worsening pain, flu-like sx >24 hrs, fever/chills, syncope

Needs follow up to assess abortion completion (fail to find gestational sac on US) - if incomplete need MVA for retained PoC

Slightly lower success rate than surgical (92-99% vs. 99%)

Question 3

2nd Trimester abortion

• indications
• how do methods vary from first trimester
• are surgical or medical more common?

Answer 3

Indications: 10% of all abortions during 2nd trimester due to genetic/structural fetal conditions, maternal health conditions develop

Methods vary due to increasing fetus size and changing uterus response to meds

90% 2nd trimester evacs done surgically

Both med/surg abortions SAFER for mother throughout ENTIRE 2nd timester than CONTINUATION of pregnancy