The quality of evidence (I-III) and classification of recommendations (A-E) are defined at the end of the "Major Recommendations."
Summary Statements
- Women choosing pregnancy termination are entitled to quality care by trained practitioners. (III)
- Preoperative treatment with metronidazole decreases the risk of postoperative pelvic inflammatory disease in patients with bacterial vaginosis. (I)
- Medical abortion and suction curettage are safe and effective alternatives up to 56 days' gestation. However, medical abortion is associated with a higher rate of persistent viable gestation. (II-1)
- Preprocedural cervical dilatation facilitates vacuum aspiration and decreases the incidence of cervical laceration and uterine perforation. (II-2)
- Prophylactic antibiotics administered perioperatively with surgical abortion reduce the risk of post-abortal endometritis. (I)
- Pain management for suction curettage may involve premedication with non-steroidal anti-inflammatory medications, intravenous sedation, and paracervical block, alone or in combination. (III)
- Intravenous oxytocin and intracervical vasopressin, alone or in combination, decrease blood loss in surgical abortions in gestations of 15 weeks or more. (I)
- Both medical termination and dilatation and evacuation (D&E) are safe and effective methods of uterine evacuation in the second trimester. Hysterotomy is associated with increased morbidity. (II-3)
- Several effective methods of medical termination are available for use in the second trimester. Available evidence does not support the use of one method over another. (III)
- Mechanical dilatation of the cervix prior to medical termination in the second trimester reduces the risk of cervical laceration and uterine rupture. Cervical ripening with prostaglandin is more likely to result in unsupervised delivery. (II-2)
Summary of Recommendations
- Manual vacuum aspiration can be performed safely and effectively in an office setting up to 10 weeks' gestation. (B)
- A cannula size in mm equal to or greater than the gestational age in weeks should be used for manual vacuum aspiration. (B)
- First and second trimester abortions should be performed by experienced personnel in hospitals or outpatient facilities. (B)
- If bacterial vaginosis is suspected, the patient should be treated with metronidazole perioperatively. (A)
- Pre-abortion screening should include Rh status, and cervical cultures for sexually transmitted infections and bacterial vaginosis. Cervical cytology and sickle cell testing should be done when appropriate. (A)
- Medical abortion with misoprostol and methotrexate should be considered in carefully selected patients who will be compliant with follow-up. (A)
- A follow-up system must be in place to provide for surgical evacuation of the uterus if medical abortion fails. (A)
- Ultrasound or measurement of beta-hCG levels should be used in follow-up in order to determine whether or not the uterus has been evacuated after medical abortion. (B)
- A paracervical block with 0.5% or 1% lidocaine should be placed before vacuum aspiration. (B)
- Pre-procedural dilatation of the cervix may be considered. Synthetic or osmotic dilators, laminaria tents, or misoprostol may be used. (B)
- Perioperative prophylaxis antibiotic coverage should be used routinely in order to reduce the incidence of post-abortal infection. (A)
- Physicians using intravenous medications and local anaesthesia must be trained in resuscitation and management of complications arising from the use of these medications. (B)
- Gross examination of the fresh tissue must be made after surgical abortion. (A)
- Medical induction and D&E are both safe and effective methods of second trimester termination. However, D&E is considered superior between 14 and 18 weeks' gestation. The particular technique should be selected according to the expertise of the physician and wishes of the patient. (B)
- Oral, rectal, or buccal misoprostol, oxytocin infusion (intraoperatively or postoperatively), and intracervical injection of vasopressin, alone or in combination, should be performed with D&E in gestations longer than 14 weeks. (B)
- Further research is needed to determine optimal regimens for medical termination in the first and second trimester. (B)
Conclusion
All therapeutic abortion techniques require proper training. Operators must be skilled, not only for the initiation of abortion, but also in the management of incomplete and failed procedures, uterine perforation, and such complications as hemorrhage, infection, and cervical laceration. Adequate training and ongoing experience using modern techniques with new methods will lead to a significant decrease in complication rates.
Definitions:
Quality of Evidence Assessment*
I: Evidence obtained from at least one properly randomized controlled trial
II-1: Evidence from well-designed controlled trials without randomization
II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group
II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
Classification of Recommendations**
- There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination
- There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination
- There is poor evidence regarding the inclusion or exclusion of the condition in a periodic health examination
- There is fair evidence to support the recommendation that the condition not be considered in a periodic health examination
- There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination
*The quality of evidence reported in these guidelines has been adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on the Periodic Health Exam.
**Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on the Periodic Health Exam.
