The Safety and Quality of Abortion Care in the United States (2018) / Chapter Skim
Currently Skimming:
2 The Safety and Quality of Current Abortion Methods
2 The Safety and Quality of Current Abortion Methods
Pages 45-94
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From page 45... ...
The objective of this chapter is to examine this literature, focusing on the safety and effectiveness of current abortion methods and the extent to which these methods could expose women to the risk of such serious complications as the need for blood transfusion, surgery, or hospitalization. The chapter also examines whether the type of facility or method of sedation or anesthesia affects the risk of adverse outcomes.
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From page 46... ...
-approved protocol for medication abortion was updated in 2016 based on extensive research showing improved outcomes with a revised regimen (CDER, 2016)
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Nations, based in Geneva, Switzerland. WHO develops clinical guidelines on reproductive health care with the stated objective of improving health outcomes.
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. It is also integral to the informed consent process -- a legal and ethical obligation to all patients defined by state and federal law, malpractice standards, and professional standards (ACOG, 2015; AMA, 2016; Joint Commission Resources, 2016; Kinnersley et al., 2013)
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From page 49... ...
. Recent studies suggest improved contraceptive use with the placement of implants or the initiation of other contraceptive methods at the time of the abortion or when mifepristone is administered for an early medication abortion (Hognert et al., 2016; Raymond et al., 2016a; Whaley and Burke, 2015)
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. In a study of nearly 4,500 medication abortion patients aimed at assessing the feasibility and efficacy of foregoing routine use of ultrasound, Bracken and colleagues (2011)
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. SAFETY AND EFFECTIVENESS OF CURRENT ABORTION METHODS Several methods -- medication, aspiration, dilation and evacuation (D&E)
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. In 2014, medication abortions accounted for approximately 45 percent of all U.S.
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. A recent systematic review of this regimen -- including 33,846 medication abortions -- found an overall effectiveness rate of 96.7 percent for gestations up to 63 days (9 weeks)
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Expected Side Effects It is common for medical procedures to result in side effects in addition to the intended outcome. Medication abortions involve cramping, pain, and bleeding, similar to the symptoms of a miscarriage (ACOG and SFP, 2014; Borkowski et al., 2015; FDA, 2016a)
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. The Society of Family Planning suggests that medication abortion may be preferable to aspiration abortion when patients, including those with extreme obesity, are at risk of procedural and anesthetic complications (SFP, 2012)
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analyzed more than 13,000 electronic medical records documenting the outcomes of medication abortions (up to 9 weeks' gestation) performed in private Los Angeles clinics from November 2010 to August 2013.
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In a recent 7-year retrospective cohort study in Iowa, researchers compared the rate of clinically significant adverse events (hospital admission, surgery, blood transfusion, emergency department treatment, or death) after medication abortion for 8,765 telemedicine patients and 10,405 in-person patients (Grossman and Grindlay, 2017)
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Women who lived more than 50 miles from an abortion clinic that provided only surgical abortions were 16 percent more likely to have a medication abortion (adjusted odds ratio [aOR] = 1.16; 95% confidence interval [CI]
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surveillance reports use the catchall category of "curettage" to refer to nonmedical abortion methods. The committee assumed that CDC curettage estimates before 13 weeks' gestation refer to aspiration procedures and that curettage estimates after 13 weeks' gestation are D&E procedures.
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study of private Los Angeles clinics described in the prior section, the efficacy rate for almost 17,000 aspiration abortions performed up to 9 weeks' gestation was 99.8 percent, compared with 99.6 percent for medication abortions9 for the same gestational period (Ireland et al., 2015)
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. Infection Current clinical guidelines recommend routine antibiotic prophylaxis before all aspiration abortions (NAF, 2017a; RCOG, 2015; SFP, 2011b; WHO, 2014)
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. The procedure is typically performed in two stages, although the specific approaches to cervical preparation, instrumentation, and other aspects may vary (Grossman et al., 2008; Ibis Reproductive Health, 2015; Lohr et al., 2008)
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. One study, however, suggests that a history of multiple prior cesarean deliveries may significantly increase the risk of a major complication.
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. In a retrospective cohort study of 4,968 women undergoing aspiration and D&E abortions at a large outpatient clinic in 2012–2014, obesity was not associated with increased risk of complications10 (Benson et al., 2016)
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Uterine perforation While uterine perforation is more common in D&E than in aspiration procedures, the incidence remains quite low and is likely related to the availability of cervical preparation and ultrasound guidance (Grossman et al., 2008)
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. The safety and efficacy of different medications and medication regimens for inducing abortion has been assessed in RCTs, retrospective analyses, prospective observational studies, and systematic reviews (Ashok et al., 2002, 2004; Constant et al., 2016; Goh and Thong, 2006; Gouk et al., 1999; Hamoda et al., 2003; Kapp et al., 2007; Mauelshagen et al., 2009; Ngoc et al., 2011; Sonalkar et al., 2017; Wildschut et al., 2011)
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. Complications The expected side effects of induction abortions are similar to those described above for medication abortions at or before 10 weeks' gestation: cramping, pain, and bleeding, as well as nausea, vomiting, diarrhea, chills, and headache (Borgatta, 2011; Ngoc et al., 2011; Wildschut et al., 2011)
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. Before a woman leaves a facility after an abortion procedure (or after she has taken the appropriate medication in the case of medication abortion)
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From page 69... ...
. The pain management approach that is best for women undergoing medication, aspiration, D&E, or induction abortions depends not only on which method is used but also on weeks' gestation, the patient's preferences for pain control, her comorbidities (if any)
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ASA I patients are healthy, and ASA II patients have mild systemic disease;17 both are medically eligible for all options up to deep sedation in office-based settings. The vast majority of abortion patients -- young women -- are in these categories.
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No special equipment or emergency arrangements are required for medication abortions. If moderate sedation is used during an aspiration
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As noted above, NSAIDs reduce the discomfort of pain and cramping safely and effectively during a medication abortion. Aspiration Pain Management Paracervical blocks are used routinely to reduce the pain of cervical dilation during aspiration procedures (Allen et al., 2013; Nichols et al., 2009)
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systematic review described above identified 11 studies that report patient outcomes related to the use of local anesthesia, moderate sedation, or general anesthesia for aspiration abortions. Anesthesia-related complications were rare regardless of the clinical setting or level of sedation: ≤0.2 percent of office-based procedures and ≤0.5 percent of procedures in surgical centers and hospital-based clinics.
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. The levels of pain in later-gestation induction abortions are said to be similar to those in normal delivery, but the committee found no studies documenting this (Smith et al., 2016; Viviand et al., 2003)
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Among the 16.1 million legal abortions performed from 1998 to 2010, there were 108 deaths (0.7 per 100,000)
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S Jones, Advancing New Standards in Reproductive Health (ANSIRH)
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; and other basic elements of care. In most states, the regulations apply to all abortion methods regardless of weeks' gestation, use of sedation, or the invasiveness of the procedure.
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Thirty-five states have abortion-specific regulations requiring women to receive counseling before an abortion is performed, and abortion patients in many of these states are offered or given inaccurate or misleading information (verbally or in writing) on reversing medication abortions, risks to future fertility, possible breast cancer risk, and/ or long-term mental health consequences of abortion ( uttmacher Institute, G 2017a)
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. In 17 states, medication abortions must be performed in a facility that meets the structural standards of ASCs even though the abortion will occur outside the clinical setting, and there is no evidence to suggest that these regulations improve safety or quality.
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2012. Women's preferences for pain control during first-trimester surgical abortion: A qualitative study.
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Journal of Family Planning and Reproductive Health Care 41(3)
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2015. Medication abortion.
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2015. Mifepristone with buccal misoprostol for medical abortion: A systematic review.
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2016. Two prophylactic medication approaches in addition to a pain con trol regimen for early medical abortion <63 days' gestation with mifepristone and m isoprostol: Study protocol for a randomized, controlled trial.
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2016. Intravenous sedation with out intubation and the risk of anesthesia complications for obese and non-obese women undergoing surgical abortion: A retrospective cohort study.
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2017b. Medication abortion.
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2016. Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion -- a randomized controlled equivalence trial.
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2007. Mifepristone in second-trimester medical abortion: A randomized controlled trial.
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2011. Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: A systematic review.
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2016. Effect of depot medroxyprogesterone acetate injection timing on medical abortion efficacy and repeat pregnancy: A randomized controlled trial.
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2012. Paracervical block for pain control in first-trimester surgical abortion: A randomized controlled trial.
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2016. Nonpharmaceutical pain control adjuncts during first-trimester aspiration abortion: A review.
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2015. Complications from first-trimester aspiration abortion: A systematic review of the literature.
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