Surgical methods for first trimester termination of pregnancy

RHL Commentary by OL Odusoga, OA Olatunji

1. EVIDENCE SUMMARY

The review compares the safety and efficacy of dilatation and curettage (D&C) with manual vacuum aspiration (MVA) methods in the termination of first trimester pregnancy. It also evaluates the use of flexible versus rigid vacuum aspiration cannula. The outcomes compared in both cases were excessive blood loss, blood transfusion, cervical injury, febrile morbidity, incomplete or repeat uterine evacuation procedure, re-hospitalization, postoperative abdominal pain or therapeutic antibiotic use and duration of operation.

Only adequately randomized controlled trials with good methodological quality were considered to be eligible for the review. Three trials met the criteria. Two of the trials compared (D&C) with vacuum aspiration, while one compared rigid metal cannula with flexible plastic cannula for vacuum aspiration.

The duration of the procedure was found to be statistically significantly shorter (1.0 minute less on average; 95% CI: -1.5 - -0.6 minutes) for manual vacuum aspiration than for (D&C) in the only trial that reported this outcome. All other outcomes compared were similar with both methods. Both procedures were conducted under local anaesthesia (paracervical block) in the two trials.

No significant differences were noted between the use of rigid and flexible cannula in all the outcomes measured in the single trial involving 300 women.

The search strategy used for the review, the selection of the trials for inclusion in the review and the process of data extraction from the trials were adequate. The outcomes compared were well assessed. However, the sample size was small and this may be responsible for the lack of differences noted between the two methods (D&C vs. MVA) and between the use of the two different cannulae (rigid vs. flexible). This point is a limitation of the review as some large observational studies could have provided useful information (1).

The nature of the procedures also makes blinding of the operators impossible and liable to introduction of bias, although assessment of the outcome measures was adequately concealed.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS

2.1. Magnitude of the problem

Available statistics indicate that termination of early pregnancy is prevalent in Nigeria and most developing countries, especially in sub-Saharan Africa (2, 3, 4, 5, 6.) The incidence seems to be increasing (2, 3, 4, 5, 6), especially among teenagers (7).

The true magnitude, however, may never be known owing to the social, moral, and legal issues relating to abortion in the region (7, 8). In most countries of sub-Saharan Africa abortion laws are highly restrictive and facilities for the safe performance of the procedure lacking. Available, relatively safe facilities are inaccessible to the majority of women seeking abortion, either because of the cost of the service or of the location of the facility. Women, therefore, have limited access to safe methods of terminating unwanted pregnancy. The result is, of course, high incidence of morbidity and, in fact, mortality from complications of abortion. For instance, at the Ogun State University Teaching Hospital in Sagamu, Nigeria, complications of abortions topped the list of gynaecological admissions between 1997 and 1999 (unpublished hospital statistics); admissions for complications of abortion are also high in the order of gynaecological admissions in other parts of the region (2, 3, 4, 5, 6). Abortion complications are a leading cause of maternal mortality in Nigeria, accounting for about 40 % of maternal deaths (9). Abortion and its complications have been implicated as risk factor for secondary infertility (10). ectopic pregnancy (11, 12) and mid-trimester spontaneous abortions in subsequent pregnancies (13).

2.2. Feasibility of the intervention

No intervention was recommended by the review but the findings of Edelman (1), referred to in the review, are in agreement with the experience in most under-resourced areas that MVA with flexible cannula can be safely used for the termination of first trimester abortions, especially by less experienced staff like medical officers and junior residents. This technique is quite feasible in these regions and should be encouraged. A limiting factor to the intervention in most of the under-resourced regions, however, is the restrictive abortion laws, although, quite often, they are not enforced. The intervention may, however, still be widely employed for the treatment of incomplete abortions and for the management of first trimester abortions performed on medical grounds.

2.3. Applicability of the results of the Cochrane Review

Although the studies included in this review were conducted in industrialized countries and in tertiary institutions, there is nothing to suggest that the findings of the review would not be applicable to developing-country settings. The finding that (D&C) was not clearly superior to MVA in these tertiary care settings under trial conditions suggests that the use of MVA could be encouraged in lower levels of health care in low-income countries.

2.4. Implementation of the intervention

In developing countries in which abortion laws are not restrictive, either of the two techniques may be used once adequate training is provided to health care personnel. However, owing to its relative simplicity and to the fact that D&C was not found to be superior to MVA, the latter may be encouraged in lower levels of the health care system. However, since abortion laws are restrictive in many developing countries, especially in sub-Saharan Africa, the implementation of both procedures would be legally impracticable. The first step in the implementation of either of the two interventions in this regard, therefore, may be to encourage a change in these laws. Governments in developing countries need to be aware of the enormity of the problems that result from unsafe abortions and how they affect the health and the economy of the public.

2.5. Research

Further research into surgical methods for the termination of first trimester pregnancy should include client and provider preference as outcomes.

Sources of support: Center for Research in Reproductive Health (CRRH), Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria.

References

• Edelman DA, Brenner WE, Berger GS. The effectiveness and complications of abortion by dilatation and vacuum aspiration versus dilatation and rigid curettage. American journal of obstetrics and gynecology 1974;119:473–480.
• Mtimavalye L, Lisasi D, Ntuyabaliwe WK. Maternal mortality in Dar Es Salaam, Tanzania, 1974-1977. East African medical journal 1980;111-118.
• Kapiga SH, Justesen A, van Asten HA. Abortions in a hospital setting: hidden realities in Dar Es Salaam, Tanzania. Studies in family planning 1992;23:325-329.
• Unuigbe JA, Orhue AA, Oronsaye AU. Abortion related morbidity and mortality in Benin City, Nigeria. International journal of gynaecology and obstetrics 1988;26:435-439.
• Olukoya AA. Pregnancy termination: result of a community-based study in Lagos, Nigeria. International journal of gynaecology and obstetrics 1987;25:41–46.
• Ampofo DA. The motivation for reproduction and the new population dimensions of Ghana. East African medical journal 1970;47:217-222.
• Aggarwal VP, Mati JK. Review of abortions at Kenyatta National Hospital Nairobi. East African medical journal 1980;57:138-143.
• Bleek W. Induced abortion in Ghanaian family. African studies review 1978;21:103-120.
• Akingba JB. Abortion mortality and other health problems in Nigeria. Nigerian medical journal 1977;7:465-471.
• Okonofua FE. Induced abortion: a risk factor for secondary infertility in Nigerian women. Journal of obstetrics and gynaecology 1994;14:272-276.
• Orhue AA, Unuigbe JA, Ogbeide WE. Contribution of previous induced abortion to tubal ectopic pregnancy. West African medical journal 1989;8:257-263.
• Olatunbosun OA, Okonofua FE. Ectopic pregnancy: the African experience. Postgraduate doctor Africa 1986;8:74-78.
• Ladipo OA. Preventing and managing complications of induced abortion in third world countries. International journal of gynaecology and obstetrics 1989;3:21-28.

This document should be cited as: OL Odusoga, OA Olatunji. Surgical methods for first trimester termination of pregnancy: RHL commentary (last revised: 11 November 2002). The WHO Reproductive Health Library; Geneva: World Health Organization.