Beyond 7 menstrual weeks of gestation, larger cannulas and vacuum sources are required to evacuate a pregnancy.
This procedure, standard vacuum curettage, is the most common method of abortion in the United States. By recent
convention, procedures performed before 13 menstrual weeks are called suction or vacuum curettage, whereas similar
procedures carried out after 13 weeks to perform mid-trimester abortion are termed D&E. Equipment, facilities, and
trained personnel to handle emergencies should be available when these procedures are performed.
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Uterine size and position should be noted during a pelvic examination performed before the procedure. Ultrasonography
is advised if there is a discrepancy of more than 2 weeks between the uterine size and menstrual dating. If not already
performed, tests for gonorrhea and chlamydia should be obtained, and the cervix and vagina should be prepared with
a germicide. Paracervical block is established with 20 mL or less of 1% lidocaine injected deep into the cervix at the
3, 5, 7, and 9 o’clock positions to form a ring of anesthetic at the junction of the cervix and lower uterine segment.
Conscious sedation can be added by using a variety of drugs. However, if conscious sedation is used, a pulse oximeter
is advised and oxygen should be available. The cervix should be grasped with a single-toothed tenaculum placed
vertically with one branch inside the canal. The uterine depth can be measured with a sound. Dilation then should be
carefully performed with a tapered dilator.
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Alternatively, hygroscopic dilators (laminaria) can be used before evacuation for a few hours or overnight. Although
these dilators require several hours to achieve cervical dilation, there is a fivefold reduction in cervical lacerations and
a threefold reduction in uterine perforations when laminaria are used instead of forcible dilation. Laminaria do not
increase postabortal infection. Synthetic dilators work faster, either by producing both dilatation and cervical softening
or only producing softening. One trial comparing a prostaglandin analogue with the synthetic hygroscopic dilators found
that the hygroscopic dilators were more effective for preparation of the cervix before first-trimester vacuum curettage.
A single rod of laminaria or a synthetic hygroscopic dilator can become entrapped by a resistant cervix and fragment
upon attempted removal. Therefore, for first-trimester procedures, two or more laminaria or a synthetic hygroscopic
dilator plus a small rod of laminaria should be used.
A vacuum cannula with a diameter in millimeters that is one less than the estimated gestational age (eg, 9-mm size
for an estimated 10-week gestation) should be used to evacuate the cavity. After the tissue is removed, there should
be a quick check with a sharp curette, followed by a brief reintroduction of the vacuum cannula. The aspirated tissue
should be examined as described previously.
The risk of infectious morbidity is lowered when antibiotics are used prophylactically with induced abortion.
Tetracycline or its analogues, doxycycline and minocycline, are probably the best of the current agents for this purpose
because of their broad spectrum of antimicrobial effect and oral absorption. D-negative patients should receive D
(Rho[D]) immune globulin before leaving the facility.
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