12.3 Surgical abortion


Vacuum aspiration (either manual or electric) is an appropriate method of surgical abortion. Instrumental curettage must not be used.

12.3.1 Relative contra-indications

– Purulent cervicitis and pelvic infection: delay the procedure if possible, until antibiotic treatment has been finalized. If the procedure cannot be delayed, start antibiotic therapy before doing the procedure.
– Coagulation disorders: risk of haemorrhage. Aspiration must be performed in a facility where emergency surgery and blood transfusion are available.

12.3.2 Equipment

See Chapter 9, Section 9.5.3.

12.3.3 Technique

Follow precautions common to all intrauterine procedures (Chapter 9, Section 9.1.1).

Patient preparation

– Start antibiotic therapy if infection is present and intervention cannot be delayed. For antibiotic therapy, see Chapter 9, Section 9.6.6.

– Administer misoprostol sublingually or vaginally into the posterior fornix: 400 micrograms as a single dose, at least 3 hours before the procedure2 to open the cervix and prevent traumatic cervical dilation.

– Administer antibiotic prophylaxis: doxycycline PO, 200 mg as a single dose or azithromycin PO, 1 g as a single dose, one hour before the procedure.

– Administer oral premedication before paracervical block:
• An hour before the procedure:
diazepam PO: 10 mg
• A half-hour before the procedure:
paracetamol PO: 1 g
+ codeine PO: 30 mg if < 60 kg; 60 mg if > 60 kg
or
tramadol PO: 50 mg if < 60 kg; 100 mg if > 60 kg

Then, for the rest of the procedure (preparation equipment, paracervical block, dilation, aspiration, examination of aspirated contents), see Chapter 9, Section 9.5.4.

Immediately after the procedure

An intrauterine device can be inserted (if there is no pelvic infection) if this is the contraceptive method that the patient has chosen.

12.3.4 Patient follow-up

Immediate

– Settle the patient comfortably during the monitoring period (at least 2 hours).

– Monitor vital signs and blood loss.

– Pain management: paracetamol and/or ibuprofen.

– The patient can go home if the vital signs are stable, if she can walk and she has been given the following information:
• Cramps will continue for a few days.
• Bleeding will last for 8 to 10 days.
• Menstrual periods will resume within 4 to 8 weeks.
• Fertility returns rapidly; ovulation can occur as early as 2 weeks post-abortion. Begin contraception that same day (Chapter 11, Section 11.5).
• Personal hygiene: cleansing with soap and water once daily; no vaginal douches.
• Seek immediate medical attention in case of danger signs: severe pain or heavy bleeding, foul smelling discharge or fever.

Post-abortion visit

A consultation is advised 10 to 14 days after the procedure: look for signs of infection and incomplete abortion, and check if contraception is well tolerated.

12.3.5 Complications

See Chapter 9, Section 9.6.6.