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In the United States, about 1.5 million legal abortions are performed each year; 90% of these procedures are performed in the first trimester of pregnancy. Teenagers and women older than age 40 years have the highest abortion rates. Before 16 weeks of gestation, legal abortion as practiced in the United States may be performed safely in an office setting with simple instruments. Adequate preoperative and postoperative counseling is essential, and options to abortion should be presented.
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 for partial birth 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.
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 partial-birth abortion. 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 pregnancy termination, abortion, mifepristone out ectopic pregnancy and to decrease the risk of incomplete abortion.
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.
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 the3, 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.
Alternatively, hygroscopic dilators (laminaria) can be used before evacuation for a few hours or overnight before partial-birth abortion.