10/27/2017 Surgical termination of pregnancy: First trimester - UpToDate

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Surgical termination of pregnancy: First trimester

Author: Jody Steinauer, MD, MAS

Section Editor: Robert L Barbieri, MD
Deputy Editor: Sandy J Falk, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2017. | This topic last updated: Jun 29, 2016.

INTRODUCTION — Suction curettage is the most commonly used method of pregnancy termination in the
United States [1]. The procedure, also referred to as dilation and evacuation, is usually performed between the
7th and 13th menstrual weeks. According to the Centers for Disease Control, over 96 percent of abortions in the
United States in 2001 were performed by suction curettage [2]. The procedure does not require hospitalization
except in women with medical or surgical disorders that place them at higher surgical risk.

Suction curettage of the uterus in the first trimester will be reviewed here. General issues regarding preoperative
evaluation and patient preparation, anesthesia, complications, and follow-up, and second trimester pregnancy
termination are discussed separately. (See "Overview of pregnancy termination" and "Overview of second-
trimester pregnancy termination".)

DILATION — Dilation of the cervix is usually necessary to allow insertion of instruments and removal of bulky
uterine contents. However, very early pregnancies (eg, less than seven weeks of gestation) may not require
cervical dilation. In pregnancies 7 to 13 weeks, the endocervical canal can either be dilated manually or osmotic
dilators or prostaglandins can be used to gradually dilate the cervix. The latter two methods require a few hours
to work and may involve additional patient visits; therefore, many practitioners and clinics due not use them in
the first trimester. (See "Overview of pregnancy termination", section on 'Cervical preparation'.)

CURETTAGE

Manual vacuum aspiration — Vacuum aspiration is generally performed with an electric suction device,
however, it may also be performed with a manual aspirator. At less than 10 weeks of gestation, it appears that
manual vacuum aspiration (MVA) is as safe and effective as electric vacuum aspiration (EVA), and may result in
less pain and blood loss [3,4]. A systematic review that compared MVA to EVA for termination of pregnancy at
less than 10 weeks reported no significant differences between the two methods for complete abortion rate or
patient satisfaction [3].

Both EVA and MVA produce about 60 mmHg of suction, but manual aspiration has the advantage of being
quieter. Patients are often disturbed by the noise of the electric device [5]. In contrast to an electric suction
device, the manual vacuum aspirator is more portable, inexpensive, and does not require electricity, thereby
making it a favorable choice for low-resource settings.

The manual vacuum aspirator is a hand-operated, 50 or 60 mL syringe in which vacuum is produced retracting a
plunger at the other. The syringe is connected to the Luerlock end of either a 3 to 4 mm rigid (eg, Karman
cannula (picture 1)) or 6 mm flexible cannula. The products of conception are aspirated by rapidly withdrawing
and depressing the syringe plunger 20 to 30 times. The cannula is moved in and out and simultaneously rotated
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in a 360 degree arc. The catheter is removed under continuous maximum negative pressure when aspiration of
intrauterine contents appears to be complete. Suction will decrease when the syringe is 80 percent full.

Electric vacuum aspiration — Electric vacuum aspiration can be used for terminations at all gestational ages.
To perform this procedure, a rigid curved suction curette (picture 2) is inserted into the uterine cavity without
suction. The diameter of the curette in millimeters equals the gestational age in weeks of the pregnancy (ie, a #8
suction curette [8-mm diameter] would be used to evacuate an eight-week [menstrual weeks] size uterus).

The curette is connected to the collection vessel with transparent polyethylene tubing after the tip of the curette is
within the uterine cavity. Suction is then applied using an aspiration device. The curette is rotated side to side
(not in and out) in a wide arc during tissue aspiration; this reduces the likelihood of instrument perforation of the
uterine fundus (figure 1). When no further tissue can be aspirated, the curette is withdrawn under continuous
suction.

A metal curette may then be used to gently scrape the endometrial cavity to verify that all products of conception
have been removed (see 'Sharp curettage' below).

Sharp curettage — Vacuum aspiration of uterine contents is preferable to sharp curettage [6], although sharp
curettage may be performed at the end of the procedure to assess the uterine cavity for remaining tissue. In a
well-designed trial, women with incomplete abortion were randomly assigned to vacuum aspiration or sharp
curettage. Compared to sharp curettage, vacuum aspiration was associated with statistically significantly
decrease in blood loss, less pain, and shorter duration of procedure. No difference was found in need for re-
evacuation. Serious complications, such as uterine perforation, were rare in both groups.

The sharp metal curette used to check for retained tissue should be the largest curette that easily passes
through the cervical canal. An empty uterus contracts and is characterized by a gritty sensation during curettage.
If products remain within the cavity after sharp curettage, suction curettage is repeated [7]. Placing the
abdominal hand on the fundus stabilizes the uterus and enhances depth perception.

EXAMINATION OF TISSUE — For pregnancies less than 7 weeks of gestation, the aspirate is examined by
placing it in a small amount of sterile water or saline, washing away adherent blood and clots, and looking for
fetal membranes and/or fronds indicative of placental villi [8]. Backlighting through a glass dish is useful for
identifying these structures. Presence of products of conception is highly predictive of a complete abortion and
routine examination by a pathologist is probably not necessary in these cases [9,10]. However, many state
regulations require that all of the tissue obtained should be sent to the pathology department for evaluation,
although the need for this practice has been challenged [9]. For pregnancies ≥7 weeks of gestation, the products
of conception should be examined in the procedure room to verify the presence of both villi and fetal parts;
ideally a cranium, four extremities, and a rib cage are identifiable by the late first trimester. Gestational age
should be confirmed and recorded after measuring the fetal foot length (table 1).

Failure to obtain a sufficient volume of tissue necessitates repeating the procedure. Absence of products of
conception may indicate an incomplete procedure or an ectopic pregnancy; diagnostic measures (eg, ultrasound
examination, serial human chorionic gonadotropin (hCG) assays) should be initiated in such cases. If an ongoing
intrauterine pregnancy is diagnosed, the procedure can be attempted again with ultrasound guidance (if a sac
can be visualized) or in one or two weeks when the sac is larger, or, in some cases, a medical abortion can be
offered.

Women with suspected ectopic pregnancies should be monitored carefully with serial hCG levels; follow-up
within 24 to 48 hours is obligatory, and all of these women must be cautioned about the symptoms of ectopic
pregnancy rupture. (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

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It is important to remember that early pregnancies may be complicated by complete or partial mole, which
require specialized follow-up because some cases progress to malignant forms of gestational trophoblastic
disease (GTD). It has been estimated that four of 1000 women having early termination of pregnancy have a
molar pregnancy (1/1000 complete mole, 3/1000 partial mole). In one study, 15 such women were diagnosed
one to 12 months after their abortion procedure and thus did not undergo standard GTD monitoring for
recurrent/persistent disease [11]. Compared to 36 women diagnosed at the time of pregnancy termination, the
women with delayed diagnosis of GTD were at high risk of developing a life-threatening hemorrhage or needing
surgical intervention or chemotherapy. The possibility of GTD should be considered if menses have not returned
by six weeks after the procedure or persistent vaginal bleeding or uterine enlargement occur. (See "Hydatidiform
mole: Epidemiology, clinical features, and diagnosis".)

POSTOPERATIVE CARE — Postoperative care and follow-up are discussed elsewhere. (See "Overview of
pregnancy termination", section on 'Postoperative care' and "Overview of pregnancy termination", section on
'Follow up'.)

COMPLICATIONS — First trimester suction curettage is the safest method for surgical pregnancy termination;
second-trimester techniques of extraction, intraamniotic instillation of abortifacients, and hysterotomy or
hysterectomy all carry higher mortality rates [12-14]. Complications of pregnancy termination, such as
hemorrhage, uterine perforation, infection, and retained products of conception, are discussed in detail
separately. (See "Overview of pregnancy termination", section on 'Complications'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and
“Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
“patient info” and the keyword(s) of interest.)

● Basics topics (see "Patient education: Abortion (The Basics)")

● Beyond the Basics topics (see "Patient education: Abortion (pregnancy termination) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Osmotic dilators can be used to reduce the risk of cervical lacerations in pregnancies of 7 to 13 weeks of
gestation, but require a few hours to work and may require additional patient visits. Therefore, many
practitioners and clinics do not use them in the first trimester. (See 'Dilation' above.)

● Suction curettage is the most commonly used method of first trimester pregnancy termination in the United
States. Suction curettage results in reduced pain and blood loss, and shorter procedure time than sharp
curettage. (See 'Curettage' above.)

● For pregnancies <10 weeks, electric or manual suction curettage can be used. Manual suction is safe and
effective, and may decrease intraoperative pain or bleeding. (See 'Manual vacuum aspiration' above.)

● The aspirate is examined by placing it in a small amount of sterile water or saline, washing away adherent
blood and clots, and looking for fetal membranes and/or fronds indicative of placental villi. Backlighting

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through a glass dish is useful for identifying these structures. Absence of products of conception may
indicate an incomplete procedure or an ectopic pregnancy; further diagnostic measures should be initiated in
such cases. (See 'Examination of tissue' above.)

ACKNOWLEDGMENT — The author and UpToDate would like to acknowledge Dr. Frank W Ling and Dr. Lee P
Shulman, who contributed to earlier versions of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Pazol K, Creanga AA, Jamieson DJ, Centers for Disease Control and Prevention (CDC). Abortion
Surveillance - United States, 2012. MMWR Surveill Summ 2015; 64:1.
2. www.cdc.gov/mmwr/preview/mmwrhtml/ss5309a1.htm (Accessed on March 08, 2005).
3. Wen J, Cai QY, Deng F, Li YP. Manual versus electric vacuum aspiration for first-trimester abortion: a
systematic review. BJOG 2008; 115:5.
4. Goldberg AB, Dean G, Kang MS, et al. Manual versus electric vacuum aspiration for early first-trimester
abortion: a controlled study of complication rates. Obstet Gynecol 2004; 103:101.
5. Dean G, Cardenas L, Darney P, Goldberg A. Acceptability of manual versus electric aspiration for first
trimester abortion: a randomized trial. Contraception 2003; 67:201.
6. Verkuyl DA, Crowther CA. Suction v. conventional curettage in incomplete abortion. A randomised
controlled trial. S Afr Med J 1993; 83:13.
7. Shulman LP, Elias S, Simpson JL. Induced abortion for genetic indications: techniques and complications. I
n: Genetic Disorders and the Fetus: Diagnosis, Prevention and Treatment, Milunsky A (Ed), Johns Hopkins
University Press, 1992. p.721.
8. Munsick RA. Clinical test for placenta in 300 consecutive menstrual aspirations. Obstet Gynecol 1982;
60:738.
9. Paul M, Lackie E, Mitchell C, et al. Is pathology examination useful after early surgical abortion? Obstet
Gynecol 2002; 99:567.
10. Heath V, Chadwick V, Cooke I, et al. Should tissue from pregnancy termination and uterine evacuation
routinely be examined histologically? BJOG 2000; 107:727.
11. Seckl MJ, Gillmore R, Foskett M, et al. Routine terminations of pregnancy--should we screen for gestational
trophoblastic neoplasia? Lancet 2004; 364:705.
12. Hodgson JE. Major complications of 20,248 consecutive first trimester abortions: problems of fragmented
care. Adv Plan Parent 1975; 9:52.
13. Nathanson BN. Ambulatory abortion: experience with 26,000 cases (July 1, 1970, to August 1, 1971). N
Engl J Med 1972; 286:403.
14. Hodgson JE, Portmann KC. Complications of 10,453 consecutive first-trimester abortions: a prospective
study. Am J Obstet Gynecol 1974; 120:802.

Topic 3287 Version 12.0

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GRAPHICS

Karmen uterine cannula

Karmen cannula used for menstrual evacuation. Note curved tip of cannula
(insert).

Graphic 53042 Version 2.0

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Rigid plastic uterine suction curette

Nonflexible curved #10 suction curette (10-mm diameter) used for evacuation
of uterine contents.

Graphic 60556 Version 2.0

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Procedure for suction curettage pregnancy termination

(A-C) Rotation of the suction curette. Little rotation should occur when the instrument is
near the uterine wall, to avoid perforation.

Graphic 78988 Version 2.0

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Gestational age based upon fetal foot length

Foot length, mm Gestational age, weeks

6 10

9 12

14 14

20 16

27 18

33 20

39 22

Graphic 64496 Version 1.0

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Contributor Disclosures
Jody Steinauer, MD, MAS Nothing to disclose Robert L Barbieri, MD Nothing to disclose Sandy J Falk, MD,
FACOG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

Conflict of interest policy

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