Historically, hypertonic saline is important because it was the first effective labor-induction method for mid-trimester
abortion. Maternal hazards unique to hypertonic saline include cardiovascular collapse, pulmonary and cerebral edema,
and renal failure if the solution is accidentally injected intravenously. All patients are at risk for serious disseminated
intravascular coagulopathy. Attention to proper technique for saline amnioinfusion by gravity flow through connecting
tubing from a single-dose bottle makes such complications rare. More common problems with hyper~ tonic saline are
similar to problems associated with all of the labor induction methods: failed abortion, incomplete abortion, retained
tissue, hemorrhage, infection, and embolism.
When hypertonic saline is administered by itself, the mean time between instillation and abortion is 33-35 hours.
Augmentation with oxytocin reduces this time to 25-26 hours and improves efficacy, but there is an increased
occurrence of disseminated intravascular coagulopathy, water intoxication, and cervical or uterine rupture.

OTHER APPROACHES

Hysterotomy and Hysterectomy

Hysterotomy is essentially a cesarean delivery. There is little indication for this procedure as the primary method for
abortion because the risk of major complications and death is greater with hysterotomy and hysterectomy than for any
other abortion technique. In most cases, failed abortion is now managed with parenteral prostaglandins, and the only
time hysterotomy should be used for a failed abortion is when a uterine anomaly is present.
The coexistence of pregnancy and a separate indication for hysterectomy (eg, cervical cancer) has been taken as
an indication for gravid hysterectomy. Most patients are best served by a simpler means of pregnancy termination and
a more complete evaluation of their other gynecologic problems before definitive therapy. In these rare cases, referral
of the patient is preferable to the addition of a major surgical procedure to her other medical problems.

Selective Reduction
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In cases of multifetal pregnancies, selective reduction by means of ultrasound-guided intracardiac injection of potassium
chloride has been practiced as a means of avoiding the risks of extreme prematurity for the surviving pregnancies.
Coagulation surveillance is advised after second-trimester procedures. Selective reduction should not be attempted with
twin-twin transfusion syndrome because of the possibility of embolism and infarction in the surviving twin.

Subsequent Reproduction
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Legal abortion as currently practiced in the United States has no measurable adverse effect on later reproduction. This
probably reflects the safety of current abortion technology. Most abortions are performed by vacuum curettage under
local anesthesia in the first trimester. The impact of mid-trimester methods on subsequent pregnancy is less well
established and may vary with the method used. For example, forced dilation of the cervix to a large diameter for D&E
in the late second trimester may increase the risk of prematurity later. To avoid this complication, laminaria, their
synthetic alternative, or low-dose prostaglandins should be used to prepare the cervix for late abortion.

LEGAL ISSUES

Some states have laws requiring that certain mandatory information be given to patients or that a certain period must
elapse after obtaining consent before abortion can be performed. In some jurisdictions, minors must notify their
parent(s), obtain parental consent, or obtain judicial consent before obtaining an abortion.

Fetal Death In Utero

Fetal death in utero can be managed with D&E, provided that the surgeon is familiar with the procedure. Vaginal
prostaglandin E2 is highly effective for this problem, usually producing fetal abortion in about 10 hours, but often with
significant vomiting, diarrhea, and fever as side effects. Beyond 28 weeks of gestation the full dose of vaginal
prostaglandin E2 should not be used, or overstimulation and uterine rupture may occur. The standard suppository can
be cut into quarters and administered 5 mg at a time for better control of uterine activity. The same low-dose regimen
can be used cautiously in patients with asthma if immediate respiratory support (inhalation) is available. Blood or
amniotic fluid may impair vaginal absorption of the prostaglandin. Coagulation studies should be obtained
preoperatively because disseminated intravascular coagulopathy is a significant risk after either D&E or vaginal
prostaglandin E2 for management of fetal death.

Intrauterine Prostaglandins
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Intraamniotic prostaglandin is an effective abortion regimen, but it has several disadvantages, including incomplete
abortion, the need for a second injection in many cases, the risk of cervical rupture in the primigravida, and the lack
of a direct toxic effect on the fetus. Results with intraamniotic prostaglandin F2ca are much improved if overnight
treatment with laminaria is used before infusion. Mean times to abortion are reduced from 29 hours to 14 hours, and fewer patients require a second dose. Cervical rupture is very rare. Incomplete abortion is common with prostaglandin abortion, and routine curettage is advised. This can be accomplished easily under local anesthesia in a properly equipped treatment room and reduces rates of postabortal hemorrhage and infection to low levels. Failed prostaglandin abortions can be managed by D&E or by intramuscular or vaginal prostaglandin. To avoid uterine rupture, oxytocin should not be used until after fetal expulsion because prostaglandin and oxytocin are synergistic.
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Systemic Prostaglandins

Three different prostaglandins are available for systemic administration: prostaglandin E2 vaginal suppositories;
carboprost tromethamine for intramuscular injection; and misoprostol, an analogue of prostaglandin E1. Prostaglandin
E2 is given as a 20-mg vaginal suppository every 3 hours. The mean time to abortion is 13.4 hours, with 90% of patients
aborting by 24 hours. When 250 mcg of carboprost tromethamine is given intramuscularly every 2 hours, the mean time
to abortion is 15-17 hours, with about 80% of patients aborting by 24 hours. Misoprostol is given vaginally as a single
0.200-mg tablet every 12 hours. Mean time to abortion is comparable to that of the other two prostaglandin regimens.
Vomiting and diarrhea are common with prostaglandin E2 and carboprost, but are rare with misoprostol. About one third
of patients treated with prostaglandin E2 will have a temperature elevation of 1 EC or more. This temperature elevation
is not seen with carboprost or misoprostol. An ultrasound-guided fetal intracardiac injection of either potassium chloride
or digoxin may be given. Alternatively, hypertonic sodium chloride can be given as an intraamniotic injection
Retained placenta is common with all prostaglandin-induced abortions. If spontaneous expulsion has not occurred within 30 minutes or heavy bleeding occurs, instrumental evacuation should be done to prevent further blood loss. Thiscan be accomplished with low-dose intravenous sedation in a treatment room equipped with a uterine aspirator.
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Dilation and Evacuation
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Transcervical instrumental evacuation of the uterus (D&E) is the method most commonly used in the United States for
mid-trimester abortions before 21 menstrual weeks. Two D&E techniques are used and differ primarily in the preparatory
steps that precede the evacuation. In the one-stage technique, forcible dilation is performed slowly and carefully to
sufficient diameter to allow insertion of large, strong ovum forceps for evacuation. The better approach is a two-stage
procedure in which multiple laminaria are used to achieve gradual dilatation over several hours before extraction.
Overnight placement of one set of laminaria is sufficient preparation for the early mid-trimester, but beyond 18-20
weeks, two sets of laminaria and 2 days of preparation are often used. Oral tetracycline or doxycycline should be started
after laminaria insertion and continued for 2 days after uterine evacuation. Uterine evacuation is accomplished with
long, heavy forceps, using the vacuum cannula to rupture the fetal membranes, drain amniotic fluid, and ensure
complete evacuation. A large-bore, 16-mm vacuum system facilitates the procedure.
The procedure causes discomfort despite a paracervical block, and most patients will benefit from conscious seda-tion.
If general anesthesia is elected, potent inhalation agents should be avoided or used only in low concentrations to
avoid uterine atony and increased blood loss. Standard care of the anesthetized patient must be provided, with
continuous monitoring of tissue oxygenation and end-expiratory carbon dioxide and frequent monitoring of vital signs.
The patient must be closely supervised until she is fully recovered from anesthesia.
Preoperative ultrasonography is necessary for all cases 14 weeks and beyond. Intraoperative real-time
ultrasonography helps to locate fetal parts within the uterus. Paracervically administered vasopressin has been demon-strated
to significantly reduce bleeding, but vasopressin must be used with caution. A maximum of 4 units should be
used, and it is usually diluted with saline or Xylocaine. Vasopressin should not be used in women with heart disease
or hypertension. Intravenous oxytocin is begun early in the procedure, just after rupture of the membranes.
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Coagulopathy can be seen after D&E, apparently because tissue thromboplastins have been released into the
maternal venous sinusoids. The use of oxytocin and intracervical vasopressin may reduce this risk. To avoid negative
pressure in the uterine vasculature, the Trendelenburg position should not be used.
After the procedure, the operator must examine the fetal parts carefully to be sure that evacuation is complete. If the
fetal calvarium has been retained in the uterus and gentle attempts at extraction fail, the procedure should be completed
under ultrasound guidance. If this is not available, it is best to stop, administer an oxytocin infusion for 2 hours, and
try again. By then, the remaining fetal parts usually will have been pushed down to the internal cervical os and they can
be extracted easily.

Dilation and evacuation becomes progressively more difficult as gestational age advances, and in the United States
instillation techniques are often used after 21 weeks. Dilation and evacuation can be offered in the late mid-trimester,
but the technique should be modified. The use of two sets of laminaria tents for a total of 36-48 hours is favored. A
further modification is the Hern combination method. After multistage laminaria treatment, urea is injected into the
amniotic sac. Extraction is then accomplished after labor begins and after fetal maceration has occurred.
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Failed abortion or excessive bleeding requires vacuum curettage. No serious complications or side effects have
occurred with mifepristone in this dosage. However, sulprostone, the prostaglandin E2 analogue used in Europe, has
been associated with myocardial infarction in three cases, resulting in one death. All three women were cigarette
smokers and were older than age 35. Misoprostol, the prostaglandin E1 analogue used with mifepristone in the United
States, has not been related to myocardial ischemia.
Another effective medical regimen for early abortion is the combination of the antifolate agent methotrexate with
misoprostol. Methotrexate is given as a single intramuscular dose followed 5-7 days later with vaginal misoprostol.
Efficacy appears to be slightly less than that observed with the mifepristone and misoprostol combination, and bleeding
may last longer. In the higher doses used to treat malignancy, methotrexate can have significant side effects, but these
are extremely rare with the low-dose regimen described above.

Patients who have recently had an abortion and are experiencing complications often seek care at a local hospital
emergency department. A physician managing such a patient should make every effort to communicate with the
abortion provider to learn the details of the procedure, any suspected complications, results of screening tests, results
of the fresh examination of the aborted tissue, and whether D immune globulin was given if the patient is D negative.
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Hemorrhage
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Excessive bleeding may indicate uterine atony, a low-lying implantation, a pregnancy of more advanced gestational age
than the first trimester, or perforation. Management requires rapid reassessment of gestational age by examination of
the fetal parts already extracted and gentle exploration of the uterine cavity with a curette and forceps. Intravenous
oxytocin should be administered, and the abortion should be completed. The uterus then should be massaged to ensure
contraction. When these measures fail, the patient should be transferred immediately to a hospital and should receive
intravenous fluids and have her blood crossmatched. Persistent postabortal bleeding strongly suggests retained tissue
or clot (hematometra) or trauma, and prompt surgical intervention with laparoscopy and repeat vacuum curettage is
indicated.

Hematometra
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Lower abdominal pain of increasing intensity in the first 30 minutes after the procedure suggests either hematometra
or postabortal syndrome. If there is no fever or bleeding is brisk, and on examination the uterus is large, globular, and
tense, hematometra is the possible diagnosis. This condition could be mistaken for a broad ligament hematoma, except
that the mass is midline and arises from the cervix. The treatment is immediate reevacuation. Pretreatment with ergot
or the use of oxytocin reduces the incidence of this phenomenon.

The most common postabortal complication is a triad of pain, bleeding, and low-grade fever. Often, this complication
can be managed initially by administration of oral antibiotics and ergot preparations. However, most cases are caused
by retained gestational tissue or a clot in the uterine cavity. These symptoms are best managed by a repeat uterine
evacuation, performed under local anesthesia in an ambulatory setting.

Anesthesia

Local anesthesia is preferred because general anesthesia increases the risk of uterine perforation, visceral injury,
hemorrhage, and death. However, when local anesthesia is used, complications include convulsions, syncope, and
fever. The addition of epinephrine to the local anesthetic is contraindicated. Rarely, fatal anaphylaxis as a result of the
metabisulfite preservative in epinephrine solutions has occurred in women with asthma.

Cervical Shock

Vasovagal syncope produced by stimulation of the cervical canal can be seen after paracervical block. Brief tonic-clonic
activity rarely may be observed and is often confused with seizure. It is distinguished by the presence of a very slow
pulse, rapid patient recovery, and the absence of a postictal state. The routine use of atropine with paracervical anesthe-
sia or the use of conscious sedation prevents cervical shock.

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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The risk of death from first-trimester abortion is less than 1 per 100,000 abortions. The risk of death increases with
gestational age and by type of procedure. Dilation and evacuation (D&E) is safer than other options for the early mid-trimester.
Hysterotomy and hysterectomy, two procedures rarely indicated for abortion, are the least safe. General
anesthesia increases the risk of death from vacuum curettage abortion.
Maternal conditions for which termination of a desired pregnancy should be considered include cyanotic heart disease
with pulmonary hypertension, severe hypertension, previous myocardial infarction, and other comparable major
illnesses. Major anomalies and mid-trimester premature rupture of membranes are recognized fetal implications for
termination. With any maternal or fetal condition that would pose a risk to the health of the mother or fetus, the decision
should be carefully weighed by the woman in consultation with the physician.
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MENSTRUAL EXTRACTION

Sensitive pregnancy tests allow early diagnosis of pregnancy, and many women seek abortion services within 1-2 weeks
of the missed period. Abortion of these early pregnancies with a small-bore vacuum cannula is called menstrual
regulation, menstrual extraction, or minisuction. The only instruments required are a speculum, a tenaculum, a Karman
cannula, and a modified 50 mL syringe. At the end of the procedure, the tissue is rinsed and examined in a clear dish
of water or saline over a light source to detect chorionic villi and the gestational sac. This examination is performed to
rule out ectopic pregnancy and to decrease the risk of incomplete abortion.
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