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Surgical Abortion: Types, Reasons, Procedure And Recovery

Surgical Abortion Types, Reasons, Procedure And Recovery

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Surgical abortion is the procedure to remove pregnancy contents from the uterus through the cervixusing special instruments. These procedures are only done in licensed clinics or hospitals by board-certified doctors. Surgical abortion is usually recommended due to contraindications and constraints for medical abortion in a case.

Surgical abortions do not take too long, and most women can go home on the same day. However, the procedure also has complications such as infections, bleeding, and injuries. You may discuss the benefits and risks with the healthcare provider and choose the best method of abortion based on individual factors and legal policies.

Read this post to know about the types, reasons, preparation, procedure, complications, and effectiveness of surgical abortion procedures.

Types Of Surgical Abortion

Based on the method of procedure, surgical abortions can be of the following types (1).

1. Vacuum aspiration

Vacuum aspiration, also called suction aspiration, removes the fetus and products of conception by gentle suction. This procedure is done under sedation, local anesthesia, or general anesthesia, depending on the individual factors.

If the pregnancy is up to 14 weeks, a local anesthetic is given. However, pregnancybeyond14 weeks requires procedures under general anesthesia or sedation.

2. Dilatation and evacuation (D&E)

Dilatation and evacuation (D&E) is a surgical procedure involving dilation of the cervix and evacuation of the uterus. This is usually done between 15 and 24 weeks (after the first trimester) of pregnancy.

Cervical preparation is done a day before surgery. Then, under general anesthesia, the forceps are used to remove the contents of pregnancy from the womb.

Reasons For Surgical Abortion

Surgical abortion is considered if the gestation age is beyond the recommended limit or there are contraindications to do a medical abortion. Reasons for abortion may include (2):

  • Baby has birth defects or genetic problems
  • Pregnancy is harmful to maternal life (therapeutic abortion)
  • Mothers personal decision not to continue the pregnancy
  • Pregnancy resulted from traumatic events, such as sexual assault

In some cases, medical abortion may not be an option, leaving surgical abortion as the only alternative. Common contraindications to medical abortion may include (3):

  • Allergy to the abortion pills or injections
  • Suspected ectopic pregnancy
  • Hemodynamic instability
  • Bleeding disorders
  • Anticoagulant (blood thinners) treatment
  • IUD in place
  • Chronic adrenal failure
  • Inherited porphyria

The decision to end a pregnancy is very personal. Healthcare providers may discuss the feelings, risks, benefits, other possibilities and consider your choices to guide you to make the right decision.

Preparation For The Surgical Abortion

According to the National Abortion Federation 2020 Clinical Policy Guidelines for abortion care, all women or couples considering abortion are counseled nonjudgmentally about the other possibilities (4).

The steps for preparation of abortion may include (5):

  • Health education sessions could be conducted, and they may last around 20 to 40 minutes. Healthcare providers may discuss options such as continuing pregnancy, adoption, parenting, and termination of pregnancy. They may also discuss future birth control methods (contraception). If your desire to end your pregnancy, doctors may discuss the risks, benefits, and details of abortion procedures.
  • Doctors will review your medical history, lab tests, and ultrasound images to estimate gestational age. Based on gestational age and other factors, the method of abortion is planned.
  • Verify the insurance information and collect co-payment if applicable before the procedure.
  • Informed consent is signed before the procedure after discussing the details.
  • Assessment of vitals, such as pulse, blood pressure, and weight, is done before the procedure, and suitable anesthesia is given.

The procedure’s privacy and safety are ensured in all approved clinics, and no women are identified in the waiting area as desiring for abortion. Guardian’s permission is required for abortions in minors (below 18) and persons with mental illnesses.

The Procedure Of Surgical Abortion

Board-certified obstetricians and gynecologists can perform surgical abortion procedures if there are valid reasons. After anesthesia, the steps of dilation and evacuation procedures may include (6):

  • Vagina and cervix are observed using a speculum and sterilized
  • Cervix is stretched (dilated) with thin rods called dilators
  • Narrow forceps are inserted into the uterus, and pregnancy contents removed
  • A tube connected with the suction machine is inserted into the cervix, and the remaining pregnancy contents are evacuated from the uterus

Dilation and evacuation (D&E) procedure may take 10-20 minutes, and pain is not felt during the procedure. After the procedure, you will be shifted to the recovery area. It is not recommended to drive for 24 hours after anesthesia.

In a vacuum aspiration procedure, cervical dilators are placed a day before or a few hours before the procedure. The steps of vacuum aspiration may include (6):

  • A speculum is inserted after placing it in the pelvic exam position, and the vagina and cervix are sterilized
  • A local anesthetic is injected to numb the cervix, and medication for pain or sedation is given intravenously or by mouth; medications to reduce blood loss, such as vasopressin, can also be given
  • Cervix is dilated, and the cannula (tube) is inserted through the cervix to aspirate the pregnancy tissues from the uterus
  • Vacuum aspiration may take 10-15 minutes, and some women may feel nausea, sweating, or faint after the procedure
  • Some women may require a dilation and curettage (D&C) procedure after a vacuum aspiration if any pregnancy tissues remain in the womb

Misoprostol is often used to soften the cervix in some women before the surgical abortion procedure. Antibiotic injections are also given before the procedure to prevent infections.

Recovery After Surgical Abortion

You can go home on the same day of the procedure if there are no complications. However, women who underwent anesthesia may require assistance and often remain in the hospital or be cautioned to do certain activities such as driving for 24 hours.

Among women who receive local anesthesia, quicker recovery is seen if it is done before 14 weeks, and often women can go home unattended and drive sooner. However, with all types of surgical abortion, increasing gestational age could lead to slower recovery (5).

Antibiotics prescription is given on discharge, and the doctor may also prescribe birth control in some cases. Bleeding and cramps may last up to one or two weeks. However, most women can return to their work and activities within a day or two after surgical abortion. However, you may follow the care instructions provided by the doctor until you completely recover. Follow-up visits are not needed unless there are complications.

Cost And Effectiveness Of Surgical Abortion

The cost of surgical abortion could vary based on several factors, including the type of procedure, the gestational age, and other supportive care required by the woman, if any. In some cases, an increased cost may be associated with improved outcomes. For instance, a study on cost analysis of surgical abortion procedures found an increased cost of $336 associated with a 13% efficacy increase. These analyses were sensitive to the probability of success, cost of a visit, and extra visits. Inpatient procedures were more expensive than outpatient vacuum aspiration (7).

Early procedures are more cost-effective than advanced stages, depending on other circumstances. The cost may increase if the woman requires further medications or follow-ups due to complications.

Complications Of Surgical Abortion

According to the Royal College of Obstetricians and Gynecologists, abortion is safer than childbirth if performed according to the guidelines (8). However, nearly three percent of surgical abortions can result in complications. The risk of developing complications depends on the weeks of gestation. It means the higher the gestation age, the more chances of complications (9).

The possible complications of surgical abortions may include (9):

  • Heavy bleeding: Normally, the bleeding after abortion is similar to menstruation. However, some women may experience severe hemorrhage (bleeding) after surgical abortion. Severe bleeding may require blood transfusions and dilatation and curettage (D&C) of the uterus.
  • Infections: Surgical abortion can contribute to a chronic infection called pelvic inflammatory disease (PID) in some women. High temperature (fever) after abortion can indicate infection and often require antibiotic treatment. The infection could occur due to bacteria moving from the perineum, sexual transmission of the bacteria, or if the procedure was not done with standard sterilization practices. If left untreated, infections can result in sepsis and septic shock in some cases.
  • Uterus injuries: There is a risk for uterine wall damages from surgical instruments during the abortion. Perforation of the uterus during an abortion can lead to bleeding and peritonitis (abdominal wall infection). Although it is a rare complication, it can be life-threatening due to severe blood loss.
  • Cervix injury: Stretching (dilatation) of the cervix is done before surgical abortions. Multiple procedures can weaken the cervix and result in cervical incompetence. An incompetent cervix may open before childbirth since it is too weak to remain closed under the weight of a growing baby. This may lead to miscarriage in future pregnancies and often requires cervical cerclage (stitch) to secure the pregnancy.

Infections and bleeding are common complications of surgical abortion. Cervical and uterine injuries are rare. Doing surgical abortions in approved clinics with board-certified professionals may reduce the risk of these complications. Illegal abortions are often associated with severe complications and often require hospitalization to manage them.

Precautions After A Surgical Abortion

Follow your doctor’s recommendations to reduce the risk of infection after the abortion procedure. Usually, the following precautions are recommended to be followed for up to two weeks after the procedure or until a few days after the bleeding stops(9).

  • Avoid swimming
  • Use sanitary pads and avoid tampons or menstrual cups
  • Avoid sexual intercourse
  • Shower instead of bathe or sauna

Doctors also recommend follow-ups and plans for the next pregnancy based on the reasons for the abortion.

Medical Abortion Vs. Surgical Abortion

Women can choose surgical abortion based on the policies of the country and gestational age. They are pros and cons to both medical and surgical abortion. You may weigh the risks and benefits of each procedure with your healthcare provider and choose the best method for you.

The decision aid on the National Institute for Health and Care Excellence (NICE) website may help decide based on evidence. In addition, the below table may help to compare medical and surgical abortion benefits and risks (10).

Medical abortionSurgical abortion
ProcedureTwo medications are given to terminate the pregnancyOperation is required to remove the pregnancy
LocationAt home, clinic, or hospital, depending on the week of gestationIn clinic or hospital
Visibility of pregnancy productsYou will see pregnancy products pass; they may be more visible after nine weeks of gestationYou will not see any pregnancy products
 

Pain

 

Painful when passing the products; some pain may be felt for a few days or weeks but manageable with painkillers

 

Pain is not felt until you are awake from sedation; painkillers might be needed to control post-abortion pain

BleedingVaginal bleeding is heavier than the normal period, lasting up to 12 days but decreasing gradually 

Vaginal bleeding is heavier than normal, lasting for a week but decreasing gradually

Short-term complicationsAbortion pills may cause nausea, vomiting, and diarrhea in 100 or more in every 1000 women

One in 1000 women may have serious complications such as sepsis, uterus injury, or severe bleeding

Risks may increase as the pregnancy advances

 

Nausea, vomiting, and diarrhea may occur in 100 or more in 1000 women who used cervical softening medication

Serious complications such as severe bleeding, injuries, or sepsis may occur in one in 1000 women.

In rare cases, complications related to anesthesia may occur

 

Further tests to determine successful abortion

 

 

A scan or pregnancy test is needed after two weeks if done at home; not usually required if done in clinic or hospitals

 

Usually not required

 

Likelihood of  another procedure to complete abortionAbout 70 in 1000 women require a surgical procedure to complete an abortionAbout 35 in 1000 women require further surgery to complete an abortion

When To Seek Medical Help

You may contact your doctor or visit the emergency room if you develop fever or heavy bleeding after the abortion procedure. Severe cramping or abdominal pain also requires medical care. Never hesitate to call your doctor and ask if you have any concerns after the surgery.

Contraceptive pills or contraceptive injections can be obtained from the doctor’s office for birth control after the abortion. You may also discuss the use of other contraceptives, such as intrauterine devices and barrier methods, and their efficacy with the healthcare providers.

Surgical abortion could be an alternative to medical abortion, especially in cases of advanced gestational age. Since the procedure is surgical, ensure you choose a good and certified clinic. Discuss the procedure and its outcomes, including complications, extensively with the doctor. Consider the use of contraceptives after abortion to prevent undesired pregnancies in the future.

References:

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Dr Bisny T. Joseph

Dr. Bisny T. Joseph is a Georgian Board-certified physician. She has completed her professional graduate degree as a medical doctor from Tbilisi State Medical University, Georgia. She has 3+ years of experience in various sectors of medical affairs as a physician, medical reviewer, medical writer, health coach, and Q&A expert. Her interest in digital medical education and patient education made... more