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Therapeutic Abortion

Preparation of the uterine cervix before evacuation of second-trimester pregnancy Abortion during the second trimester of pregnancy accounts for 10-15% of abortions performed worldwide. Surgical evacuation, called dilation and evacuation (D&E), is the preferred method of second-trimester abortion, as opposed to induction of labor, in most developed countries where D&E and medical methods are both available (Lohr 2008; RCOG 2004). In order to perform a D&E, surgical instruments must pass through the cervix safely, the cervix must be opened prior to the procedure. Cervical preparation can be done with medications or with small rod-like devices that are placed inside the cervix. The most commonly used medications for cervical preparation are called prostaglandins. The small-rod like devices used for cervical preparation are called cervical dilators. Dilators are placed inside the cervix several hours before the procedure or even a day or two before the procedure. In general, dilators work by absorbing moisture from the cervix which causes the dilators to swell and get larger. As the diameter of these dilators expands the dilator puts radial pressure on the cervical walls and causes the cervix to open. We looked at how these preparation methods compared with respect to safety, procedure time, need for additional dilation, ability to perform the procedure, and patient and provider acceptability. We found that all methods reviewed were safe. Certain dilators called laminaria appeared to result in more cervical opening (dilation) than the prostaglandin medications, however no difference was seen between dilators and prostaglandins with respect to safety, length of procedure, or the ability to complete the procedure. We found that when mifepristone, a medication that blocks the action of a hormone called progesterone, was used with a prostaglandin called misoprostol that many women ended up expelling the pregnancy before their desired surgical procedure. Due to this increased rate of expulsions prior to planned D&E, we feel that the combination of mifepristone and misoprostol should not be used for cervical preparation when women are desiring a surgical procedure instead of an induction. We found that one day of cervical preparation is just a good as two days and that same-day cervical preparation appears to be safe in the early part of the second trimester.

Routine antibiotics to prevent infection for women seeking care after incomplete abortion Antibiotics are generally given when there are signs of infection. The review of trials showed difficulties for women in continuing to take antibiotics and returning for care, so single dose antibiotics may be more suitable in these circumstances. The trials did not provide enough evidence to show the effects of routine antibiotics for women after incomplete abortion. Antibiotic prophylaxis for first trimester induced abortion Infection of the upper genital tract, including the uterus and fallopian tubes, can cause complications after induced abortion. Antibiotics given around the time of the abortion (prophylaxis) could prevent this complication. We found 19 randomised controlled trials that looked at the effect of antibiotic prophylaxis on post-abortal upper genital tract infection amongst women requesting induced abortion in the first trimester of pregnancy. We looked at the effect of any antibiotic prophylaxis regimen on the outcome. Overall, the risk of post-abortal upper genital tract infection in women receiving antibiotics was 59% that of women who received placebo. There were, however, differences between the trial results over and above what would be expected by chance alone. It should be noted that, if the infection is caused by a sexually transmitted organism, antibiotic prophylaxis will not protect the woman from becoming reinfected if her sexual partner has not been treated. Preparing the cervix with nitric oxide donors before surgical abortion in the first three months of pregnancy This review compared drugs called nitric oxide donors with other drugs. We found that nitric oxide donors are better than placebo (a sugar pill). Prostaglandins are better than nitric oxide donors for preparing the cervix. Medical methods for early termination of pregnancy can be safe and effective Medical abortion, and uses the hormones prostaglandins and/or mifepristone (an antiprogesterone often called RU486), and/or methotrexate. This review of trials found that medical methods for abortion in early pregnancy can be safe and effective, with the most evidence of effectiveness for a combination of mifepristone and misoprostol. Almost all of the trials were done in wellresourced settings where women returned for a check-up.

Planned abortion after three months of pregnancy - which medical procedure is the best. *** Misoprostol is the drug of choice for medical pregnancy termination, preferably in combination with mifepristone which facilitates the effectiveness of misoprostol. Misoprostol works best when it is administered into the vagina. Women who had previously given birth could take misoprostol by mouth (under the tongue). Irrespective of the medication used for second trimester termination there is a considerable risk of surgical intervention because of vaginal bleeding or incomplete abortion. Abortion after three months of pregnancy can be done by an operation or with medicines - which way is better We found two studies. The first compared dilation and evacuation (D&E) to injecting a drug into the pregnant womb. The second compared D&E to drugs taken by mouth and by vagina. The D&E operation was better than injecting medicines into the womb. Medicines taken by mouth and vagina worked as well and were as acceptable as a D&E, but caused more pain and side effects. More studies with modern medicines used for abortion after 3 months of pregnancy are needed. Preparing the cervix before first trimester surgical abortion This review found that cervical preparation decreased the length of time necessary for an abortion procedure, but did not seem to decrease rates of uncommon abortion complications. Misoprostol worked better with less sideeffects than other similar medications. Misoprostol is most effective with the least side-effects when placed in the vagina, but when placed under the tongue it is equally effective. Another drug called mifepristone worked better than misoprostol; however, it is more expensive to use. All methods of preparation take at least 2-3 hours or more to work. The review could not determine whether women preferred one method best. D&C and vacuum aspiration for first trimester termination of pregnancy . There are several different surgical techniques for early termination of pregnancy - D&C, vacuum aspiration, hysterotomy. The cervix (opening of the uterus) can be prepared beforehand with hormones to minimise the risk of damage. The review found that both, D&C and vacuum aspiration, are safe and effective methods for first trimester termination of pregnancy and complications are rare. The review does not reveal women's or surgeons' preference of one method over the other.

Pain control in first trimester surgical abortion Pain control methods can be divided in local anesthesia, conscious sedation, general anesthesia and non-pharmacological methods. Data to support the benefit of the widely used local anesthetic is inadequate. While general anesthesia achieved complete pain control during the procedure, other forms of anesthesia such as conscious sedation with a paracervical block improved postoperative pain control