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A randomized controlled trial comparing surgical termination of pregnancy with and without continuous ultrasound guidance
Abstract
Approximately 50 million abortions are performed worldwide each year, and the majority of them are surgical terminations of pregnancy (STOP). Therefore, the safety of this procedure is a global public health concern. It is not known whether routine use of intraoperative ultrasound guidance improves the outcome of first trimester STOP.
To investigate whether surgical termination of pregnancy in the first trimester with continuous ultrasound guidance is safer than the conventional procedure without ultrasound guidance.
A randomized controlled trial.
A teaching hospital in London, UK. Participants: Women undergoing STOP in the first trimester. Intervention: Participants were randomized to have the procedure with or without continuous ultrasound guidance.
The primary outcome measures were intraoperative and short-term complications (anaesthetic complication, haemorrhage, ongoing pregnancy, cervical trauma, uterine perforation, need for laparoscopy and/or laparotomy, repeat evacuation, and infection). The secondary outcomes were the blood loss, procedure time, and convalescence time.
A total of 230 women (115 in each arm of the trial) participated in the study. Follow-up data were available for analysis in all but 15 (8 in control group and 7 in intervention group) cases. Baseline characteristics were similar in both groups. The overall complication rate was 9.8 percent. STOP under ultrasound guidance had a complication rate of 3.7% (4/108) in comparison to 15.9% (17/107) without ultrasound (RR 0.23, 95% CI 0.08-0.67). Intraoperative ultrasound guidance also had a statistically significant beneficial effect in reducing the blood loss, procedure time, and convalescence time.
STOP in the first trimester under continuous ultrasound guidance was associated with a lower rate of complications than the conventional procedure without ultrasound.
... Intraoperative US (IOUS) has become increasingly common across a wide range of specialties since its introduction in 1961 to facilitate the detection of renal calculi [2]. It has since been used within the field of gynecology to facilitate various operations from procedures as minor as removing a lost contraceptive implant [3][4][5] or intrauterine device [6], to more complex, invasive procedures including surgical termination of pregnancy, hysteroscopy and laparoscopic myomectomy [7][8][9]. More recent developments in US technology have resulted in greatly enhanced image quality and real-time IOUS has become increasingly utilized within the gynecological setting. ...
... Dilation and curettage (D&C), with or without suction/vacuum aspiration, is a frequently performed gynecological procedure, making its safety paramount [7,10]. However, it is historically carried out blindly with an early complication rate of approximately 6% [12]. ...
... The group with US guidance demonstrated significantly reduced rates of infection, retained products of conception requiring repeat evacuation procedure, intra-and post-operative blood loss, procedure duration and convalescence time. The study concluded that eight patients required US guidance to prevent one additional complication (95% CI: 5-23) [7]. ...
Ultrasound is a readily available, safe and portable imaging modality that is widely applied in gynecology. However, there is limited guidance for its use intra-operatively especially with complex gynecological procedures. This narrative review examines the existing literature published on the use of intraoperative ultrasound (IOUS) in benign gynecology and in gynecological oncology. We searched for the following terms: ‘intraoperative,’ ‘ultrasonography,’ ‘gynecology’ and ‘oncology’ using Pubmed/Medline. IOUS can minimize complications and facilitate difficult benign gynecological procedures. There is also a role for its use in gynecological oncology surgery and fertility-sparing surgery. The use of IOUS in gynecological surgery is an emerging field which improves visualization in the surgical field and aids completion of minimally invasive techniques.
... [10][11][12] On the other hand, uterine perforations following gynecological procedures are reported to be uncommon, ranging from 0.8 to 6.4/1000 procedures. [13] This occurrence is said to be even lower (0.1-3/1000 induced abortions) when manual vacuum aspiration (MVA) is used. [14,15] In some of the literature, uterine perforations following unsafe abortion are reported to be 0.4-15/1000 abortions. ...
... [17,19] Uterine perforations generally are rare complications of uterine procedures. [13,20] However, when they occur, they are commoner in uterine evacuation carried out by dilation and curettage [18,[21][22][23][24][25][26][27] as the instruments used were metallic with a higher chance of uterine perforation and subsequent prolapse of small bowel through the vagina. [21,23,26,[28][29][30] These cases presented between a few hours to 15 days [29] ; the presentations were overt with intestinal prolapse. ...
Introduction
Uterine perforation following manual vacuum aspiration (MVA) of early pregnancy is an uncommon occurrence. It is even more unusual to be complicated by bowel herniation and intestinal obstruction. Proper evaluation and intervention are required to ameliorate the attendant morbidity.
Case Report
We reported a case of a 39-year-old known retroviral disease P 1 + [1] nonalive who presented 2 weeks after MVA with clinical and radiological features of complete small bowel obstruction. She was resuscitated and had a laparotomy that revealed a herniated loop of small bowel through a uterine perforation. Resection and anastomosis were done; she made a full recovery and was subsequently discharged on the 7th postoperative day.
Conclusion
Public enlightenment, safe sex practices, and public access to health care covered by health insurance would reduce the incidence of this uterine perforation.
... However, the incidence of uterine perforation has been estimated to be very low, at approximately 0.8-6.4/1000 procedures [4]. It mainly depends on the technique, the healthcare provider's experience and the risk factors associated with the preexisting medical problem [5][6][7]. ...
... Parity, advanced age and general anaesthesia increase the risk of uterine perforation, while uterine retroversion does not significantly contribute [8][9][10][11]. Therefore, in a healthy uterus, perforation can often be misdiagnosed or overlooked, because of the low expectation of this complication, and this may also contribute to the low incidence reported by the current literature [4]. Still, the non-obstetric diagnostic and therapeutic indications for D&C cover a wide spectrum of conditions accompanied by abnormal uterine bleeding, such as endometrial hyperplasia, prolonged heavy menstrual bleeding or postmenopausal bleeding [12,13]. ...
Objective:
Omentum involvement resulting from uterine perforation is a rare complication following intrauterine procedures that might require immediate intervention due to severe ischemic consequences. This review examines the prevalence of this complication, risk factors, the mode and timing of diagnosis, the proper management and the outcome.
Methods:
A systematic literature search was conducted on PubMed, PubMed Central and Scopus using uterine perforation, D&C, abortion and omentum as keywords. The exclusion criteria included the presence of the uterus or placenta's malignancy and uterine perforation following delivery or caused by an intrauterine device.
Results:
The review included 11 articles from 133 screened papers. We identified 12 cases that three evaluators further analysed. We also present the case of a 32-year-old woman diagnosed with uterine perforation and omentum involvement. The patient underwent a hysteroscopic procedure with resectioning the protruding omentum into the uterine cavity, followed by intrauterine device insertion.
Conclusion:
This paper highlights the importance of a comprehensive gynaecological evaluation following a D&C procedure that includes a thorough clinical examination and a detailed ultrasound assessment. Healthcare providers should not overlook the diagnosis of omentum involvement in the presence of a history of intrauterine procedures.
... This study evaluated the clinical effects of negative pressure suc- This has been confirmed by other studies. [12][13][14][15] In the present study, the incidence of surgical complications in the ultrasound group was lower than that in the non-ultrasound group (1% vs. 14%), and the difference was statistically significant (Table 3 and Table 4). This also confirms the findings from previous studies. ...
... 10,11 Some studies have reported surgical termination of pregnancy under ultrasound monitoring. In one review, Grewal et al. performed a randomized controlledtrial showing that complication rates were lower for surgical termination of pregnancy performed under ultrasound guidance than for surgical termination of pregnancy without ultrasound guidance.12 ...
Objective
To observe the effectiveness of ultrasound monitoring during negative pressure suction for abortion.
Methods
This retrospective study analyzed patients with abortion who underwent negative pressure suction, excluding 23 cases with incomplete information and missing interviews, leaving a total of 200 patients included in the study. They were divided into an ultrasound group (n = 100) and a non‐ultrasound group (n = 100) based on whether ultrasound monitoring was used. The ultrasound group was applied negative pressure suction under ultrasound monitoring, and the non‐ultrasound group was applied traditional negative pressure suction. The operative time and complications were assessed after the treatment.
Results
The operative time in the ultrasound group was 3.19 ± 0.62 min and in the non‐ultrasound group was 6.35 ± 1.20 min, revealing a significantly shorter operative time in the ultrasound group than in the non‐ultrasound group (P < 0.05). There was one case of uterine residual in the ultrasound group. There were eight cases with uterine residuals, four cases with intrauterine adhesions, one case with missed aspiration, and one case with perforation of the uterus in the non‐ultrasound group. The complication rate in the ultrasound group was less than that in the non‐ultrasound group (P < 0.05).
Conclusion
Ultrasound‐monitored negative pressure suction has obvious advantages over ordinary negative pressure suction in that it can shorten operation time, reduce operative complications, and ensure a safe and effective abortion.
... Operative time was calculated from the start of instrument introduction after cervical dilatation to the end of the procedure. Significant uterine bleeding was considered if blood loss was more than 500 ml [10]. Uterine infection (endometritis) was suspected if the temperature increased (38 °C on at least two occasions) or with the presence of abnormal vaginal discharge and pelvic tenderness. ...
... Furthermore, Capmas et al. [21] found that hysteroscopic removal of retained conception products is an efficient alternative procedure as regards removing the entire uterine contents, less incidence of postoperative intrauterine adhesions and preserving the fertility rate. Our results also agreed with Acharya et al. [10], who concluded that intra-operative ultrasound is associated with a significant decrease in the complication rate of surgical management for early pregnancy loss. ...
Objective
We aimed to evaluate the hysteroscopic management of first-trimester pregnancy loss compared to surgical evacuation either blind or under ultrasonographic guidance.
Methods
This clinical trial included 315 women with first-trimester pregnancy loss, divided equally into three groups. Group 1 underwent traditional blind surgical evacuation, group 2 underwent ultrasound-guided evacuation, and group 3 underwent hysteroscopic management. All women were assessed for retained products, surgical complications, the need for further management, and pregnancy occurrence after evacuation within 2 years of follow up.
Results
The rate of presence of conception remnants and the need for further treatment was significantly higher in group 1 compared to groups 2 and 3 (4.8% vs. 0% vs. 0%, P = 0.012). The conception rate within 2 years was significantly lower in group 1 compared to groups 2 and 3 (57.4% vs. 73.2% vs. 82.7%, P = 0.002), and the duration needed to conceive was significantly prolonged in group 1 compared to groups 2 and 3 (9.8 vs. 8.3 vs. 6.9 months, P < 0.001). Interestingly, women who underwent hysteroscopic management needed a significantly shorter time to conceive than those who underwent ultrasound-guided evacuation (6.9 vs. 8.3 months, P = 0.006).
Conclusions
Hysteroscopic management of first-trimester pregnancy loss was superior to ultrasound-guided surgical evacuation regarding the time interval to conceive. Both techniques were superior to the blind evacuation technique regarding removal of the whole conception remnants, need for further treatment and fertility outcomes.
Clinical trial registration : It was first registered at ClinicalTrials.gov on 16/03/2017 with registration number NCT03081104.
... In addition to having pre-abortion ultrasound, evidence has shown that ultrasound-guided surgical abortions are generally safer than without ultrasound guidance with reduced the risk of uterine perforation (11). In a randomized control trial by Acharya et al (11), complications of abortion were significantly reduced under ultrasound-guidance (<4%) in comparison to without ultrasound guidance (>15%). ...
... In addition to having pre-abortion ultrasound, evidence has shown that ultrasound-guided surgical abortions are generally safer than without ultrasound guidance with reduced the risk of uterine perforation (11). In a randomized control trial by Acharya et al (11), complications of abortion were significantly reduced under ultrasound-guidance (<4%) in comparison to without ultrasound guidance (>15%). Another related randomized control trial showed that the incidence of uterine perforation was 0% with ultrasound guidance and approximately 3% without ultrasound guidance (12). ...
Uterine perforation is a rare major complication of surgical abortion which can be detected by ultrasound. In the last four decades, over 70% of case reports on uterine perforation in surgical abortions were from developing countries. Yet ultrasound was rarely used in detecting uterine perforation. This case report presents two cases of uterine perforation in surgical abortions which were detected by ultrasound prior to laparotomy. In the first case, a 34-year old woman was referred to our facility as a case of hypovolaemic shock following termination of pregnancy. An ultrasound examination performed to exclude an intra-abdominal abscess collection revealed a 1.2cm defect in the fundal region of the uterus with extrusion of abdominal contents into the endometrial cavity through the defect. In the second case, a 31-year old woman presented with a history of vomiting, abdominal pain, abdominal distension and absolute constipation after undergoing an evacuation of the uterus for a spontaneous abortion at 7 weeks' gestation. Transabdominal ultrasound showed a defect of 1.4cm wide at the fundus of the uterus, with a structure extending from the abdominal cavity through the defect and into the endometrial cavity. It also showed distension of multiple bowel loops within the abdominal cavity. Sonographic detection of uterine perforation led to appropriate management in both cases. In developing countries, where the incidence of major complications of abortion is still very high, utilizing ultrasound can be helpful in detecting complications such as uterine perforation.
... In addition to having pre-abortion ultrasound, evidence has shown that ultrasound-guided surgical abortions are generally safer than without ultrasound guidance with reduced the risk of uterine perforation (11). In a randomized control trial by Acharya et al (11), complications of abortion were significantly reduced under ultrasound-guidance (<4%) in comparison to without ultrasound guidance (>15%). ...
... In addition to having pre-abortion ultrasound, evidence has shown that ultrasound-guided surgical abortions are generally safer than without ultrasound guidance with reduced the risk of uterine perforation (11). In a randomized control trial by Acharya et al (11), complications of abortion were significantly reduced under ultrasound-guidance (<4%) in comparison to without ultrasound guidance (>15%). Another related randomized control trial showed that the incidence of uterine perforation was 0% with ultrasound guidance and approximately 3% without ultrasound guidance (12). ...
... There is also a lack of information as to which patient characteristics are associated with increased blood loss at the time of uterine evacuation for first-trimester pregnancy failure. Some studies have examined the association of patient demographics with blood loss at the time of second-trimester pregnancy termination [11][12][13][14][15][16][17][18]. However, this is a different clinical scenario than first-trimester pregnancy failure. ...
Introduction
There is no clear guidance for the optimal setting for dilation and curettage (D&C) for the management of first-trimester pregnancy failure. Identifying patients at risk of clinically significant blood loss at the time of D&C may inform a provider's decision regarding the setting for the procedure. We aimed to identify risk factors predictive for blood loss of 200mL or greater at the time of D&C.
Methods
This is a retrospective cohort study of patients diagnosed with first-trimester pregnancy failure at gestational age less than 11 weeks who underwent surgical management with D&C at a single safety net academic institution between 4/2016 and 4/2021. Patient characteristics and procedural outcomes were abstracted. Women with less than 200mL versus greater than or equal to 200mL blood loss were compared using descriptive statistics, chi-square for categorical variables, and Satterthwaite t-tests for continuous variables.
Results
A total of 350 patients were identified; 233 met inclusion criteria, and 228 had non-missing outcome data. Mean gestational age was 55 days (SD 9.4). Thirty-one percent (n=70) had estimated blood loss (EBL) ≥200mL. Younger patients (mean 28.7 years vs. 30.9, p=0.038), Latina patients (67.1% vs. 51.9%, p=0.006), patients with higher body mass index (BMI, mean 30.6 vs. 27.3 kg/m2, p=0.006), and patients with pregnancies at greater gestational age (59.5 days vs. 53.6 days, p<0.001) were more likely to have EBL ≥200mL. Additionally, patients with pregnancies dated by ultrasound (34.3% vs. 18.4%, p=0.007), those who underwent D&C in the operating room (81.4% vs. 48.7%, p<0.001), and those who underwent general anesthesia (81.4% vs. 44.3%, p<0.001) were more likely to have EBL ≥200mL.
Discussion
In this study, patients with EBL ≥200mL at the time of D&C differed significantly from those with EBL<200mL. This information can assist providers in planning the best setting for their patients' procedures.
... Traditionally, MVA has been performed without USG. Our unit has added USG during MVA as it has been previously shown to have a significant reduction on the need to repeat evacuation and blood loss during the operation [25]. USG allows visualisation of the catheter placement in the uterus, ensures complete evacuation and also minimises the discomfort by keeping the number of passes of the suction catheter to a minimum [26]. ...
Background
Intrauterine adhesion (IUA) can arise as a potential complication following uterine surgery, as the surgical procedure may damage the endometrial stratum basalis. The objective of this study was to assess and compare the occurrence of IUA in women who underwent ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA) for managing first-trimester miscarriage.
Methods
This was a prospective, single-centre, randomised controlled trial conducted at a university-affiliated tertiary hospital. Chinese women aged 18 years and above who had a delayed or incomplete miscarriage of ≤ 12 weeks of gestation were recruited in the Department of Obstetrics and Gynaecology at the Prince of Wales. Recruited participants received either USG-MVA or EVA for the management of their miscarriage and were invited for a hysteroscopic assessment to evaluate the incidence of IUA between 6 and 20 weeks after the surgery. Patients were contacted by phone at 6 months to assess their menstrual and reproductive outcomes.
Results
303 patients underwent USG-MVA or EVA, of whom 152 were randomised to ‘USG-MVA’ and 151 patients to the ‘EVA’ group. Out of the USG-MVA group, 126 patients returned and completed the hysteroscopic assessment, while in the EVA group, 125 patients did the same. The incidence of intrauterine adhesion (IUA) was 19.0% (24/126) in the USG-MVA group and 32.0% (40/125) in the EVA group, showing a significant difference (p < 0.02) between the two groups. No significant difference in the menstrual outcomes at 6 months postoperatively between the two groups but more patients had miscarriages in the EVA group with IUA.
Conclusions
IUAs are a possible complication of USG-MVA. However, USG-MVA is associated with a lower incidence of IUA postoperatively at 6–20 weeks. USG-MVA is a feasible, effective, and safe alternative surgical treatment with less IUA for the management of first-trimester miscarriage.
Trial registration
The study was registered with the Centre for Clinical Research and Biostatics- Clinical Trials Registry (CCRBCTR), which is a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) (Unique Trial Number: ChiCTR1900023198 with the first trial registration date on 16/05/2019)
... Traditionally, MVA has been performed without ultrasound guidance. Our unit has added ultrasound guidance during MVA as it has been previously shown to significantly reduce infection rates, the need to repeat evacuation and reduce blood loss during the operation [28]. We previously postulated that complications will be lower in USG-MVA as USG guidance allows clear visualization of the catheter placement in the uterus, as well as enabling complete evacuation with minimal passes of the suction catheter to reduce discomfort [10]. ...
Ultrasound-guided manual vacuum aspiration (USG-MVA) is a feasible and effective outpatient treatment to treat early pregnancy loss.
This was a prospective observational study at a university-affiliated hospital. All women undergoing either a USG-MVA or electric vacuum aspiration (EVA) were invited to return 3–6 months later for follow-up at which women completed a questionnaire to document their post-evacuation menstrual and reproductive history, and underwent a hysteroscopy if they were not pregnant. The severity of intrauterine adhesion (IUA), if present, was graded (Stage I-III) according to the American fertility society classification.
A total of 292 women had a hysteroscopy after their initial surgical evacuation, USG-MVA 169(57.9%) versus EVA 123(42.1%). Women undergoing EVA as opposed to a USG-MVA had a 12.9% higher incidence of IUA (24.1% vs. 37.0%, p = 0.042) equivalent to 1.84 times higher risk (95% CI 1.01–3.34; p = 0.048). Women having EVA continued to show an increased but not statistically significant trend towards an increased risk of IUA after adjusting for the type of miscarriage (aOR = 1.3; 95% CI 0.66–2.50; p = 0.46).
There were no significant differences in their reproductive outcomes and fewer women post-USG-MVA complained of hypomenorrhea. IUA may still occur in women undergoing USG-MVA but it is lower than the rate in women undergoing EVA.
Clinical trials registry The trial was registered with the Centre for Clinical Research and Biostatistics – Clinical Trials Registry (CCRBCTR), a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) with a Unique Trial Number: CUHK_CCRB00541 on 22 Dec 2016.
... D&C can be performed with a metal curette or by vacuum aspiration, which is potentially less harmful [3][4][5]. The safety and completeness of removal may be optimized by ultrasound guidance [9][10][11][12]. Recent studies indicated that a good alternative for curettage is hysteroscopic removal (HR) [2,[13][14][15][16][17]. ...
Objectives
To compare intrauterine adhesion (IUA) formation after hysteroscopic removal (HR) of retained products of conception (RPOC) with IUA formation after ultrasound-guided electric vacuum aspiration (EVA) and externally validate the outcomes of an RCT.
Study design
This prospective cohort study was conducted from April 2015 until June 2022 in 2 Dutch teaching hospitals and one Belgian university hospital. Women opting for EVA underwent the procedure as soon as possible. In the HR group, the therapeutic hysteroscopy was performed at least eight weeks after the end of pregnancy. Postoperatively, an office second-look hysteroscopy was offered to all patients. Women were included if they had been diagnosed with RPOC ranging from 1 to 4 cm on ultrasound and did not want to participate in the RCT. EVA was performed using a Karman cannula. Operative hysteroscopy consisted either of hysteroscopic morcellation with the TruClear™ System or the Intrauterine BIGATTI Shaver or cold loop resection with a bipolar resectoscope.
Results
Of 178 included women, 124 were treated with HR and 28 with EVA. Outcomes of HR and EVA did not differ significantly in terms of complications (5.6 % vs 3.6 %; p = 1.00). Second-look hysteroscopy showed IUAs in 14 of 91 women (15.4 %) after HR and in 1 of 16 (6.3 %) after EVA (p = .461). Completeness of removal was significantly higher (90.1 %) after HR than after EVA (68.8 %) (p = .035). Additional operative hysteroscopy was required in 14.3 % of the HR group versus 37.5 % in the EVA group (p = .036).
Conclusion
In our cohort study, no significant differences in IUAs or complications were found. RPOC removal with HR was more often complete than removal with EVA, and additional therapeutic hysteroscopy was less frequently required after HR. These findings need to be correlated with those of RCTs.
Clinical trial registration
The study was registered in de Dutch Trial Register (NTR4923). Date of registration 23-11-2014. Date of first enrollment 01-01-2015. https://trialsearch.who.int/Trial2.aspx?TrialID=NTR4923
... The MVA procedure being performed by consultants or a fellow in our unit may also contribute to these positive outcomes.In our unit, we simultaneously perform an abdominal ultrasound while instrumenting the cervix and uterus. This aims to reduces the risk of perforation, ensure complete uterine evacuation, and avoid excessive curettage.15 However, there is limited evidence for this in the literature and further studies are required. ...
Introduction
Manual vacuum aspiration (MVA) is a safe and effective alternative option for the management of first‐trimester miscarriage, termination of pregnancy, or retained pregnancy tissue. Ireland's first MVA clinic was set up in the Rotunda Hospital in April 2020.
Objective
To identify the number of women who have undergone MVA since establishing our service, to assess the efficacy and safety of MVA in that service, and to develop local Irish studies that further support the safety of MVA, adding to the international body of evidence.
Methods
With the approval and assistance of the Clinical Audit Committee, we obtained a log of all patients who underwent MVA in the first 18 months of the service. We performed a retrospective electronic chart review using Maternal and Newborn Clinical Management System. We collected the data and preformed a descriptive analysis.
Results
In total, 86 women underwent MVA, 85 (98.8%) of which were successfully completed. There were no immediate procedural complications, inter‐hospital transfers, or emergency electric vacuum aspiration (EVA) required. We obtained an incomplete evacuation rate of 4.7% (n = 4).
Conclusion
We have demonstrated that the MVA service in the Rotunda Hospital is a safe, effective management option with advantages for both the patient and the healthcare system. We recommend consideration for provision of funding and resources to enable expansion of this service nationally in order to give women greater autonomy of choice in the management of early pregnancy complications and termination of pregnancy.
... One randomized study investigated whether or not continuous ultrasound guidance improved outcome for firsttrimester termination of pregnancy [2]. 230 women were randomized to D&C with or without US guidance. ...
Introduction: Many gynecologic procedures may benefit from the use of real-time ultrasonography. The goal of this review is to summarize the use of ultrasound in some of the main gynecologic procedures, with focus on cervical cerclage procedure. Recent findings: Ultrasound guidance has been shown to decrease both operative time and complication rates in curettage procedures. In addition, intraoperative ultrasound use reduces recurrence rates after hysteroscopic resection of uterine myoma or septa. Ultrasound guidance may improve the efficiency of cervical cerclage by direct visualization of tightening and assist in measures of prognostic factors following the procedure. Conclusion: Intraoperative ultrasound guidance appears to be a safe and valuable tool for the gynecologic surgeon. It may reduce complication and re-operation rates and may improve the efficacy of some procedures.
... For instance, a randomized controlled trial (RCT) showed that ultrasound guidance during abortion reduced complications. 3 Nonetheless, obstetricians should bear in mind that the total complication and incomplete abortion-incidence rates were still significantly higher in D&C than in EVA for induced abortions. ...
Aim:
In Japan, dilatation and curettage (D&C) is a common procedure for spontaneous miscarriage and induced abortion, and its safety has long been an issue. Electric vacuum aspiration (EVA) is also common, but manual vacuum aspiration (MVA) was introduced recently, with medical abortions using mifepristone or misoprostol which are not yet legally accepted. This nationwide retrospective study surveyed the surgical methods and complications associated with spontaneous miscarriage and induced abortion at less than 12 weeks of gestation in Japan to assess their safety, in comparison with a similar survey for induced abortions in 2012.
Methods:
Questionnaires were sent to 4176 facilities with a license for induced abortion surgeries in 2019. The questions included were the methods used, number of spontaneous miscarriages and induced abortions, and number of complications (uterine perforation, incomplete abortion, and gross bleeding requiring blood transfusion).
Results:
Responses were received from 1706 facilities (40.9%). Although EVA with sharp curettage was the most common surgical method, which was used for 11 953 spontaneous miscarriages (28.9%) and 24 045 induced abortions (37.3%), the most common surgical method per facility was D&C, and the rates of D&C for spontaneous miscarriages (38.4%) and induced abortions (44.7%) performed in general hospitals were significantly higher than those in clinics (24.1% and 22.0%, respectively). There was no significant difference in the complication incidence rate among surgical methods for spontaneous miscarriages. However, in induced abortion surgery, the total complication and incomplete abortion incidence rates for D&C were significantly higher than those for EVA without sharp curettage (47/15 162 [0.31%] vs. 29/18 693 [0.16%], p = 0.00362, 45/15 162 [0.30%] vs. 27/18 693 [0.14%], p = 0.00285, respectively). There was no significant difference in the complication incidence rate between MVA and other surgical methods for each abortion surgery.
Conclusion:
In Japan, especially in general hospitals, D&C is still widely used for miscarriage and induced abortion surgery. Its complication-incidence rates significantly decreased compared with that of the nationwide survey in 2012, but were still significantly higher than EVA without sharp curettage. Few facilities used MVA, but its complication rate was comparable with those of other surgical methods.
... In most of these (80%), RPOC occurred after miscarriage or TOP (10%), whereas in the remaining 10% placental remnants occurred after delivery (by both vaginal and caesarean section). If retained placental tissue is suspected, whether to proceed directly to surgical intervention, or try medical treatment remains controversial (Acharya et al., 2004). ...
Background:
About 15-20% of pregnant women will miscarry spontaneously during the first trimester. Traditionally, the surgical treatment of placental remnants has been dilation and curettage (D&C). However, because of its 'blind' nature there is a risk of serious complications, such as infection, adhesion, uterine perforation, or bowel injury. Hysteroscopy, with direct visualization of the uterine cavity, decreases these complications. In this retrospective case series we evaluated the efficacy and the feasibility of operative hysteroscopy using the Intrauterine Bigatti Shaver (IBS ® ) for the treatment of placental remnants, both, in a University hospital in Italy and in a private hospital in Iran.
Materials and methods:
From December 2013 to April 2018 a retrospective medical records review, of patients undergoing placental remnant removal with the IBS ® , was performed. Sixty-five patients suspected of retained products of conception (RPOC) underwent operative hysteroscopy during this period using the IBS ® . Placental remnants were confirmed histologically in 52 cases (80%). The median age of the patients was 36 years. Placental remnants were observed after 42 early miscarriages, 5 terminations of pregnancy, 4 vaginal deliveries and 1 cesarean delivery. Thirty-two patients had abnormal uterine bleeding, 15 were asymptomatic and 5 had subfertility after miscarriage. Most cases (90%) were diagnosed by transvaginal ultrasound.
Results:
The median interval between surgery and the end of pregnancy was 56 days (a range of 15-90 days). The size of placental remnants was between 15 and 30mm. Three women showed a cavity filled with placental tissue residual (more than 4cm). The median resection time was 4.5 minutes and the median total surgery time was 6.6 minutes. Median fluid deficit [saline solution] was 240 ml. In two cases there was excessive intraoperative bleeding, and one patient required a conversion to bipolar resectoscope for hemostatic reasons. No perforation or postoperative complications occurred. There was no need for second-look operative hysteroscopy and postoperative ultrasound confirmed complete evacuation of the RPOC. Only one patient had a minor adhesion.
Conclusion:
The IBS ® seems to be an effective and safe instrument for the removal of placental remnants. It allows for short operation time with a high success and low complication rate.
... Placental remnants occur frequently after pregnancy. Depending on pregnancy duration, pregnancy outcome, and management thereafter, the prevalence of placental remnants lies between 0.5% and 19% (Dewhurst 1966;Rome 1975;King et al. 1989;Hoveyda & MacKenzie 2001;Luise et al. 2002;Guillem et al. 2003;Acharya et al. 2004;Zhang et al. 2005). ...
... 8 Intra-operative ultrasound has been increasingly used in a wide range of specialties, since its introduction in 1961 to facilitate detection of renal calculi during urological sur- gery. 9 It has since been used successfully in a variety of cir- cumstances within gynaecological practice, including surgical termination of pregnancy, 10 hysteroscopy, 11 and laparoscopic myomectomy. 12 This case demonstrates the novel application of intra-operative ultrasound to increase accuracy in the resection of ovarian lesions too small to be visualised laparoscopically. ...
... 19 In addition, a randomized controlled trial comparing the use of ultrasound during surgical first-trimester abortion of 330 women found significantly fewer repeat procedures for retained products, reduced blood loss and procedure time in the group with ultrasound guidance. 20 Many experienced providers however are quite capable and comfortable performing routine second-trimester abortions without ultrasound guidance, and will instead use it only in special circumstances, such as known uterine anomalies or multifetal gestations. ...
... Romero 5 , Darney 6 , Kohlenberg 7 Elsayed 8 y Acharya 12 reportan un aumento del riesgo de perforación e infección por evacuación incompleta, lo que se corrobora con nuestros resultados cuando no se utiliza el ultrasonido con base en la diferencia significativa en específico el sangrado 8---10,12 . El legrado o aspiración manual endouterina guiada por ultrasonido tiene la ventaja de asegurar una evacuación completa de la cavidad uterina, disminuye la prevalencia del dolor y el riesgo de sangrado y evita el riesgo de perforación uterina 5,6,8,9,12,13 . La ultrasonografía intraoperatoria no solo ofrece una guía visual al cirujano, además da la seguridad de la evacuación uterina completa 8,10,12 . ...
El legrado uterino o la aspiración manual endouterina en el aborto es una técnica que se realiza a ciegas, guiada por signos subjetivos. El uso de ultrasonido transoperatorio para guiar la evacuación no está descrito en la técnica original, pero hay algunos estudios que avalan su uso para realizar el procedimiento y asegurar su finalización de forma inequívoca, disminuyendo las complicaciones agudas.
... Acharya conducted another randomized controlled trial comparing the surgical evacuation of missed miscarriage cases with or without ultrasound and we found that the operative time is shorter and blood loss is fewer during the evacuation when ultrasound was used. However; no retained products of conception while were reported when using the ultrasound [13] . ...
Background: Surgical evacuation is one of the most popular methods of termination of pregnancy in cases of missed miscarriage. The current study aims to compare the improvement of surgical evacuation of first-trimester miscarriage when done with and without transabdominal ultrasonographic guide.
Materials and methods: Setting: Women Health Hospital, Assiut University, Egypt.
Design: A randomized clinical trial conducted on 200 pregnant women with 1st trimester miscarriage who scheduled for surgical evacuation. It carried out in the period between the 1st of May 2014 and the 30th of April 2015. The women were randomly assigned to either undergone surgical evacuation blindly (group I) or under ultrasound
guidance (group II). The main outcome measures were achievement of complete miscarriage,
operative time and blood loss during the procedure.
Results: Two-hundred participants were recruited in the study. The mean amount of blood loss during the procedure was significantly higher in group I when compared with group II (P = 0.002). Also there was a statistical significant difference in the operative time between both groups, group I showed longer time than in group II (P = 0.0001). After surgical evacuation, 14 cases (14%) in group I and 3 cases (3%) in
group II were reported to have remnants of conception. No cases of uterine perforation occurred in both groups.
Conclusion: The use of intraoperative ultrasound during surgical evacuation is associated
with a significant reduction in its complications, however; the cost of using ultrasound needs further investigations.
... Method: We found one report in literature using the following search words: pregnancy termination, uterus, perforation and ultrasound. 1 The risk of perforation is considered low but the true incidence is unknown. The reported incidence is largely based on self-reporting and many perforations are not recognised. ...
Introduction: Ultrasound is under utilised in assessing surgical complications such as uterine perforation resulting from surgical termination of pregnancy.
Method: We found one report in literature using the following search words: pregnancy termination, uterus, perforation and ultrasound.¹ The risk of perforation is considered low but the true incidence is unknown. The reported incidence is largely based on self‐reporting and many perforations are not recognised.
Conclusion: A South Australian study reported the perforation risk following a surgical termination as 0.05% in the first trimester and 0.32% in the second trimester (13–20 weeks).
... This case report reminds us that, to minimize uterine perforation with fallopian tube incarceration, uterine evacuation must be conducted by a trained operator who can avoid uterine perforation or who can easily recognize signs of perforation and stop the procedure. Furthermore, an ultrasound scan done during the procedure, especially for difficult cases, may help the operator in avoiding or diagnosing early uterine perforation [3]. ...
Background
Limited evidence exists on the influence of hospital procedure volume, socioeconomic status, and comorbidities on surgical abortion outcomes.
Objective
Our study aimed to assess the association between hospital procedure volume, individual and neighborhood deprivation, comorbidities, and abortion-related adverse events.
Study Design
A nationwide population-based cohort study of all women hospitalized for surgical abortion was conducted from January 1, 2018, to December 31, 2019 in France. Annual hospital procedure volume was categorized into four levels based on spline function visualization: very low (<80), low ([80-300[), high ([300-650[), and very high-volume (≥650) centers. The primary outcome was the occurrence of at least one surgical-related adverse event, including hemorrhage, retained products of conception, genital tract and pelvic infection, transfusion, fistulas and neighboring lesions, local hematoma, failure of abortion, admission to an intensive care unit or death. These events were monitored during the index stay and during a subsequent hospitalization up to 90 days. The secondary outcome encompassed general adverse events not directly linked to surgery.
Results
Of the 112,842 hospital stays, 4,951 (4.39%) had surgical-related adverse events and 256 (0.23%) had general adverse events. The multivariate analysis showed a volume-outcome relationship, with lower rates of surgical-related adverse events in very high-volume (2.25%, aOR=0.34, 95%CI [0.29-0.39], p<0.001), high-volume (4.24%, aOR=0.61, 95%CI [0.55-0.69], p<0.001), and low-volume (4.69%, aOR=0.81, 95%CI [0.75-0.88], p<0.001) when compared to very low-volume centers (6.65%). Individual socioeconomic status (aOR=1.69, 95%CI [1.47-1.94], p<0.001), neighborhood deprivation (aOR=1.31, 95% CI [1.22-1.39], p<0.001), and comorbidities (aOR=1.79, 95%CI [1.35-2.38], p<0.001) were associated with surgical-related adverse events. Conversely, the multivariate analysis of general adverse events did not reveal any volume-outcome relationship.
Conclusion
The presence of a volume-outcome relationship underscores the need for enhanced safety standards in low-volume centers to ensure equity in women's safety during surgical abortions. However, our findings also highlight the complexity of this safety concern which involves multiple other factors including socioeconomic status and comorbidities that policymakers must consider.
Ultrasound within the field of gynecology has played an imperative role in the diagnosis of various conditions. Real time ultrasonography provides a useful adjunct to many minor gynecological procedures, including oocyte collection and embryo transfer in assisted reproductive technology (ART), aspiration of ovarian cysts or pelvic abscesses, insertion and removal of intrauterine devices and guiding endometrial biopsies. As such, advancement in technology of this non-invasive and cost-effective resource has enabled wider application of the modality across the speciality, with many gynecologists now skilled in carrying out the above procedures through office based ultrasound. However, the use of intraoperative ultrasound (IOUS) is not as widely reported in gynecological surgery, despite it being considerably implemented across other surgical specialties.
Objective:
To study the comparison between hysteroscopic morcellation of retained products of conception with ultrasound guided electric vacuum aspiration in terms of intrauterine adhesion formation, as well as efficacy and complications.
Design:
Randomized controlled, non-blinded trial conducted in three teaching hospitals and one university hospital from April 2015 to June 2022.
Subjects:
One-hundred seventy-three women with retained products of conception on ultrasound, ranging from 1 to 4 cm, were randomized to receive either hysteroscopic morcellation or electric vacuum aspiration.
Intervention:
Hysteroscopic morcellation was performed with the TruClear™ System (Medtronic, Minneapolis, MN, USA). Electric vacuum aspiration was performed using an 8 or 10 mm flexible plastic Karman cannula under ultrasound guidance. Women allocated to vacuum aspiration underwent the procedure as soon as possible.
Main outcome measures:
In the hysteroscopic morcellation group, an office diagnostic hysteroscopy was planned a minimum of 6 weeks after the end of pregnancy, followed by retained product of conception removal at least 8 weeks after the end of the pregnancy. Postoperatively, an office second-look hysteroscopy was scheduled to assess the primary outcome of intrauterine adhesions.
Results:
Postoperative intrauterine adhesions were seen in 9 of 63 patients (14.3%) in the hysteroscopic morcellation group and 13 of 64 patients (20.6%) in the vacuum aspiration group (-6% [-19.1% to 7.1%], p=.348). Significantly more retained product of conception were completely removed by hysteroscopic morcellation compared to vacuum aspiration (95.2% vs 82.5% (-14%[-24.9% to -3.1%]), and additional operative hysteroscopy was less frequently necessary in the hysteroscopic morcellation group (12.5%) compared to the vacuum aspiration group (31.3%) (-20.1% [-34.3% to -6%]). Median operating time was shorter for vacuum aspiration compared with hysteroscopic morcellation (5.80 min vs 7.15 min) No differences were observed between hysteroscopic morcellation and vacuum aspiration for the occurrence of intra- or postoperative complications (5.5% vs 5.0%, and 2.7% vs 1.3%, respectively).
Conclusion:
In our randomized controlled trial, no significant differences were found in the occurrence of intrauterine adhesions and complications. However, the retained products of conception were more often completely removed by hysteroscopic morcellation than vacuum aspiration, and the hysteroscopic morcellation group required fewer additional hysteroscopic treatments.
Introduction:
Manual vacuum aspiration is increasingly accepted as an alternative to medical or surgical evacuation of the uterus after first-trimester miscarriage. This study aimed to assess the efficacy of ultrasound-guided manual vacuum aspiration (USG-MVA) in the management of first-trimester miscarriage.
Methods:
This retrospective analysis included adult women with first-trimester miscarriage who underwent USG-MVA in Hong Kong between July 2015 and February 2021. The primary outcome was the efficacy of USG-MVA in terms of complete evacuation of the uterus, without the need for further medical or surgical intervention. Secondary outcomes included tolerance of the entire procedure, the success rate of karyotyping using chorionic villi, and procedural safety (ie, any clinically significant complications).
Results:
In total, 331 patients were scheduled to undergo USG-MVA for first-trimester miscarriage or incomplete miscarriage. The procedure was completed in 314 patients and well-tolerated in all of those patients. The complete evacuation rate was 94.6% (297/314), which is similar to the rate (98.1%) achieved by conventional surgical evacuation in a previous randomised controlled trial in our unit. There were no major complications. Samples from 95.2% of patients were suitable for karyotyping, which is considerably higher than the rate of suitable samples (82.9%) obtained via conventional surgical evacuation in our previous randomised controlled trial.
Conclusion:
Ultrasound-guided manual vacuum aspiration is a safe and effective method to manage first-trimester miscarriage. Although it currently is not extensively used in Hong Kong, its broader clinical application could avoid general anaesthesia and shorten hospital stay.
Background:
Dilation and Curettage (D&C) may be performed with or without transabdominal ultrasound guidance. We aimed to evaluate the association between the use of ultrasound guidance during D&C for first-trimester missed abortion (MA) and D&C related complication rates.
Methods:
A retrospective cohort study including women in the age of 20-45 years, who underwent D&C for first-trimester MA in a hospital-based setting between 2013-2019. The study population was divided into two groups - the study group which included women who underwent D&C with ultrasound guidance (US group) and the control group, which included women who underwent D&C without ultrasound guidance (N-US group). Gynecologic, obstetric and operative related data were collected from electronic medical records.
Results:
Three-hundred and seventy-eight women were included in the study, 86 women in the US group and 292 women in N-US group. Baseline maternal characteristics and procedure-related characteristics did not differ between the groups. No significant difference between the US group and N-US group was shown when comparing D&C related complications - retained products of conception rate (2.3% vs. 5.5%, respectively; p=0.385), uterine perforation rate (1.2% vs. 0.3%, respectively; p=0.404), and the total complication rate (8.1% vs. 12.3%, respectively; p=0.338). In a multivariate analysis, the use of ultrasound guidance during D&C was not found to be associated with lower complication rate (adjusted Odds Ratio (aOR) 95% confidence interval (CI) 1.468 (0.578-3.729), p=0.419).
Conclusions:
Performance of D&C under ultrasound guidance for first-trimester MA, in a hospital-based setting, was not associated with lower complication rate, suggesting that the common practice of performing D&C without the use of ultrasound is an acceptable approach.
This chapter focuses on the techniques, complications, and risks of abortion performed during the first and second trimesters of pregnancy. Detecting fetal disorders in the first trimester permits women to undergo first‐trimester pregnancy termination, a procedure that is safer and less emotionally traumatic than termination performed later in pregnancy. An accurate determination of gestational age is required for performing suction aspiration. Second‐trimester pregnancy termination procedures have morbidity and mortality rates higher than first‐trimester techniques. The most commonly used systemic abortifacients for second‐trimester pregnancy termination are prostaglandin analogs, most commonly misoprostol, that stimulate uterine contractions and result in the expulsion of the products of conception. The development of novel molecular diagnostic procedures for screening and diagnosis has increased our ability to detect an increasing number of severe neonatal, pediatric, adolescent, and adult conditions.
Intraoperative ultrasound (IOUS) is a valuable adjunctive tool that can provide real-time diagnostic information in surgery that has the potential to alter patient management and decrease complications. Lesion localization, characterization and staging can be performed, as well as surveying for additional lesions and metastatic disease. IOUS is commonly used in the liver for hepatic metastatic disease and hepatocellular carcinoma, in the pancreas for neuroendocrine tumors, and in the kidney for renal cell carcinoma. IOUS allows real-time evaluation of vascular patency and perfusion in organ transplantation and allows for early intervention for anastomotic complications. It can also be used to guide intraoperative procedures such as biopsy, fiducial placement, radiation, or ablation. A variety of adjuncts including microbubble contrast and elastography may provide additional information at IOUS. It is important for the radiologist to be familiar with the available equipment, common clinical indications, technique, relevant anatomy and intraoperative imaging appearance to optimize performance of this valuable imaging modality.
Ultrasound plays a key role in diagnosis and guidance in reproductive medicine and surgery. In the field of reproductive surgery, some of the interventions, especially intrauterine procedures, are regularly conducted without imaging guidance but instead performed based on clinical skills and experience alone. Operative real-time US provides concurrent visualisation of the structures, contents and planes and operating instruments and, therefore, has the potential to improve efficacy and safety of the operative interventions. Ultrasound should be used in our operating theatres more often to guide various intrauterine procedures to reduce the intra-operative risks and complications including uterine perforations and visceral injury. The use of ultrasound necessitates an additional assistant experienced in ultrasound in the theatre, but regular use of ultrasound improves the training opportunities of the trainees and clinicians.
Induced abortion is a common experience in women's reproductive lives worldwide. Serious morbidity and mortality from legal abortion by modern medical and surgical methods is very rare. Patient preference should guide choice of abortion method wherever possible. Patient preparation for an abortion includes non‐judgmental decision making support, focused medical assessment including determination of gestational age, and a discussion of the risks and benefits of treatment options to ensure informed consent. Almost all methods of contraception can be initiated immediately following an uncomplicated abortion should a woman wish to use birth control to prevent future unintended pregnancies.
Recurrent pregnancy loss is associated with psychological stress for not only the woman but her whole family. The most effective method to ensure complete evacuation after miscarriage is still surgical. Other methods such as expectant and medical management are also effective and available options.
Objectives:
To compare vaginal misoprostol treatment with expectant management in early non-viable pregnancies with vaginal bleeding with regard to complete evacuation of the uterine cavity within 10 days.
Methods:
Parallel randomized controlled, open label, trial conducted in Skåne university hospital, Sweden. Patients with anembryonic pregnancy or early fetal demise (crown-rump length <33mm) and vaginal bleeding were randomly allocated to either expectant management or single dose 800μg of misoprostol vaginally. Patients were evaluated clinically and by ultrasound until complete evacuation of the uterus (no gestational sac in the uterine cavity and maximum anterior-posterior diameter of the intra-cavitary contents <15 mm as measured by transvaginal ultrasound on a midsagittal view). Follow-up visits were planned at 10, 17, 24 and 31 days. Dilatation and evacuation (D&E) was recommended if miscarriage was not complete in 31 days, but was performed earlier on patient's request, or if there was excessive bleeding as judged clinically. Analysis is by intention to treat. Main outcome measure is number of patients with complete miscarriage without D&E <10 days. Clinical Trials NCT01033903.
Results:
Ninety-four patients were randomized to misoprostol and 95 to expectant management. After exclusion of three patients and withdrawal of consent by two patients 184 patients (n=94, n=90) were included. Miscarriage was complete <10 days in 62/94 (66 %) of the patients in the misoprostol group and in 39/90 (43%) of those in the group managed expectantly (risk difference 23%, 95% confidence interval 8% to 37%). At 31 days the corresponding figures were 81/94 (86%) and 55/90 (61%) (risk difference 25%, 12% to 38%). Two patients from each group underwent emergency D&E because of excessive bleeding and one of these in each group received blood transfusion. The number of patients undergoing D&E on their own request was higher in the expectantly managed group, 15/90 (17%) versus 3/94 (3%) (risk difference14%, 4% to 23%) as was the number of patients making out of protocol visits, 50/90 (56%) versus 27/94(29%) (risk difference27%, 12% to 40%). More patients in the misoprostol group than in the expectantly managed group experienced pain, 91/91 (100%) versus 71/77 (92.2%) (risk difference 7.8%, 1.0% to 16.8%), and used painkillers, 85/91 (93%) versus 59/77 (77%) (risk difference 17%, 5% to 29%). No major side effects were reported in any group.
Conclusions:
Misoprostol treatment is more effective than expectant management in early non-viable pregnancies in women with vaginal bleeding with regard to complete evacuation of the uterus. Both methods are safe but misoprostol treatment is associated with more pain than expectant management.
Objectives:
Some providers use oxytocin during dilation and evacuation (D&E) to prevent or treat hemorrhage although evidence to support this is scarce. We sought to describe the association between prophylactic oxytocin use, estimated blood loss (EBL), and surgical outcomes during D&E.
Study design:
We performed a chart review of 730 women at 14 to 26weeks gestation who had a D&E at our institution between May 2010 and May 2014 to assess the association between prophylactic oxytocin use and EBL. We determined whether sociodemographic and health-related factors were associated with excessive blood loss (EBL≥250mL) and whether oxytocin use was associated with complications, including hemorrhage (i.e. EBL≥500mL or interventions for bleeding). We performed univariate analyses and multivariable regression models to evaluate the relationship between health-related factors and EBL≥250mL.
Results:
Providers used prophylactic oxytocin in 59.9% of procedures. Asian (p=.005 and Native Hawaiian/Pacific Islander (p=.005) race, nulliparity (p=.007) and higher gestational age (p<.001) were associated with prophylactic oxytocin use. We found no difference in mean EBL (116.2 +/- 105.5mL versus 130.7 +/- 125.5mL, p=.09), EBL≥250mL (31.4% vs. 68.6%, p=.15), or complications (6.1% vs. 7.1%, p=.73) including hemorrhage (1.4% vs. 5.3%, p=.14) between those who did not receive prophylactic oxytocin and those who did. No transfusions occurred in either group. In multivariable regression modeling, the adjusted OR for excessive blood loss was 0.42 (95% CI 0.16-1.07) with prophylactic oxytocin use.
Conclusions:
Prophylactic oxytocin use during D&E was not associated with hemorrhage or transfusion in our population.
Implications:
Routine use of interventions for bleeding, such as intravenous oxytocin, should be based on scientific evidence or not performed. Findings from our study provide information on how oxytocin use is associated with blood loss during D&E.
La place de l’échographie dans le parcours de soins de l’interruption volontaire de grossesse (IVG) est fondamentale. Bien qu’elle puisse améliorer la qualité des soins au décours de l’IVG, elle ne doit pas constituer un frein à son accès. La place de l’échographie dans la datation de la grossesse et les alternatives possibles ont donc été étudiées. Une analyse de la littérature a ensuite été réalisée afin de déterminer sa place dans le suivi post-IVG. Lorsqu’une échographie est réalisée, l’estimation de la datation de la grossesse se fait par la mesure de la longueur cranio-caudale (LCC), définie par Robinson, ou par la mesure du diamètre bipariétal (BIP) définie par le Centre français d’échographie fœtale (CFEF) à partir de 11 SA (courbes de Robinson et CFEF) (grade B). De nouvelles courbes ont été actualisées dans l’étude INTERGROWTH. Au vu de la littérature, dans le contexte des demandes d’IVG, un delta de 5 jours est à prendre en compte notamment lorsque la datation de la grossesse évaluée sur la mesure de la LCC ou du BIP correspond à un terme proche de 14 SA (respectivement 80 mm et 27 mm) (accord professionnel). Ainsi la mesure échographique étant fiable à ± 5 jours lorsque les critères de réalisation sont respectés, l’IVG peut être réalisée lorsque les mesures de LCC et/ou de BIP sont respectivement inférieures ou égales à 90 mm et/ou 30 mm (courbes INTERGROWTH) (accord professionnel). Si la réalisation d’une échographie de datation doit être encouragée, pour les femmes déclarant bien connaître la date de leurs dernières règles et/ou la date du rapport sexuel à risque, et pour lesquelles un examen clinique par un professionnel de santé formé est possible, l’absence d’accès à l’échographie de routine ne devrait donc pas être un frein à la programmation de l’IVG demandée (accord professionnel). En cas de grossesse intra-utérine d’évolutivité incertaine, ou de grossesse de localisation indéterminée, sans symptômes particuliers, la patiente doit pouvoir bénéficier de la réalisation d’une échographie endovaginale pour augmenter la précision du diagnostic (grade B). Concernant le suivi post-IVG, les résultats de différentes études de la littérature permettent de ne pas recommander l’utilisation en routine de l’échographie lors de l’IVG instrumentale (accord professionnel). Si celle-ci est réalisée au décours immédiat de l’intervention un endomètre supérieur à 8 mm doit conduire à une réaspiration immédiate (grade B). L’étude échographique de l’endomètre quelques jours après une IVG instrumentale n’apparaît pas pertinente. En cas d’IVG médicamenteuse, la réalisation systématique d’une échographique post-IVG ne peut être recommandée en routine d’après l’analyse de la littérature (grade B). Si elle est pratiquée, l’échographie endovaginale après une IVG médicamenteuse devrait être réalisée à distance (après 15 jours) (accord professionnel). Lorsque l’examen échographique est effectué lors du suivi, son seul but devrait être de déterminer si le sac gestationnel est présent (accord professionnel). Enfin, si une échographie est réalisée dans le parcours d’une IVG, la réalisation d’un compte rendu doit être encouragée précisant les éventuelles anomalies gynécologiques retrouvées mais son absence ne doit pas retarder la programmation de l’IVG (accord professionnel).
This chapter provides an introduction to the methods of induced abortion, both medical and surgical. The differential diagnosis and assessment of common post-procedural complaints are discussed, namely, pain, fever, and vaginal bleeding. Management of specific postabortal complications is reviewed, including infection, hemorrhage, uterine perforation, and hematometra.
This chapter focuses on the techniques, complications, and risks of abortion performed during the first and second trimesters of pregnancy. Chorionic villus sampling (CVS) and first-trimester endovaginal ultrasonography permit the cytogenetic and genomic assessment of the fetus in the first trimester. Detecting fetal disorders in the first trimester permits women to undergo first-trimester pregnancy termination, a procedure that is safer and less emotionally traumatic than termination performed later in pregnancy. Second-trimester pregnancy termination procedures have morbidity and mortality rates higher than first-trimester techniques. Some centers have begun to utilize preoperative or preinduction procedures to ensure the delivery of a demised fetus. Prior to dilation and evacuation (D and E), either a potassium chloride (KCl) intracardiac injection or umbilical cord avulsion can be performed, whereas a KCl intracardiac injection can be performed prior to initiation of systemic pharmacotherapy for a labor induction pregnancy termination.
Introduction, Miscarriage is the most common complication of pregnancy. It rarely causes serious health problems, but it can adversely affect women's social and psychological wellbeing. Ectopic pregnancy is less common than miscarriage, but it remains the leading cause of first-trimester maternal mortality and is associated with significant physical and psychosocial morbidity. According to the Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom, there are around 1000 000 pregnancies per year in the UK, with approximately 700 000 deliveries occurring each year. It is estimated that the number of miscarriages per year is at least 200 000 and the number of ectopic pregnancies at least 10 000. The maternal mortality rate in relation to early pregnancy complications in the UK in the 3 years between 2003 and 2005 was 0.47/100 000 maternities for ectopic pregnancy (a total of ten deaths) and 0.05/100 000 maternities for miscarriage (one recorded death). Thus, despite a relatively low mortality rate, the overall impact of these disorders on women's health is significant. Miscarriage is conventionally quoted to affect one in five pregnancies and ectopic pregnancy to occur in 1/100 gestations; however, establishing the true rate of these early pregnancy complications is challenging owing to the lack of accurate data. Hospital statistics provide information regarding the rate of miscarriage and ectopic pregnancy resulting in hospital admissions. However, the majority of women diagnosed with miscarriage are nowadays managed without admission to hospital.
Grammatici certant et adhuc subjudice lis est. (Scholars dispute, and the case is still before the courts.) Horace (Quintus Horatius Flaccus) (65–8 b.c.E.) Ars Poetica 18 b.c.E, III, 7. HISTORY OF ABORTION. This chapter reviews the history and epidemiology of modern pregnancy termination. In this review, the surgical and medical techniques appropriate for various gestational ages are presented, potential complications are considered, and the psychological issues surrounding abortion are discussed. Controversy concerning human fertility contraception or spontaneous or induced abortion dates to ancient times. Issues involving the ethics of pregnancy termination and techniques for abortion have long been a part of medical practice. Society continues to struggle both with the problems of abortion ethics as well as access to procedures. Recent decades have seen various legal efforts by individual states to limit or entirely proscribe pregnancy termination. A historical review of abortion practices provides some perspective to modern practitioners on these contentious modern debates and indicates how long these issues have been debated without societal resolution. Greek, Roman, and Hebrew laws generally did not protect the fetus before recognizable features were formed during development. Before that point, abortion could be performed without official reprisal [1]. The Old Testament refers to accidental miscarriage but does not refer specifically to induced abortion. The Talmud, however, states that the fetus can be sacrificed to save the life of the mother [2]. The issue of pregnancy termination was discussed in some detail by the classical philosophers.
This chapter focuses on the techniques, complications, and risks of abortion performed during the first and second trimesters of pregnancy. Chorionic villus sampling (CVS) and first-trimester endovaginal ultrasonography permit the cytogenetic and genomic assessment of the fetus in the first trimester. Detecting fetal disorders in the first trimester permits women to undergo first-trimester pregnancy termination, a procedure that is safer and less emotionally traumatic than termination performed later in pregnancy. Second-trimester pregnancy termination procedures have morbidity and mortality rates higher than first-trimester techniques. Some centers have begun to utilize preoperative or preinduction procedures to ensure the delivery of a demised fetus. Prior to dilation and evacuation (D and E), either a potassium chloride (KCl) intracardiac injection or umbilical cord avulsion can be performed, whereas a KCl intracardiac injection can be performed prior to initiation of systemic pharmacotherapy for a labor induction pregnancy termination.
Although uterine perforation is a potentially life-threatening complication of curettage abortion, little is known about the risk factors associated with uterine perforation or how to prevent it. Using linear logistic regression, we analyzed 67,175 curettage abortions performed at 13 institutions in the United States from 1975 through 1978. The overall incidence of confirmed perforation was 0.9 per 1,000 abortions. Performance of the abortion by a resident rather than by an attending physician was a powerful risk factor for perforation (relative risk, 5.5; 95% confidence interval, 3.3 to 9.2). Use of Laminaria for dilation had a protective effect, although this effect was not statistically significant (relative risk, 0.17; 95% confidence interval, 0.02 to 1.2). Among factors beyond the control of the physician, advancement of gestational age and previous delivery were significant risk factors. Use of Laminaria and performance of the abortion by an attending physician considerably lowered the risk of uterine perforation.
(JAMA 1984;251:2108-2111)
3036 induced abortions from the years 1977, 1978, 1979 and 1980 were analysed. They included all abortions performed with the suction method at Akershus Central Hospital, except for those done in combination with a sterilization procedure. The main determinants of complication rates were parity, period of gestation and, for minor complications, whether the patient was treated as an inpatient or an outpatient. Women who had not previously given birth had a higher complication rate than parous women. Complication rates were lowest during weeks 7-10. Outpatients had fewer readmissions, repeat curettages, and infections, than inpatients. There was a tendency to cause a larger dilatation of the cervical canal than was technically necessary.
Objective To assess the value of routine histological examination of tissue samples collected at termination of pregnancy in the first trimester and emergency surgical uterine evacuation.
Setting The gynaecological department of a teaching hospital.
Design Prospective study of women attending the gynaecological department in a 12-month period.
Participants All women undergoing a therapeutic first trimester medical or surgical abortion or an emergency surgical evacuation of a failed pregnancy, suspected incomplete spontaneous miscarriage or incomplete induced abortion.
Main outcome Association of pre-operative clinical diagnosis and the post-operative histological result.
Results Of 1576 women studied, the histological report confirmed that products of conception were obtained in 1465 (93%); in two women (0.13%) molar changes were reported confirming the pre-operative diagnosis by ultrasound. Products of conception were not confirmed in the tissue specimens in 0.5% medical terminations, 5% surgical terminations, 10% evacuations following a previous evacuation, 12% evacuations for a failed pregnancy, and 19% evacuations for an incomplete miscarriage. In 87 women (6%), decidua was reported; two of these women had undergone an evacuation for an ultrasound diagnosis of spontaneous miscarriage, but in both a tubal ectopic pregnancy was subsequently diagnosed.
Conclusion There did not appear to be any obvious benefit from routine histological examination of tissue removed at termination of pregnancy or emergency uterine evacuation. The histological result was sometimes not consistent with the pre-operative diagnosis and may result in unnecessary further investigation and treatment unless due consideration is given to the clinical presentation.
The benefits of non-invasive, correctly-directed instrumentation coupled with an ability to predict complete evacuation of the uterus can make intraoperative ultrasound an important addition in the continued and improved care of women with a perforated uterus and retained products of conception. Two such cases are reported.
Diagnostic ultrasound has an important place to play in aiding the obstetrician who has an abortion practice. It is most useful in accurately dating the time of conception. Based on sonographic dating, an abortion may be possible in patients with multiple pregnancy or in whom there is a mass in addition to pregnancy. The performance of a saline or urea abortion is made easier since the precise site of the uterus can be mapped out. Once an abortion has commenced, the presence or absence of retained products can be easily verified by ultrasound.
PIP
Diagnostic sonography has been helpful in aiding the obstetrician who performs abortion and in deciding which technique will be appropriate in patients with a borderline gestational age. It is useful in accurately dating the time of conception. With the aid of sonographic dating, an abortion may be possible in patients with multiple pregnancy or in whom there is an additional mass. A saline or urea abortion can be facilitated since the precise site of the uterus can be visualized. In addition, the presence of absence of retained pro ducts following an abortion can be easily detected by ultrasound.
We performed aspiration of early pregnancy on 100 women requesting termination, using a low caliber angled catheter under sonographic guidance, without analgesia or anesthesia. The sonographic inclusion criteria for the study were: (1) mean gestational sac diameter less than 30 mm, or (2) crown rump length less than 10 mm when an embryo was visualized. The uterine content was successfully evacuated in all cases and none needed an additional curettage. Two women developed mild endometritis which responded to antibiotic therapy. This refinement of this 'menstrual regulation' technique seems to be safer when compared with the reported results of the original technique.
This article grew out of a keynote address prepared for the conference, "From Abortion to Contraception: Public Health Approaches to Reducing Unwanted Pregnancy and Abortion Through Improved Family Planning Services," held in Tbilisi, Georgia, USSR in October 1990. The article reviews the legal, religious, and medical situation of induced abortion in Europe in historical perspective, and considers access to abortion services, attitudes of health professionals, abortion incidence, morbidity and mortality, the new antiprogestins, the characteristics of abortion seekers, late abortions, postabortion psychological reactions, effects of denied abortion, and repeat abortion. Special attention is focused on the changes occurring in Romania, Albania, and the former Soviet Union, plus the effects of the new conservatism elsewhere in the formerly socialist countries of central and eastern Europe, particularly Poland. Abortion is a social reality that can no more be legislated out of existence than the controversy surrounding it can be stilled. No matter how effective family planning services and practices become, there will always be a need for access to safe abortion services.
The frequency and management of uterine perforation during first-trimester abortions remain a matter of continuing debate among gynecologists. The rate of uterine perforations was 1.3/1000 procedures (eight cases) in 6408 women undergoing first-trimester abortions at our clinic. We also performed 706 first-trimester abortions at the time of laparoscopic sterilization. Two perforations (2.8/1000 procedures) were reported before laparoscopy. Twelve (15.6/1000 procedures) unsuspected perforations were discovered during direct laparoscopic visualization. This represents a 19.8/1000 procedure rate of perforation (14 cases). All 22 patients with perforations were managed conservatively, and no immediate or late complications were noted. Our data suggest that the true incidence of uterine perforations is significantly underestimated and serious complications caused by perforations are rare. Conservative therapy is recommended rather than early surgical intervention.
Second trimester elective abortion is safest when accomplished with cervical dilation and instrumental uterine evacuation (D and E), but this procedure carries with it a risk of uterine perforation and possible intra-abdominal trauma. In order to determine if the routine use of intraoperative ultrasonography reduces the risk of this feared and serious complication, 353 elective abortions at 16 to 24 weeks gestation performed without sonography were compared to 457 in which sonography was routinely employed. All 810 operations were carried out in one clinic using the same operative technique. The routine intraoperative use of ultrasonographic imaging to guide intrauterine forceps during uterine evacuation for second trimester elective abortion resulted in a significant reduction in uterine perforation, the rate declining from 1.4% to .2%. These findings support the routine use of intraoperative ultrasonography for second trimester elective abortion to reduce the incidence of uterine perforation and make the procedure a safer one.
The value of real time ultrasonography (RTUS) in the management of first trimester elective pregnancy terminations was studied in 120 consecutive patients. RTUS was found essential in determining accurate gestational ages, identifying incomplete pregnancy terminations, diagnosing abnormal pregnancies, and in performing difficult terminations. It is suggested that RTUS be employed in the routine management of first trimester pregnancy terminations.
Intraoperative ultrasound was used as an adjunct in difficult dilatation and evacuation (D&E) procedures for first-trimester abortions. This technique was useful in eight technically difficult D&Es in the presence of acute retroflexion, acute anteflexion, cervical stenosis and lower uterine segment fibroids.
Complications subsequent to 5,851 consecutively induced first-trimester abortions during the period 1980-85 were analysed. Three hundred and fifty-six abortions (6.1%) led to complications requiring hospital admission. According to bivariable analysis, women below 25 years of age, women with parity 0, women with no spontaneous and with no induced abortions, and women in gestational week 8 had significantly higher postabortal complication rates than women 25 years of age and older (p less than 0.001), women with previous births (p less than 0.0001), women with spontaneous abortions (p less than 0.005), women with induced abortions (p less than 0.005), and women in other gestational age groups (p less than 0.0005). The mean stay in hospital per complicated abortion was 5.3 days. It was discussed whether the administration of prophylactic antibiotics to women with a history of pelvic inflammatory disease and young women completing their first pregnancy could reduce the complication rate.
This communication describes a technique of sonographically monitored uterine curettage. This method is of particular value in the management of postabortal endomyometritis associated with retained products of conception or in any situation in which anatomic variation (for instance, retroversion) makes curette insertion difficult.
PIP
This communication describes a technique of sonographically monitored uterine curettage. This method is of particular value in the management of postabortal endomyometritis associated with retained products of conception or in any situation in which anatomic variation, e.g. retroversion, makes a curette insertion difficult.
3036 induced abortions from the years 1977, 1978, 1979 and 1980 were analysed. They included all abortions performed with the suction method at Akershus Central Hospital, except for those done in combination with a sterilization procedure. The main determinants of complication rates were parity, period of gestation and, for minor complications, whether the patient was treated as an in-patient or an out-patient. Women who had not previously given birth had a higher complication rate than parous women. Complication rates were lowest during weeks 7-10. Out-patients had fewer readmissions, repeat curettages, and infections, than in-patients. There was a tendency to cause a larger dilatation of the cervical canal than was technically necessary.
PIP
For elective abortion, ultrasound is helpful in the determination of gestational age prior to elective procedures and in the localization of the amniotic sac prior to midtrimester intraamniotic injection. According to various reports, ultrasound is potentially useful in determining whether products of conception remain after an elective procedure. 2 cases are described in which the use of real-time ultrasound during an elective abortion procedure aided the operator and very likely reduced the risk of significant complications. In the 1st case of a 43-year-old white, married woman, para 2-0-0-2, the cervix was dilated and an 8 mm suction catheter was introduced. Despite multiple attempts, no products of conception were obtained. With the use of ultrasound direction, the catheter (visible on ultrasound) was reintroduced and directed toward the gestational sac past the leiomyomas that protruded into the cavity. The uterus was evacuated without further difficulty, and the patient subsequently did well. The 2nd case was that of a 26-year-old, black primigravid woman who presented for an elective therapeutic abortion at 17 weeks' gestation. With the patient under local anesthesia, the cervix was dilated to 14 mm and a 14 mm plastic suction catheter was introduced. The procedure was performed without difficulty, except that, despite the use of various extraction instruments, the vertex could not be located and removed. With the use of ultrasound visualization, the grasping forceps (visible on ultrasound) were introduced and directed toward the vertex, enabling its removal with minimal difficulty. The patient tolerated the procedure well and had no further difficulty. As illustrated by these 2 case reports, the use of ultrasound to guide the suction catheter or other extraction instruments has proved to be very useful. Although direct sonar visualization may be needed only occasionally, this technique should be valuable in reducing the incidence of retained products of conception, failed procedures, and perforations that may complicate difficult abortion operations. It is recommended that the availability of ultrasound should not encourage the operator to perform procedures that otherwise would have considerable risk.
Although uterine perforation is a potentially life-threatening complication of curettage abortion, little is known about the risk factors associated with uterine perforation or how to prevent it. Using linear logistic regression, we analyzed 67,175 curettage abortions performed at 13 institutions in the United States from 1975 through 1978. The overall incidence of confirmed perforation was 0.9 per 1,000 abortions. Performance of the abortion by a resident rather than by an attending physician was a powerful risk factor for perforation (relative risk, 5.5; 95% confidence interval, 3.3 to 9.2). Use of Laminaria for dilation had a protective effect, although this effect was not statistically significant (relative risk, 0.17; 95% confidence interval, 0.02 to 1.2). Among factors beyond the control of the physician, advancement of gestational age and previous delivery were significant risk factors. Use of Laminaria and performance of the abortion by an attending physician considerably lowered the risk of uterine perforation.
The incidence of uterine perforation while performing legal abortions was evaluated in the Stockholm area. Among 84,850 legal abortions performed during 1982-1992 there were 145 cases of uterine perforation, 0.17%. In about half of these cases an immediate exploration of the abdomen was decided upon and in 18 patients there were significant bleeding and/or lacerations to organs situated in the pelvis. No case of intestinal perforation was encountered. It is likely that many of these injuries would have healed just as well unattended. Based on this study, the authors advocate a conservative approach in dealing with uterine perforation in connection with vacuum aspiration for legal abortion.
PIP
In Sweden, where abortion is legal during the first 18 weeks of pregnancy, uterine perforation is the most serious potential complication. An analysis of the 84,850 legal induced abortions performed at the six public hospitals in Stockholm, Sweden, in 1982-92 revealed 145 cases (0.17%) of uterine perforation. 49 (33.8%) of these women had experienced at least one prior induced abortion. In women where uterine size exceeded 12 weeks of pregnancy, there were only four instances (2.8%) of uterine perforation. The perforation was caused by the suction cannula in 69 women (47.0%) and by the Hegar dilator in 30 women (20.6%). Immediate exploration of the abdomen (primarily laparotomy) was performed in 69 (47.6%) of these cases; significant bleeding and/or lacerations to organs situated in the pelvis were identified in 18 (26.1%) of these women. There were no cases of intestinal perforation. The majority of injuries would have healed without laparotomy. Unless peritoneal irritation, increasing pain, and signs of blood loss are present, a conservative approach to uterine perforation is recommended.
A case of iatrogenic uterine perforation occurred during dilation and curettage for treatment of a missed abortion at 14 weeks' gestation. Real-time transabdominal sonography was used to detect the fundal perforation and to follow serially the amount of fluid in the cul-de-sac. It is recommended that this noninvasive and direct diagnostic tool be used in the management of uterine perforation.
The benefits of non-invasive, correctly-directed instrumentation coupled with an ability to predict complete evacuation of the uterus can make intraoperative ultrasound an important addition in the continued and improved care of women with a perforated uterus and retained products of conception. Two such cases are reported.
National Audit of Induced Abortion 2000—Report of England and Wales
- Royal College
Royal College of Obstetricians and Gynaecologists. National Audit of Induced Abortion 2000—Report of England and Wales. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness and Support Unit, London: RCOG Press; 2001.
Abortion complications: prevention and management A clinician's guide to medical and surgical abortion
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Lichtenberg ES, Grimes DA, Paul M. Abortion complications: prevention and management. In: Paul M, Lichtenberg ES, Borgatta L, Grimes D, Stubblefield PG, editors. A clinician's guide to medical and surgical abortion. New York: Churchill Livingstone; 1999. p. 197–216.
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edition, No. 136. London: The Stationary Office; 2000. p. 50.
Joint Study of the Royal College of General Practitioners and the Royal College of Obstetricians and Gynaecologists. Induced abortion operations and their early sequelae
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Should tissue from pregnancy termination and uterine evacuation routinely be examined histologically?
- V Heath
- I Chadwick
- S Cooke
- I Z Mckenzie
Heath V, Chadwick I, Cooke S, Mckenzie IZ. Should tissue from
pregnancy termination and uterine evacuation routinely be examined
histologically? Br J Obstet Gynaecol 2000;107:727-30.
Should tissue from pregnancy termination and uterine evacuation routinely be examined histologically?
- Heath
Early pregnancy termination: an improved technique for “menstrual regulation” with ultrasound assistance
- Capsi