Original Research
Safety of Outpatient Surgical Abortion for
Obese Patients in the First and
Second Trimesters
Lyndsey S. Benson, MD, MS, Elizabeth A. Micks,
and Sarah W. Prager, MD, MAS
OBJECTIVE: To evaluate the relationship between obesity
and surgical abortion complications in the outpatient setting.
METHODS: We conducted a retrospective cohort study
of 4,968 women undergoing surgical abortion at a large
outpatient clinic network from September 2012 to July
2014. We used log-binomial regression to evaluate body
mass index (BMI) as an independent risk factor for first-
and second-trimester abortion complications. Body mass
index was analyzed as both a continuous and categorical
predictor. We assessed complications including need for
uterine reaspiration (including same-day reaspiration),
uterine perforation, cervical laceration, infection, emer-
gency department visit or hospitalization, and excessive
blood loss defined as estimated blood loss greater than
or equal to 100 mL.
RESULTS: The majority (77%) of procedures was per-
formed in the first trimester. Forty-seven percent of
women were normal weight or underweight, 28% were
overweight, and 25% were obese, including 4% with BMI
greater than or equal to 40. The overall complication rate
was 1.7%; the most common complications were need
for uterine reaspiration (1.0%) and excessive blood loss
(0.6%). Obesity was not associated with increased risk of
surgical complications, including when adjusting for age,
gestational age, and history of prior cesarean delivery.
From the Department of Obstetrics and Gynecology, University of Washington,
Seattle, Washington.
Presented as a poster at the American College of Obstetricians and Gynecologists
Annual Clinical Meeting, May 14–17, 2016, Washington, DC.
The authors thank Mona Walia and Cedar River Clinics for their invaluable
contributions to this study.
Corresponding author: Lyndsey S. Benson, MD, MS, 1959 NE Pacific Street,
Box 356460, Seattle, WA 98195; e-mail: lsbenson@uw.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2016 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/16
VOL. 128, NO. 5, NOVEMBER 2016
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
MD, MPH, Carly Ingalls, MD,
CONCLUSION: In a high-volume outpatient abortion
clinic with experienced health care providers, abortion is
very safe. Obesity does not appear to be an independent
predictor for abortion complications and should not be
used in isolation to refer women to hospital-based
facilities for abortion care in the first or second trimester.
(Obstet Gynecol 2016;128:1065–70)
DOI: 10.1097/AOG.0000000000001692
M ore than one third of adults in the United States
are obese (body mass index [BMI, calculated as
weight (kg)/[height (m)]2] 30 or greater).1 Women are
more likely than men to be obese with a prevalence of
38.3% in 2014.1 Obese women are at increased risk
for pregnancy complications including cesarean deliv-
ery, preeclampsia, gestational diabetes, macrosomia,
and stillbirth, when compared with women with nor-
mal BMI.2 Obese women also experience unintended
pregnancy at a higher rate than nonobese women.3,4
Despite these increased risks in pregnancy, obese
women frequently have poor access to family plan-
ning services.5 Multiple studies have identified obesity
as a risk factor for delay in receiving abortion care,
whether through delay in pregnancy diagnosis or
through outpatient clinic policies limiting services
for obese women.5,6 Increasing gestational age has
long been known to be associated with increased risk
for complications in surgical abortions, so delays in
care may put this population at greater risk.7
Few studies have investigated obesity as a risk
factor for complications in surgical abortion. Previous
studies on this topic have included limited patient
populations, not controlled for gestational age, or
have not evaluated obesity as an independent risk
factor.8–10 The majority of abortions in the United
States are performed at less than 13 weeks of gestation
in outpatient clinics, which often have BMI or weight
cutoffs.7,11 As rates of morbid or severe obesity
OBSTETRICS & GYNECOLOGY 1065
(BMI 40 or greater) continue to increase, abortion
access for obese women may continue to be limited.12
We designed this study to investigate whether
increasing BMI is an independent risk factor for
abortion complications at any gestational age and
whether this factor should be used to identify patients
who are poor candidates for outpatient procedures. The
objective of this study was to evaluate the relationship
between obesity and complications of first- and second-
trimester surgical abortion in the outpatient setting.
MATERIALS AND METHODS
We conducted a retrospective cohort study of all
women presenting for surgical abortions between
September 11, 2012, and July 1, 2014, at an outpatient
reproductive health clinic network. This clinic net-
work is comprised of three free-standing clinics in
Washington state. Patients who have pregnancies
earlier than 15 weeks of gestation have a same-day
suction dilation and curettage procedure and those at
15 weeks of gestation and above have a 2-day
procedure with osmotic dilator placement on the first
day and a dilation and evacuation (D&E) procedure
on the next day. Procedures above 22 weeks of gesta-
tion are typically completed in 3 days with 2 days of
osmotic dilators followed by a D&E procedure on the
third day. Most patients receive moderate intravenous
sedation with a combination of propofol, fentanyl, and
midazolam administered by a certified registered
nurse anesthetist as well as local anesthesia with a para-
cervical block, including vasopressin in the second
trimester. Procedures are performed by attending
physicians, family planning fellows, and residents.
Patients were included in our study if they
obtained a surgical abortion during the study time
period. Participants were excluded only if BMI data
were unavailable. First- and second-trimester proce-
dures were included. We collected data on demo-
graphic characteristics, medical comorbidities, and
procedure characteristics and complications. All data
were abstracted from the electronic medical record and
reviewed by two researchers for consistency and errors.
The primary outcome of interest was any com-
plication, including reaspiration, uterine perforation,
cervical laceration, infection, emergency department
visit, hospitalization, and excessive blood loss defined
as estimated blood loss 100 mL or greater. Although
there is no universally accepted definition of hemor-
rhage at the time of surgical abortion, this cutoff was
chosen as an amount that would generally be deemed
excessive in the setting of a first-trimester abortion.
The primary predictor was BMI, calculated as
weight in kilograms divided by height in meters
1066 Benson et al Safety of Outpatient Surgical Abortion for Obese Patients
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
squared. All patients were weighed at the time of
their visit, and height was self-reported. This was
analyzed as a continuous and categorical variable with
BMI categorized by World Health Organization
definitions: normal or underweight (BMI less than
25), overweight (BMI 25–29.9), obese class I (BMI
30–34.9), obese class II (BMI 35–39.9), and obese
class III (BMI 40 or greater), also referred to as mor-
bid or severe obesity. Multivariable analysis was per-
formed with log-binomial regression to calculate
relative risk of complications based on BMI and
adjusted for age, gestational age, and history of prior
cesarean delivery. All statistical analysis was per-
formed using STATA SE 13.1. This study was
approved by the University of Washington institu-
tional review board.
RESULTS
Our three clinic sites performed surgical abortions for
5,157 women between September 2012 and July
2014, and BMI data were available for 4,968
(96.3%) (Fig. 1). The majority (77%) of these abortions
was performed in the first trimester. Eight percent of
the abortions were performed at 20 weeks of gestation
or greater.
The median BMI in our patient population was
25.2 (interquartile range 22.1–30.0). The BMI distri-
bution was as follows: 47.0% were normal weight or
underweight, 28.4% were overweight, and 24.6% of
patients were obese, including 3.7% with BMI greater
than or equal to 40 (class III obesity). The highest
BMI in our study population was 67.3. Table 1
provides demographic characteristics of the study
population, including a comparison of obese and non-
obese women. Women in the study population who
were obese were older and more likely to be parous
and also included a higher proportion of black women
and women using Medicaid to pay for their abortion
services. The median procedure length was 6
Fig. 1. Flow diagram of study cohort.
Benson. Safety of Outpatient Surgical Abortion for Obese Patients.
Obstet Gynecol 2016.
OBSTETRICS & GYNECOLOGY
Table 1. Characteristics of Women Undergoing Abortion

Characteristic Total (N54,968) Obese* (n51,220) Nonobese (n53,748) P

Age (y) 26.666.4 27.866.0 26.266.5 ,.001

Race and ethnicity† ,.001
White 1,155 (41.2) 273 (39.3) 882 (41.8)
Black 625 (22.3) 213 (30.7) 412 (19.5)
Asian 320 (11.4) 32 (4.6) 288 (13.6)
Hispanic or Latina 209 (7.5) 40 (5.8) 169 (8.0)
Other 497 (17.7) 136 (19.6) 361 (17.1)
Insurance or other payment ,.001
Medicaid 3,393 (68.4) 927 (76.1) 2,466 (65.9)
Private 770 (15.5) 177 (14.5) 593 (15.8)
Self-pay 801 (16.1) 115 (9.4) 686 (18.3)
Gestational age (wk) 10.365.1 10.565.1 10.365.1 .27
Gestational age (wk) .16
6–9 2,805 (56.5) 662 (54.3) 2,143 (57.2)
10–13 1,008 (20.3) 270 (22.1) 738 (19.7)
14–17 526 (10.6) 128 (10.5) 398 (10.6)
18–21 378 (7.6) 104 (8.5) 274 (7.3)
22 or greater 251 (5.1) 56 (4.6) 195 (5.2)
Obstetric history
History of prior abortion 2,651 (53.4) 740 (60.7) 1,911 (51.0) ,.001
Has at least 1 child 3,092 (62.2) 908 (74.4) 2,184 (58.3) ,.001
History of prior cesarean delivery 742 (14.9) 270 (22.1) 472 (12.6) ,.001
History of medical comorbidity‡ 711 (14.3) 242 (19.8) 469 (12.5) ,.001
Data are mean6standard deviation or n (%) unless otherwise specified.
* Obese defined as body mass index (BMI) 30 or greater; nonobese defined as BMI less than 30.
†
Race and ethnicity data available for only 2,806 patients (56.5%).
‡
Composite medical comorbidity variable includes hypertension, diabetes, obstructive sleep apnea, venous thromboembolism, kidney
disease, liver disease, and asthma.

(interquartile range 4–8) minutes for obese women
and 5 (interquartile range 4–8) minutes for nonobese
women.
The overall complication rate was 1.7% (Table 2).
The most frequent complications were need for uterine
reaspiration (1.0%) and estimated blood loss greater
than or equal to 100 mL (0.6%). There was no signif-
icant difference in complications between the first and
second trimesters (1.7% compared with 1.8%, respec-
tively, P5.7). The only specific complications that were
associated with gestational age were excessive blood
loss, which was higher in the second trimester, and
uterine reaspiration, which was higher in the first tri-
mester. Indications for same-day reaspiration included
hematometra and incomplete procedure (insufficient
pregnancy tissue seen on immediate postprocedure

Table 2. Complication Rates With Surgical Abortion

Total (N54,968) Obese* (n51,220) Nonobese (n53,748)

Complication n % (CI) n % (CI) n % (CI) P

Reaspiration 47 0.9 (0.7–1.3) 12 1.0 (0.6–1.7) 35 0.9 (0.7–1.3) .88

Uterine perforation 2 0.04 (0–0.2) 0 N/A 2 0.05 (0–0.2) .42
Cervical laceration 1 0.02 (0–0.1) 0 N/A 1 0.03 (0–0.2) .57
Infection 2 0.04 (0–0.2) 0 N/A 2 0.05 (0–0.2) .42
Emergency department visit 17 0.3 (0.2–0.5) 3 0.2 (0.1–0.8) 14 0.4 (0.2–0.6) .51
Hospitalization 5 0.1 (0–0.2) 1 0.08 (0–0.6) 4 0.1 (0–0.3) .81
Bleeding (EBL 100 mL or greater)† 27 0.6 (0.4–0.8) 13 1.1 (0.7–1.9) 14 0.4 (0.2–0.7) .005
Any complication‡ 84 1.7 (1.4–2.1) 27 2.2 (1.5–3.2) 57 1.5 (1.2–2.0) 0.10
CI, confidence interval; N/A, not applicable; EBL, estimated blood loss.
* Obese defined as body mass index (BMI) 30 or greater; nonobese defined as BMI less than 30.
†
EBL data available for n54,690 patients (94.4%).
‡
Any complication5composite complication variable including all complications individually listed. Totals in each column may not equal
proportion with any complication, because some women experienced more than one complication.

VOL. 128, NO. 5, NOVEMBER 2016 Benson et al Safety of Outpatient Surgical Abortion for Obese Patients 1067

Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
pathologic evaluation). There were no anesthesia- Table 3. Unadjusted and Adjusted Relative Risk of
related complications during the study period. Complications* After Abortion
Table 2 also compares complications between
obese and nonobese women. There was no difference Unadjusted RR Adjusted RR of
Characteristic of Complication Complication
in overall complication rate, regardless of whether same-
day reaspiration was included in the composite compli- Age (y)† 1.00 (0.97–1.04) 1.00 (0.97–1.03)
cation variable. Excluding same-day reaspiration, the Race and ethnicity‡
complication rate for obese compared with nonobese White Reference N/A
Black 1.20 (0.60–2.40)
women was 1.4% compared with 0.9% (P5.1). There
Asian 1.80 (0.85–3.82)
was no clinically significant difference in mean blood Hispanic or Latina 0.55 (0.13–2.35)
loss between procedures for obese women (16.1 mL) Other 1.05 (0.48–2.13)
compared with nonobese women (13.6 mL), although Insurance or other
there was a higher proportion of obese women with payment
Medicaid Reference N/A
blood loss greater than 100 mL (1.1% compared with
Private 0.92 (0.51–1.67)
0.4%, P5.005). There was no statistically significant Self-pay 0.61 (0.31–1.23)
increase in estimated blood loss for women with BMI Gestational age (wk) 1.03 (0.99–1.07) 1.03 (0.99–1.07)
greater than or equal to 40 (class III obesity) compared Gestational age
with normal-weight women (P5.55). We also evaluated 1st trimester Reference N/A
2nd trimester 1.10 (0.67–1.79)
BMI as a continuous predictor and found no association
Prior abortion
between BMI and complications (P5.51). Women who No Reference N/A
experienced any complication had a median BMI of Yes 0.87 (0.57–1.34)
24.3 (interquartile range 21.1–29.0); women who did Prior cesarean delivery
not experience any complication had a mean BMI of None Reference Reference
1 or more 1.34 (0.77–2.30) 1.32 (0.76–2.30)
25.2 (interquartile range 22.1–29.9).
BMI (continuous)§ 1.02 (0.98–1.05) 1.01 (0.98–1.05)
We calculated unadjusted and adjusted relative BMI (kg/m2,
risks of abortion complications (Table 3). Age, gesta- categorical)
tional age, history of cesarean delivery, and BMI were Normal or Reference N/A
included in the multivariable model a priori. No addi- underweight
(less than 25.0)
tional variables met criteria for inclusion in the model.
Overweight 0.76 (0.44–1.33)
Body mass index was not associated with increased (25.0–29.9)
risk of complications, including when adjusting for Obese (30.0 or 1.33 (0.13–2.08)
age, gestational age, and history of prior cesarean greater)
delivery (Table 3). History of medical
comorbidityk
None Reference N/A
DISCUSSION 1 or more 1.41 (0.82–2.41)
In a high-volume outpatient abortion clinic with
RR, relative risk; N/A, not applicable; BMI, body mass index.
experienced health care providers, obesity does not * Complications included uterine reaspiration, uterine perforation,
appear to be an independent predictor for abortion cervical laceration, infection, emergency department visit,
complications. We investigated BMI as both a contin- hospitalization, and excessive blood loss defined as estimated
blood loss 100 mL or greater.
uous and categorical variable and were able to control †
RR of complication per 1-year increase in age.
‡
for age, gestational age, and previous cesarean deliv- §
Race and ethnicity data only available for 2,806 patients (56.5%).
ery. We saw no increase in overall complications with RR of complication per 1 unit (kg/m2) increase in BMI.
k
Composite medical comorbidity variable includes hypertension,
increasing BMI. These data provide strong evidence diabetes, obstructive sleep apnea, venous thromboembolism,
against using BMI in isolation to refer women to kidney disease, liver disease, and asthma.
hospital-based facilities. Although there was a slightly
higher risk of estimated blood loss greater than 100 complications in women undergoing outpatient first-
mL among obese women, the overall risk was low at and second-trimester surgical abortions. Examining
approximately 1%. We do not consider this outcome the previously published literature, one recent study
to be clinically relevant without an increase in found no association between medical comorbidities,
complications such as hospital transfer or blood including obesity, and first-trimester abortion compli-
transfusion. cations.10 However, obesity was not examined as an
This study demonstrates that obesity is not independent risk factor. Another study found no asso-
independently associated with an increased risk for ciation between obesity and second-trimester abortion

1068 Benson et al Safety of Outpatient Surgical Abortion for Obese Patients OBSTETRICS & GYNECOLOGY

Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
complications, although statistical power to detect
such an association was limited.9 In a larger study of
second-trimester surgical abortions, no association
was found between obesity and complications of
D&E procedures.8 More than 50% of that study pop-
ulation had D&E procedures performed at 20 weeks
of gestation or later, and the procedures were per-
formed in a hospital-based facility. This raises the
question of the relevance of these data for the majority
of women undergoing abortion nationwide, because
only 4% of surgical abortions at any gestational age
are performed in the hospital setting, and more than
90% of surgical abortions are performed in the first
trimester.7,11
Our study found a higher rate of same-day uterine
reaspiration in the first trimester. This occurred most
frequently at very early gestational ages, because
some health care providers at these clinic sites will
perform abortion as soon as a gestational sac is visible
on transvaginal ultrasonography. This can occasion-
ally result in an additional uterine aspiration within
the same encounter after not visualizing adequate
tissue on pathologic examination of the products of
conception. However, to be conservative, this is
classified as a complication in our database.
The overall complication rate was lower than that
reported in other studies.8–10 One reason for this may
be the low rate of reported hemorrhage. Our clinic
protocols include using 4 units of vasopressin in 20
mL lidocaine for paracervical block in the second tri-
mester. Most health care providers also routinely
administer 0.2 mg methergine intramuscularly imme-
diately after all second-trimester procedures in addi-
tion to 800 micrograms misoprostol placed rectally
after all procedures beyond 22 weeks of gestation.
These practices could reduce the overall bleeding with
procedures. Another explanation is that blood loss is
not measured quantitatively; it is an estimated blood
loss. Health care providers are likely to underestimate
estimated blood loss.13 This should not influence the
lack of difference in estimated blood loss or hemor-
rhage between obese and nonobese women, but likely
influences the overall low complication rate of 1.7%.
Our estimated blood loss values in particular are low;
when blood loss is measured quantitatively, average
blood loss is probably greater than 100 mL for D&E
procedures.14
Our study is limited by the overall low compli-
cation rate, because this makes comparisons between
groups more challenging. The low complication rate
also makes our statistical analyses less robust. Addi-
tionally, we understand that some of our clinic
protocols are not the same as all outpatient abortion
VOL. 128, NO. 5, NOVEMBER 2016 Benson et al Safety of Outpatient Surgical Abortion for Obese Patients
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
clinics, which is a potential limitation to the general-
izability of these findings.
One strength of the study is the large number of
patients included in the study database with complete
BMI data. Another strength is that these data include
patients from three clinic sites and seven primary
attending providers. Many medical students, resi-
dents, and fellows also participate in the care of these
patients. This diversity of care providers and sites
increases the generalizability of these results. Even
with so many trainees, and of varying skill levels, the
overall complication rate is still very low.
Ultimately, this study supports other work that
has been done in this area. Obese women do not have
higher rates of complications when controlling for
gestational age. Obesity alone should not prevent
a woman from accessing abortion in an outpatient
setting. Overall, abortion remains a very safe pro-
cedure for women at any BMI.
REFERENCES
1. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of
obesity among adults and youth: United States, 2011-2014.
NCHS Data Brief 2015:1–8.
2. Mission JF, Marshall NE, Caughey AB. Obesity in pregnancy:
a big problem and getting bigger. Obstet Gynecol Surv 2013;
68:389–99.
3. Callegari LS, Nelson KM, Arterburn DE, Prager SW, Schiff
MA, Schwarz EB. Factors associated with lack of effective con-
traception among obese women in the United States. Contra-
ception 2014;90:265–71.
4. Kaneshiro B, Edelman A, Carlson N, Nichols M, Jensen J. The
relationship between body mass index and unintended preg-
nancy: results from the 2002 National Survey of Family
Growth. Contraception 2008;77:234–8.
5. Ingraham N, Roberts SC, Weitz TA. Prior family planning
experiences of obese women seeking abortion care. Womens
Health Issues 2014;24:e125–30.
6. Foster DG, Jackson RA, Cosby K, Weitz TA, Darney PD, Drey
EA. Predictors of delay in each step leading to an abortion.
Contraception 2008;77:289–93.
7. Pazol K, Creanga AA, Jamieson DJ. Centers for Disease Con-
trol and Prevention (CDC). Abortion surveillance—United
States 2012. MMWR Surveill Summ 2015;64:1–40.
8. Lederle L, Steinauer JE, Montgomery A, Aksel S, Drey EA,
Kerns JL. Obesity as a risk factor for complications after
second-trimester abortion by dilation and evacuation. Obstet
Gynecol 2015;126:585–92.
9. Murphy LA, Thornburg LL, Glantz JC, Wasserman EC, Stan-
wood NL, Betstadt SJ. Complications of surgical termination of
second-trimester pregnancy in obese versus nonobese women.
Contraception 2012;86:402–6.
10. Guiahi M, Schiller G, Sheeder J, Teal S. Safety of first-trimester
uterine evacuation in the outpatient setting for women with
common chronic conditions. Contraception 2015;92:453–7.
11. Jones RK, Jerman J. Abortion incidence and service availability
in the United States, 2011. Perspect Sex Reprod Health 2014;
46:3–14.
1069
12. Sturm R, Hattori A. Morbid obesity rates continue to rise rap-
idly in the United States. Int J Obes (Lond) 2013;37:889–91.
13. Stafford I, Dildy GA, Clark SL, Belfort MA. Visually estimated
and calculated blood loss in vaginal and cesarean delivery. Am
J Obstet Gynecol 2008;199:519.e1–7.
14. Micks E, Edelman A, Botha R, Bednarek P, Nichols M, Jensen
JT. The effect of sevoflurane on interventions for blood loss
during dilation and evacuation procedures at 18-24 weeks of
gestation: a randomized controlled trial. Contraception 2015;
91:488–94.

Online Access to Obstetrics & Gynecology

Activate Your Online Subscription by Following These Steps:
1. On www.greenjournal.org, click on the gear box at the top right corner of
the screen and select Register.
2. On the registration screen, choose a username and password and enter your
e-mail address. (Usernames must be at least 6 characters in length and
contain no spaces or symbols; passwords must be at least 8 characters in
length and contain at least one number and one letter.)
3. Click to go to the next step of user registration.
4. On the next screen, enter your name and address and click Continue.
5. The next registration screen asks for additional information about you and
your practice to help us recommend articles and rich media that suit your
area of specialty. After entering this information, indicate your acceptance of
the End User License Agreement and click Complete Registration.
6. After you complete the registration, you will receive an e-mail from the site
asking you to confirm your registration. Click on the link in the e-mail
within 48 hours.
7. The link in the e-mail leads to a web page where you will be asked if you
want to activate your online subscription. Click on Yes! I am a subscriber
and want to activate my online subscription.
8. At the bottom of the next screen, there is a field for activating your
subscription. Enter your ACOG Member ID or your subscriber ID, which
can be found on the top left corner of the mailing label for your journal. Be
sure to enter all characters into this form field. Then click on Activate
Subscription.
Your account will now be active, and you will have full access to all content
in the journal. Read full-text articles, download an epub file for your e-reader,
listen to podcasts, watch videos, and take advantage of personalized features
that allow you to save searches and create personal collections.
rev 2/2015

1070 Benson et al Safety of Outpatient Surgical Abortion for Obese Patients OBSTETRICS & GYNECOLOGY

Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.