SOGC CLINICAL PRACTICE GUIDELINE

No. 360, June 2018

No. 360-Induced Abortion: Surgical Abortion

and Second Trimester Medical Methods

This guideline has been prepared by the Surgical Abortion

Working Group, reviewed by the Guideline Management and Abstract
Oversight Committee, and approved by the Board of the
Society of Obstetricians and Gynaecologists of Canada. Objective: This guideline reviews evidence relating to the provision
Dustin Costescu, MD, Hamilton, ON (Co-chair) of surgical induced abortion (IA) and second trimester medical
abortion, including pre- and post-procedural care.
Édith Guilbert, MD, Québec City, QC (Co-chair)
Intended Users: Gynaecologists, family physicians, nurses,
midwives, residents, and other health care providers who currently
or intend to provide and/or teach IAs.
Surgical Abortion Working Group: Dustin Costescu, MD,
Hamilton, ON (Co-chair); Édith Guilbert, MD, Québec City, QC Target Population: Women with an unintended or abnormal first or
(Co-chair); Jeanne Bernardin, MD, Moncton, NB; Amanda Black, second trimester pregnancy.
MD, Ottawa, ON; Sheila Dunn, MD, Toronto, ON; Megan Gomes,
Evidence: PubMed, Medline, and the Cochrane Database
MD, Ottawa, ON; Brian Fitzsimmons, MD, Vancouver, BC; Lola
were searched using the key words: first-trimester surgical
McNamara, RN, Gatineau, QC; Wendy V Norman, MD,
abortion, second-trimester surgical abortion, second-trimester
Vancouver, BC; Regina Renner, MD, Vancouver, BC; Konia
medical abortion, dilation and evacuation, induction abortion,
Trouton, MD, MPH, Victoria, BC and Calgary, AB; Marie-Soleil
feticide, cervical preparation, cervical dilation, abortion
Wagner, MD, Montréal, QC.
complications. Results were restricted to English or French
Disclosure statements have been received from all authors. systematic reviews, randomized controlled trials, clinical
Key Words: Induced abortion, aspiration curettage, dilation and trials, and observational studies published from 1979 to
evacuation, second-trimester induction, family planning July 2017. National and international clinical practice
guidelines were consulted for review. Grey literature was
not searched.

Values: The quality of evidence in this document was rated using the
Grading of Recommendations, Assessment, Development, and
Evaluation (GRADE) methodology framework. The summary of
J Obstet Gynaecol Can 2018;40(6):750–783 findings is available upon request.
https://doi.org/10.1016/j.jogc.2017.12.010 Benefits, Harms, and/or Costs: IA is safe and effective. The
© 2018 Society of Obstetricians and Gynaecologists of Canada. Pub- benefits of IA outweigh the potential harms or costs. No new direct
lished by Elsevier Inc. All rights reserved. harms or costs identified with these guidelines.

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opin-
ions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written
permission of the publisher.
Patients have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order
to facilitate informed choice patients should be provided with information and support that is evidence based, culturally appropriate, and tai-
lored to their needs. The values, beliefs, and individual needs of each patient and their family should be sought, and the final decision about
the care and treatment options chosen by the patient should be respected.

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 No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

SUMMARY STATEMENTS Method Selection and Technique

Periprocedural Care 6. Intracervical vasopressin may reduce blood loss in

second trimester surgical abortion (Level of evidence:
1. Women seek abortion for many reasons, each of which Low).
is valid. Counselling needs may differ for women with 7. For early second trimester surgical abortion, use of
an unintended pregnancy than for those with an in- buccal/vaginal misoprostol 400 µg 3–4 hours before di-
tended but abnormal pregnancy. lation and evacuation:
2. Doxycycline, metronidazole, and beta-lactams are each a. may not achieve as much dilation as osmotic dila-
suitable to reduce the risk of post-abortal infection (Level tors alone (Level of evidence: Moderate).
of evidence: High). b. results in similar complication rates as for osmotic
3. Moderate sedation combined with a paracervical block dilators, but does increase side effects (Level of evi-
provides improved intraoperative pain control com- dence: Medium).
pared with local anaesthesia alone (Level of evidence: c. reduces ease of procedure compared with use of
High). osmotic dilator (Level of evidence: High).
4. Feticide prior to second trimester surgical abortion is as- 8. More research is required to state whether use of
sociated with more side effects and a higher complication mifepristone confers benefit for cervical dilation prior
rate without reduction in operating time (Level of evi- to early second trimester surgical abortion (Level of
dence: Low). evidence: Very low).
5. More evidence is required to determine if feticide prior 9. For late second trimester surgical abortion, use of buccal
to second trimester medical abortion confers benefit misoprostol 400 µg 3–4 hours plus laminaria/synthetic
(Level of evidence: Very low). osmotic dilators before D&E:

ABBREVIATIONS LBW low birth weight

CHC combined hormonal contraception MA medical abortion
CI confidence interval MIFE mifepristone
COC combined oral contraceptives MISO misoprostol
CS Caesarean section MVA manual vacuum aspiration
D&C dilation and curettage NO donors nitric oxide donors
D&E dilation and evacuation NSAID non-steroidal anti-inflammatory drug
DMPA depo-medroxyprogesterone acetate OD synthetic osmotic dilators
EC emergency contraception OR odds ratio
EVA electric vacuum aspiration PCA patient-controlled analgesia
EP ectopic pregnancy PCB paracervical block
FU follow-up PGF2α prostaglandin F2α
GA gestational age PGE1 prostaglandin E1
GAn general anaesthesia PGE2 prostaglandin E2
GRADE Grading of Recommendations, Assessment, POC products of conception
Development, and Evaluation PP placenta previa
GS gestational sac PTB preterm birth
GTN gestational trophoblastic neoplasia PUL pregnancy of unknown location
hCG human chorionic gonadotropin RCT randomized controlled trial
IA induced abortion RR risk ratio
IUP intrauterine pregnancy SA surgical abortion
DIC disseminated intravascular coagulation SGA small for gestational age
IM intramuscular SOGC Society of Obstetricians and Gynaecologists
IV intravenous(ly) of Canada
KCl potassium chloride UP uterine perforation
IUCD intrauterine contraceptive device

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SOGC CLINICAL PRACTICE GUIDELINE

• achieves significantly more dilation than osmotic di- planning (Strong recommendation. Level of evi-
lators alone, without influencing procedure time dence: Low).
(Level of evidence: Moderate). 4. Placental localization by ultrasound is recommended
• does not decrease severe complications (Level of before second trimester abortion when placenta previa
evidence: Moderate), but may produce prostaglan- is suspected, and when there is a history of uterine scar
din side effects (Level of evidence: Low). (Strong recommendation. Level of evidence: Very low).
10. For late second trimester surgical abortion, use of 5. Expert consultation is advised when invasive placen-
mifepristone overnight with osmotic dilators and/or tation is suspected, particularly in women with a uterine
buccal/sublingual/vaginal misoprostol 400 µg 3–4 hours scar (Strong recommendation. Level of evidence: Very
before D&E facilitates cervical preparation and de- low).
creases procedure time (Level of evidence: Low). 6. Preoperative antibiotics should be given to all women
11. For second trimester medical abortion: undergoing surgical abortion (Strong recommenda-
• use of mifepristone 24–48 hours prior to induc- tion. Level of evidence: High).
tion reduces time to expulsion without added side 7. Women at risk or suspected to have a sexually trans-
effects (Level of evidence: High). mitted infection should be screened at the time of
• mechanical dilation with intracervical catheters prior abortion. If positive, the woman should receive evidence-
to induction rarely confers benefit (Level of evi- based treatment, in addition to any pre-procedural
dence: Low). antibiotics received. (Strong recommendation. Level of
• laminaria/synthetic osmotic dilators prior to induc- evidence: Very low).
tion do not confer any benefit and may increase both 8. Women should be offered contraception counselling
pain and time to expulsion (Level of evidence: before abortion, and provided with their chosen method
Moderate). (Strong recommendation. Level of evidence: Low).
12. Immediate placement of intrauterine contraception 9. Women undergoing first trimester surgical abortion with
reduces repeat abortion and unintended pregnancy com- no contraindications should receive non-steroidal anti-
pared with other methods (Level of evidence: Moderate). inflammatory medication (Strong recommendation.
Level of evidence: High).
Post-Abortion Care
10. Moderate sedation combined with a paracervical
block should be offered to women undergoing first or
second trimester surgical abortion when available (Strong
13. An abundant amount of evidence provides reassur-
recommendation. Level of evidence: High).
ance concerning future reproductive outcomes following
11. Feticide may be performed prior to second trimester
induced abortion (Level of evidence: Low).
surgical abortion, following discussion of both medical
14. Sharp curettage during induced abortion is associated
and psychosocial considerations (Weak recommenda-
with the development of uterine adhesions, risk of mis-
tion. Level of evidence: Low).
carriage, placenta previa, and subfertility (Level of
12. Feticide may be performed prior to second trimester
evidence: Low).
medical abortion, following discussion of both medical
and psychosocial considerations (Weak recommenda-
RECOMMENDATIONS tion. Level of evidence: Very low).

Periprocedural Care Method Selection and Technique

1. A preprocedural assessment should take place prior to 13. Early surgical abortion (<7 weeks) should be per-
induced abortion to identify somatic and mental health formed with routine preoperative and postoperative
conditions associated with an elevated risk of compli- ultrasound, direct examination of products of concep-
cations and therefore warrant an in-hospital procedure tion, and β-human chorionic gonadotropin follow-up
(Strong recommendation. Level of evidence: Very low). when products of conception are not identified (Strong
2. Women should be given an opportunity to explore the recommendation. Level of evidence: Low).
circumstances around their decision to undergo induced 14. For women who cannot or refuse serial β-human cho-
abortion and be offered counselling as deemed neces- rionic gonadotropin follow-up following early surgical
sary (Strong Recommendation. Level of evidence: Low). abortion, the procedure should be delayed until an in-
3. Ultrasound should be performed prior to induced abor- trauterine pregnancy can be confirmed (Strong
tion to confirm gestational age and aid in operative recommendation. Level of evidence: Very low).

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 No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

15. Cervical preparation is not routinely required prior to should be based on provider and patient preference
first trimester surgical abortion (Strong recommenda- (Weak recommendation. Level of evidence: Moderate).
tion. Level of evidence: Moderate). 25. For second trimester medical abortion, use of mechani-
16. Cervical priming before first trimester surgical abor- cal dilation or osmotic dilator prior to induction is not
tion may be considered in nulliparous women, and when recommended (Strong recommendation. Level of evi-
cervical dilation is expected to be difficult (Weak rec- dence: Low). Mechanical dilation may be considered
ommendation. Level of evidence : Very low). when other cervical priming approaches must be avoided
17. The following are recommended cervical preparation (Weak recommendation. Level of evidence: Low),
regimens (Strong recommendation; Level of evi- 26. For second trimester medical abortion, there is insuf-
dence: High): ficient evidence to recommend the use of nitric oxide
a. misoprostol 400 µg vaginally 3 hours pre-procedure; donors or misoprostol priming prior to induction (Weak
or recommendation. Level of evidence: Low),
b. misoprostol 400 µg sublingually, 2–3 hours pre- 27. In the presence of placenta praevia, intracervical va-
procedure; or sopressin, ultrasound guidance, and rapid removal of
c. laminaria placed intracervically 6–24 hours pre- the placenta are recommended. Expert backup is advised
procedure; or in case of significant bleeding (Strong recommenda-
d. synthetic osmotic dilator placed intracervically 3–4 tion. Level of evidence: Very low),
hours pre-procedure; or 28. Routine gross examination of the uterine contents
e. mifepristone 200–400 mg orally, 24–48 hours prior should be performed immediately after induced
to procedure. abortion (Strong recommendation. Level of evidence:
18. Vasopressin 4 units added to a 20-mL paracervical block Very low),
during second trimester surgical abortion may be used 29. Histopathological examination of products of concep-
to reduce blood loss (Strong recommendation. Level tion must be performed when gestational trophoblastic
of evidence: Low). neoplasia or ectopic pregnancy is suspected (Strong rec-
19. The use of misoprostol for second trimester medical ommendation. Level of evidence: Very low).
abortion is safe after 1 prior low-transverse Caesarean
section. There is insufficient evidence regarding its use
in women with 2 or more prior Caesarean sections or Post-Abortion Care
a prior classical Caesarean section (Weak recommen-
dation. Level of evidence: Very low). 30. Every facility where abortions are performed should
20. For early second trimester surgical abortion, cervical have written emergency protocols (Strong recommen-
preparation can be achieved with laminaria/synthetic dation. Level of evidence: Very low).
osmotic dilators alone or misoprostol 400 µg 3–4 hours 31. Every facility where abortions are performed should
pre-procedure (Strong recommendation. Level of evi- engage in regular emergency drills (Strong recommen-
dence: Moderate). dation. Level of evidence: Very low).
21. For early second trimester surgical abortion, mifepristone 32. If women fail to have a period within 8 weeks follow-
is not recommended for cervical preparation (Weak rec- ing induced abortion and/or complain of continuing
ommendation. Level of evidence: Very low). symptoms and signs of pregnancy, a new or ongoing
22. For late second trimester surgical abortion, the addi- pregnancy should be suspected and repeat procedure
tion of misoprostol 400 µg 3–4 hours pre D&E after offered (Strong recommendation. Level of evidence:
serial insertions of osmotic dilators is recommended, Very low).
but is associated with side effects (Strong recommen- 33. Sharp curettage is not recommended as a replacement
dation. Level of evidence: Moderate). for vacuum aspiration (Strong recommendation. Level
23. For late second trimester surgical abortion, use of prior- of evidence: Low), nor should routine sharp curet-
day mifepristone 200 mg orally is recommended, in tage be performed during induced abortion (Weak
addition to osmotic dilators and/or misoprostol 400 µg recommendation. Level of evidence: Low).
3–4 hours pre-procedure (Weak recommendation. Level 34. Contraception should be started as soon as possible after
of evidence: Low). the abortion (Strong recommendation. Level of evi-
24. For second trimester medical abortion, use of dence: High).
mifepristone 24–48 hours prior to misoprostol induc- 35. Women referred for abortion from a fetal diagnosis
tion is recommended (Strong recommendation. Level clinic should be offered follow-up to review any
of evidence: High). The specific timing of mifepristone additional information obtained from the abortion and

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SOGC CLINICAL PRACTICE GUIDELINE

provide support (Strong recommendation. Level of Table 1. Key to GRADE1,2

evidence: Low).
Strength of the
recommendation Definition

INTRODUCTION Strong Highly confident of the balance between

desirable and undesirable consequences
(ie, desirable consequences outweigh the
Definition and Scope
undesirable consequences, or undesirable
In Canada, approximately 100 000 Induced Abortions (IAs) consequences outweigh the desirable
occur annually.1 Most IAs are surgical (95%), and over two consequences).
thirds take place within 13 gestational weeks.1 First trimes- Weaka Less confident of the balance between
ter SA is defined as less than 14 weeks from last menstrual desirable and undesirable consequences.
period. Second trimester IA is defined as taking place Quality level of a
body of evidence Definition
between 14 and 24 weeks. Second trimester SA, most com-
monly D&E, is performed following cervical preparation High|++++ We are very confident that the true effect lies
close to that of the estimate of the effect.
and requires specialized training; second trimester MA uses
Moderate|+++0 We are moderately confident in the effect
various pharmacological combinations to effect expulsion estimate. The true effect is likely to be close
(vaginal delivery) of the pregnancy, usually in a supervised to the estimate of the effect, but there is a
setting. In Canada, there were 587 terminations over 21 weeks possibility that it is substantially different.
reported in 2015.1 Low|++00 Our confidence in the effect estimate is limited.
The true effect may be substantially different
These guidelines review evidence regarding first trimester from the estimate of the effect.

SA and second trimester SA and MA. First trimester MA Very low|+000 We have very little confidence in the effect
estimate. The true effect is likely to be
is addressed in another SOGC guideline.2 Recognizing that substantially different from the estimate
other clinical practice or accreditation standards exists,3 this of effect.
guideline is intended for providers who wish to review Examples:
current best practices and evidence. It is also intended for Strong, moderate|+++0: Strong recommendation, moderate quality of evidence.
obstetrician/gynaecologists and family physicians who Weak, low|++00: Weak recommendation, low quality of evidence.
provide abortions, some of whom may not be members of a
Weak recommendations should not be misinterpreted as weak evidence or
uncertainty of the recommendation.
an abortion provider organization.

The quality of evidence in this document was rated using

the criteria described in the GRADE methodology frame-
work (Table 1). The interpretation of strong and conditional Medical Assessment
(weak) recommendations is described in Table 2. A medical evaluation is required to identify women at el-
evated risk of an adverse event and those who may benefit
Surgical Abortion Providers from a hospital-based procedure.11 A minimal physical ex-
In Canada, most abortion providers are family physicians, amination consists of height, weight, vital signs, and pelvic
followed by gynaecologists.4 Physicians and adequately trained exam. Further examination is directed by history. Rh status
midlevel providers (midwives, nurses, and others) may safely should be determined in all women.
provide first trimester IA. Although a 2015 Cochrane review5
showed that complication rates were similar, SA failure rate Lack of vaginal parity and prior cervical surgery may lead
was slightly increased with midlevel providers.6–10 to poor cervical dilation.12 Obese women experience in-
creased operative times, with no increase in complications.13,14
PERIPROCEDURAL CARE
Women with uncontrolled medical conditions may require
specialist consultation or, rarely, admission.11 Women with
Women who are contemplating IA require timely care. A American Society of Anesthesiologists status of 3 or greater
comprehensive review of pre-abortion care is included in should undergo anaesthesia consultation and may require
the first trimester MA guideline, including a detailed dis- anaesthesia support during IA.3,15,16 Laboratory investiga-
cussion outlining differences in outcomes, risks, and patient tions should be directed by history.17 A history of CS is
preferences regarding medical versus surgical abortion.2 In associated with a higher rate of SA complications (OR 1.9,
general, MA and SA are equivalent prior to 49 days’ GA, 95% CI 1.1–3.4).18 The presence of placenta previa (PP),
and there is a small increased risk of subsequent treat- low anterior placenta with a history of CS, or bleeding dia-
ment (aspiration) and bleeding with MA beyond this limit.2 thesis increases the risk of hemorrhage.12,18

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 No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

Table 2. Judgement and interpretation of strong and conditional recommendations1,2

Strong recommendation, Conditional (weak) recommendation,
Judgement/interpretation “We recommend….” “We suggest….”
Judgement by guideline panel It is clear to the panel that the net desirable It is less clear to the panel whether the net
consequences of a strategy outweighed the desirable consequences of a strategy
consequences of the alternative strategy. outweighed the alternative strategy.
Implications for patients Most individuals in this situation would want the Most individuals in this situation would want the
recommended course of action, and only a suggested course of action, but many would not.
small proportion would not.
Implications for clinicians Most individuals should receive the intervention. Clinicians should recognize that different choices
Adherence to this recommendation according to will be appropriate for each individual and that
the guideline could be used as a quality criterion clinicians must help each individual to arrive at a
or performance indicator. management decision consistent with his or her
values and preferences.
Implications for policy makers The recommendation can be adopted as policy in Policy making will require substantial debate and
most situations. involvement of various stakeholders.

If sedation is provided, nil per os status should be re- complications and therefore warrant an in-hospital
viewed, and cardiorespiratory and airway examination procedure (Strong recommendation. Level of evi-
performed.15,16 The American Society of Anesthesiologists dence: Very low).
recommends fasting for 2 hours for clear fluids and 6 hours 2. Women should be given an opportunity to explore the
for solids prior to moderate sedation.15,16 Two retrospec- circumstances around their decision to undergo
tive studies, 1 involving over 47 000 cases, found no increase induced abortion and be offered counselling as
in complications related to low-dose sedation protocols with deemed necessary (Strong Recommendation. Level
midazolam and fentanyl in women who had a light meal of evidence: Low).
before undergoing SA up to 18 weeks of gestation.19,20
Women may have discontinued certain medications Ultrasound Scanning Including Localization of
upon learning of the pregnancy, in particular mood- Placenta and Management of Abnormal
stabilizers. Reviewing mental health conditions and Placentation
medication histories may identify women who would benefit Routine ultrasound prior to IA is recommended, as deter-
from additional anxiolysis or guidance on restarting their mination of GA is critical. 21 In second trimester SA,
medications. intraoperative ultrasound has been shown to decrease com-
As discussed in the MA guideline,2 women should be given plications including uterine perforation (UP).22
an opportunity to discuss the circumstances surrounding the In the second trimester, ultrasound is important to deter-
abortion decision. Some women present for abortion owing mine placental localization.23 If the placenta is anterior
to a fetal diagnosis or change in circumstance in the setting and low lying or previa, the risk of hemorrhage can be
of a wanted pregnancy. Common practice suggests that these substantial.24 In the presence of a uterine scar, further
women (and the man involved in the pregnancy) benefit from imaging, such as Doppler interrogation, computerized to-
counselling; however, we could not identify studies that quan- mography, or magnetic resonance imaging, is required to
tified this benefit. rule out invasive placentation, recognizing the limitations
of such studies.12,24
Summary Statement
1. Women seek abortion for many reasons, each of which Recommendations
is valid. Counselling needs may differ for women with 3. Ultrasound should be performed prior to induced abor-
an unintended pregnancy than for those with an in- tion to confirm gestational age and aid in operative
tended but abnormal pregnancy. planning (Strong recommendation. Level of evidence:
Low).
Recommendations 4. Placental localization by ultrasound is recommended
1. A preprocedural assessment should take place prior before second trimester abortion when previa is sus-
to induced abortion to identify somatic and mental pected, and when there is a history of uterine scar
health conditions associated with an elevated risk of (Strong recommendation. Level of evidence: Very low).

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SOGC CLINICAL PRACTICE GUIDELINE

5. Expert consultation is advised when invasive placen- benefits.35 Most clinicians managing second trimester MA
tation is suspected, especially in women with a uterine do not provide antibiotic prophylaxis.29
scar (Strong recommendation. Level of evidence: Very
No antibiotic option is superior to another – commonly
low).
doxycycline, metronidazole, and beta-lactams are used.33,36
The 2012 Cochrane meta-analysis found a similar risk re-
Risk and Benefits of second Trimester Surgical duction between single-dose (RR 0.63; 95% CI 0.50–0.80)
Versus Medical Abortion (Table 3) and multidose regimens (RR 0.71; 95% CI 0.55–0.92) when
The complication rate of D&E is less than 1% before 16 compared with placebo.33 Infection rates were also similar
weeks,25–27 1% between 16 and 20 weeks, 1.5% over 20 weeks, between 3- and 7-day courses of doxycycline initiated
increasing by 1% per week thereafter.25–27 Mortality has de- post-procedure.37 In another RCT, pre-procedure initia-
creased over time to 0.65 in 100 000.28 The mortality rates tion of antibiotics was significantly more effective than
for D&E were 2.5 times lower than those for MA, but this post-procedure.38 As for all medication, antibiotic steward-
difference is not statistically significant.25,26 D&E is associ- ship should be employed.39
ated with a lower risk of complications27 than MA.29 All these
rates are lower than birth mortality rate of 8.8 in 100 000 Summary Statement
live births.30
2. Doxycycline, metronidazole, and beta-lactams are each
Because of the increased risk of hemorrhage with PP, with suitable to reduce the risk of post-abortal infection
or without prior CS,24 SA is preferred to MA in this cir- (Strong recommendation. Level of evidence: High).
cumstance. If an MA takes place, urgent surgical backup
Recommendations
should be available.
6. Preoperative antibiotics should be given to all women
undergoing surgical abortion (Strong recommenda-
Preoperative Medications
tion. Level of evidence: High).
Antibiotic prophylaxis
7. Women at risk or suspected to have a sexually trans-
Although uncommon, post-abortal infections may have
mitted infection should be screened at the time of
serious sequelae. 31 Two systematic reviews and meta-
abortion. If positive, the woman should receive
analyses of 19 RCTs showed that antibiotic prophylaxis for
evidence-based treatment, in addition to any pre-
first trimester SA reduces post-abortal infection, with rela-
procedural antibiotics received. (Strong
tive risks of 0.58 (95% CI 0.47–0.71)32 and 0.59 (95% CI
recommendation. Level of evidence: Very low).
0.46–0.75),33 respectively. One RCT demonstrated a slight
superiority of universal prophylaxis compared with a screen
and treat strategy to reduce infection (RR 1.53; 95% CI Contraception
0.99–2.36).34 Few studies have examined antibiotic prophy- Since many women do not attend follow-up appoint-
laxis for second trimester SA, but limited findings show ments, contraception should be offered, according to needs,

Table 3. Risks and benefits of second trimester SA versus MA

Second trimester surgical abortion Second trimester medical abortion
1–2 days of cervical preparation before the procedure followed by a Procedure lasting hours to days with a stay of a 1–3 days in
post-anaesthetic recovery time the facility
Performed by surgical extraction Expulsion (delivery) following repeated administration of medication
Requires a procedure room, a D&E-trained provider, skilled staff, and Requires skilled nurses and an obstetrics trained provider
local/moderate sedation
Short-term analgesics and/or anaesthesia provided before and during Short-term or continuous analgesia provided during cervical dilation
the procedure and expulsion
Likely will not provide an intact fetus for viewing/holding and may limit Intact fetus may be desired when viewing/holding and/or autopsy to
autopsy results be performed
Cremation and burial may be offered Cremation and burial may be offered
Potential complications: Heavy bleeding, uterine perforation, infection, Potential complications: Heavy bleeding, infection, incomplete
incomplete abortion, transfusion (<1%), hysterectomy abortion requiring D&C, transfusion (<5%), hysterectomy
Adapted from Paul et al.12

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before IA.40,41 Although 1 RCT demonstrated improved post- sedation, paracervical and intracervical injections appear to
abortion contraceptive use after counselling compared with have similar effects.72 Total lidocaine dose should not exceed
no counselling,42 the most effective counselling type and 4.5 mg/kg and not more than 7 mg/kg if epinephrine or
timing are uncertain.43,44 vasopressin is added.73–75 Side effects of lidocaine include
lightheadedness, tinnitus, circumoral tingling, and metallic
Several RCTs and cohort studies have shown that inser- taste in the mouth. Seizures, cardiac effects, and anaphy-
tion of an IUCD immediately following SA results in higher laxis are rare and dose related. Inadvertent IV lidocaine
long-term use and lower rates of repeat abortion com- injection warrants increased monitoring for toxicity.
pared with delayed insertion or initiation of a different
contraceptive.45–49 Sedation: Moderate sedation is commonly offered for SA,
typically using fentanyl 50–100 µg IV and midazolam 1–2 mg
Summary Statement IV. Moderate IV sedation with PCB is superior to PCB
12. Immediate placement of intrauterine contraception alone76,77 or to PCB with oral opioid/benzodiazepine.78 Ad-
reduces repeat abortion and unintended pregnancy dition of nitrogen dioxide and nitrous oxide 50:50 (Entonox)
compared with other methods (Strong recommen- does not improve procedural or postoperative pain.79,80
dation. Level of evidence: Moderate).
Deep IV sedation and GAn using propofol are offered in
Recommendation some centres.71,81,82 In an RCT comparing moderate seda-
tion plus PCB versus GAn alone, intraoperative pain control
8. Women should be offered contraception counselling
was better with GAn, but postoperative pain control was
before abortion, and provided with their chosen method
worse.83 Adding a 10-mL PCB in women undergoing GAn
(Strong recommendation. Level of evidence: Low).
for SA up to 21 weeks did not improve postoperative pain.84
Preoperative medications Non-pharmacological interventions: Evidence regarding
Oral NSAIDs such as ibuprofen, diclofenac, and na- pain reduction when listening to music has been
proxen have all been shown to decrease intraoperative and conflicting.85,86 Hypnosis may reduce sedation requirement87
postoperative pain in first trimester SA compared with and decrease the need for nitrous oxide but does not
placebo.50–54 Ibuprofen was superior to tramadol for post- affect pain rating.88
operative pain,53 and oral opioids have not demonstrated
reduction in either intraoperative or postoperative pain.55,56 Summary Statement
Acetaminophen57 and ketorolac58 did not reduce pain in 3. Moderate sedation combined with a paracervical block
women undergoing GAn. provides improved intraoperative pain control com-
Benzodiazepines reduced neither pain51,59 nor anxiety60 when pared with local anaesthesia alone (Level of evidence:
administered pre-procedure in RCTs. MISO increases pre- High).
operative cramping,61–66 while data regarding intraoperative
Recommendations
pain reduction are conflicting.52,67,68 Antiemetic should be con-
sidered in women receiving IV opioids and women with 9. Women undergoing first trimester surgical abortion
hyperemesis. with no contraindications should receive non-steroidal
anti-inflammatory medication (Strong recommenda-
Analgesia/Anaesthesia first and second Trimester tion. Level of evidence: High).
SA 10. Moderate sedation combined with a paracervical
Local anaesthesia: A placebo (sham block) RCT of women block should be offered to women undergoing first
not receiving sedation for first trimester SA demonstrated or second trimester surgical abortion if possible
reduction in pain with a PCB of 20 mL 1% buffered lido- (Strong recommendation. Level of evidence: High).
caine injected at 4 sites (2, 4, 8, and 10 o’clock) with a
3-minute wait prior to dilation.69 A follow-up RCT found Analgesia for second Trimester MA
no difference in pain between immediate dilation versus PCA with 50 µg fentanyl every 3 or 6 minutes was found
waiting 3 minutes and less pain with a 4-site injection versus to be superior to 25-µg fentanyl or 2-mg morphine PCA.89
2-site.70 A Cochrane review concluded that carbonated li- NSAIDs decreased opiate requirements. 90 Controlled
docaine was superior to plain lidocaine, slow injection trials demonstrated reduction in pain during MA when
superior to fast injection, and deep superior to superficial metoclopramide was added to PCA with morphine.91 PCB
injection for first trimester SA.71 In women under moderate did not confer benefit.92,93

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Feticide Recommendation
Feticide refers to the cessation of fetal cardiac activity prior
to IA and is generally offered for psychosocial reasons 11. Feticide before second trimester surgical abortion may
(woman and provider).94 It is achieved via: be performed following discussion of both medical
and psychosocial considerations (Weak recommen-
1. transabdominal injection of pharmacological agents, dation. Level of evidence: Low).
such as:
Should feticide be used prior to second trimester MA?
• KCl (mostly used in second trimester MA),95–104
• digoxin (mostly used before second trimester SA),105–120 or In 10 descriptive studies,95,96,100,103,105–107,121,122,125 where 21 to
• lidocaine121,122 1677 women underwent feticide before second trimester MA,
2. digoxin administered transvaginally111,114,115 the rate of major maternal complications124 varied from 0%
3. umbilical cord transection123 to 0.8%.95,96,100,105,106,121,122 Two serious adverse events were
reported: 1 maternal cardiac arrest after a fetal intracar-
Feticidal agents can be injected in the amniotic diac injection of KCl99 and 1 case of Clostridium perfringens
fluid107–112,114,116–118,120 or by the intrafetal,98,105,106,110–112,118,120 sepsis.98 In a retrospective cohort study99 comparing 17
intracardiac,95,97,99,101–103,113 or intrafunic route.96,98,121 women with feticide with 51 without, no difference in re-
A GRADE approach to assessing the role of feticide was tained placenta, fever, and gastrointestinal side effects was
performed. Articles selected are related only to feticide prior noted. Women with feticide had a significant shorter time
to IA and not multifetal pregnancy reduction. to expulsion (14.8 hours vs. 9.5 hours; P = 0.006) and re-
quired fewer doses of PGE2 (2 vs. 3; P < 0.01). The mean
Should feticide be used prior to second trimester SA? GA in the feticide group was significantly greater (1 more
In 12 descriptive studies,96,103,105–108,110,112,115,117,118,123 where 8 week; P < 0.01).99 In a time series101 comparing 64 women
to 4906 women received feticide before second trimester with no feticide before 2001 with 82 women with feticide
SA, the rate of major maternal complications (major un- from 2001 onwards, D&C occurred in 82.9% of women
intended surgery, hemorrhage requiring transfusion, severe with feticide versus 65.6% of women without (P = 0.02).
pelvic infection)124 varied from 096,117 to 3.8%.115 One case One study comparing intrafunic versus intracardiac
of hyperkalemic paralysis secondary to intra-amniotic in- injection104 and 1 case series on funic injection of KCl96 re-
jection of digoxin was reported. 116 Studies reported ported live births in spite of feticide. There was no difference
extramural deliveries in 0% to 0.5%.103,110 in the major rate of complication, or in the duration of the
induction, between studied groups.104
Two RCTs111,120 compared intrafetal with intra-amniotic in-
jection of digoxin: 1 did not find any difference,111 while In cases of PP, feticide may interrupt blood flow to the pla-
the other 1 found higher rate of absent cardiac activity with centa, reducing bleeding risk.126 Two small comparative studies
intrafetal injection (94.8% vs. 82.3%; P = 0.002), but with in women with PP reported conflicting results regarding out-
a trend towards more extramural deliveries (3.8% vs. 1.5%; comes of MA, with 1 showing benefit in the feticide
P = 0.28).120 Side effects were common in both studies; 40% group.126,127
experienced fatigue or nausea and 20% experienced vom- Of note, in an acceptability study (N = 101 providers), 78%
iting, lightheadedness, or palpitations.111,120 of those who attended feticide said it improved their pro-
According to 1 RCT,109 1 cohort study,113 and 1 time-series,114 fessional practice, and 52% said it improved women’s
the major complication rate was found to be significantly experience.125 This alone is sufficient to guide the decision
higher with feticide compared with no feticide (RR 3.73; to use feticide during IA.
P = 0.002) (Level of evidence: Moderate), with no differ-
ence in procedure time (Level of evidence: Low). Vomiting Summary Statement
was more frequent with feticide (RR 5.05; P = 0.03) (Level 5. More evidence is required to determine if feticide prior
of evidence: Low). Other outcomes could not be assessed to second trimester medical abortion confers benefit
with the GRADE approach because of limited evidence. (Level of evidence: Very low).

Summary Statement Recommendation

4. Feticide prior to second trimester surgical abortion 12. Feticide may be performed prior to second trimes-
is associated with more side effects and a higher com- ter medical abortion, following discussion of both
plication rate without reduction in operating time (Level medical and psychosocial considerations (Weak rec-
of evidence: Low). ommendation. Level of evidence: Very low).

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METHOD SELECTION AND TECHNIQUE Although performed by most clinicians,149 and recom-
mended by 1 guideline,147 routine cleansing of the cervix
Early SA (<7 Weeks) is not supported by studies.150
When a woman presents for early IA – prior to 7 weeks –
either MA or SA is equally effective and acceptable. 2 Gentle cervical dilation should be achieved before the in-
Delaying SA until beyond 7 weeks (with the intention of de- troduction of an aspiration cannula 3,147,151,152; Pratt or
termining viability and rule out EP) is no longer advised,128 Denniston dilators are effective and exert lower force on
given the increasing risk of complications with advancing cervical tissue than Hegar dilators.3,152,153 The selected
GA and the emotional stress of prolonging an unintended cannula is typically the same diameter in millimetres as
pregnancy.129 GA in completed weeks (eg, 9 mm up to 9 weeks 6 days),
Early SA can be performed by MVA or EVA with similar or 1 mm smaller. Abortion by sharp curettage (D&C) is
success and complication rates.130,131 The relative lack of obsolete,3,147,151,154 and sharp curettage should not be rou-
tissue presents 2 diagnostic challenges. The first is ruling tinely performed in first trimester SA.3,147,149,151,155 Both MVA
out ongoing pregnancy,132–134 which varies from 1.3 per and EVA are safe and effective.3,130,147,151
1000 under 6 weeks of gestation when performed by a
Blood loss is typically minimal,156,157 even in women on an-
skilled provider using routine preoperative and postopera-
ticoagulant therapy.151 There is no evidence that anticoagulants
tive transvaginal ultrasound, direct examination of POC,
need to be stopped for SA prior to 84 days.156 Immediate
and rigorous FU135,136 to 23 per 1000 when multiple pro-
examination of the aspirated uterine contents should be done
viders are involved.137
at the time of the procedure to identify POC.3,147,151
The second diagnostic challenge is excluding EP in the setting
of a PUL, when a yolk sac (and, in some instance, a defi- Cervical dilation prior to first trimester abortion
nite GS) has not been seen. Early SA may provide
confirmation of IUP if villi are identified on tissue exam. Routine cervical priming is not recommended3,41,151,152 because
A PUL, unless intraoperatively confirmed to be an IUP, it adds delay, is associated with side effects, and the base-
should be followed with serial serum β-hCG. A 50% drop line complication rate is very low. However, nulliparous
in levels is expected within 24 hours following successful women with a late first trimester gestation and women with
pregnancy evacuation.128,135–138 uterine anomalies or known cervical stenosis may benefit
from cervical priming.152 Cervical preparation agents include
While some studies suggest slightly higher pain ratings in synthetic osmotic dilators (ODs), laminaria, prostaglan-
early SA,139,140 these can be performed using local anaesthesia. dins (PGE1, PGE2, PGF2α), MIFE, and NO donors. Use
of pharmacological agents requires informed consent owing
Recommendations to the risk of anomalies if pregnancy continues.
13. Early surgical abortion (<7 weeks) should be pro-
vided with routine preoperative and postoperative Three Cochrane reviews,158–160 1 comprehensive review,152
ultrasound, direct examination of products of con- and a few additional RCTs131,161–163 have been published on
ception and β-human chorionic gonadotropin follow- cervical priming prior to first trimester SA. The following
up when products of conception are not identified conclusions were reached:
(Strong recommendation. Level of evidence: Low).
14. For women who cannot or refuse serial β-human cho- • When compared with placebo, cervical dilation was im-
rionic gonadotropin follow-up following early surgical proved when MISO, gemeprost, MIFE, dinoprostone,
abortion, the procedure should be delayed until an carboprost, and NO donor were used.152,158–160
intrauterine pregnancy can be confirmed (Strong rec- • Compared with placebo, MISO significantly reduced
ommendation. Level of evidence: Very low). procedure time and force required for dilation and
blood loss, although side effects such as nausea and/or
First Trimester SA (7 to <14 Weeks) cramping were significantly higher.162,158,159,164 There is a
First trimester SA is one of the most common and safe sur- significant reduction in incomplete abortion as well
gical procedures performed in Canada,1,141 with a risk of (0.78% vs. 2.26%; RR 0.35; 95% CI 0.21–0.58, number
serious complications under 0.2%.1,25,28,142–144 Use of a no touch needed to treat = 68).164
technique and antibiotic prophylaxis reduce the risk of
infection.32,33,36,145 Routine IV access for first trimester SA Based on data from comparative studies, the following con-
is not required,3,146–148 but most providers recommend it. clusions can be made about MISO:

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SOGC CLINICAL PRACTICE GUIDELINE

• MISO 400 µ g is superior to MISO 200 µ g 158,162 or c. laminaria placed intracervically 6–24 hours pre-
gemeprost 1 mg.158 procedure; or
• Vaginal and sublingual routes are superior to oral,158,163 and d. synthetic osmotic dilator placed intracervically 3–4
sublingual are superior to vaginal.158 hours pre-procedure; or
• Effectiveness and side effects of MISO increase with e. mifepristone 200–400 mg orally, 24–48 hours prior
dosage.162 One recent RCT161 did not find differences to procedure.
among oral, vaginal, and sublingual administration of
MISO 400 µg 1.5 to 4 hours pre-procedure; however, Second Trimester SA (≥14 Weeks)
side effects, such as nausea and diarrhea, were signifi- D&E consists of cervical preparation, dilation, and extrac-
cantly more frequent in the sublingual group.161 tion with a combination of aspiration and forceps. It is safe
• There are no comparative studies on buccal MISO for cer- when performed by trained clinicians. Routine cervical prepa-
vical priming in first trimester SA. ration is recommended, as are IV access, no touch technique,
• The most effective timing of MISO is 3–4 hours and rapid access to uterotonics.3 Very high doses of oxy-
vaginally152,158 or 2–3 hours sublingually pre-procedure.158 tocin are required to obtain any significant clinical effect on
uterine tone.165 Direct examination of uterine contents should
With respect to other forms of cervical ripening: take place at the time of the procedure. When compared
with first trimester procedures, second trimester SA is as-
• MIFE 200 mg 24–48 hours orally prior is superior to
sociated with more complications, which increase with
MISO 600 orally or 800 µg vaginally 16–24 hours pre-
advancing GA.163,164,166
procedure without a difference in side effects.158
• Laminaria is superior to PGF2α or Gemeprost 1 mg ad- Does prophylactic vasopressin reduces blood loss in
ministered 3–4 hours pre-procedure; PGF2α is associated second trimester SA?
with unplanned expulsions prior to procedure.158 Two RCTs167,168 assessed the use of vasopressin for second
trimester SA. In 1 RCT,163 vasopressin 4 units in 20 mL of
No difference in initial dilation was observed:
local anaesthetic (n = 181) compared with placebo (n = 156)
significantly reduced blood loss from D&E, without in-
• between MISO 200–400 µg 4 hours pre-procedure and
creasing blood pressure (Level of evidence: Moderate).
overnight laminaria,158 OD,159 or PGF2α 125 µg IM 2 hours
Beyond 15 weeks, vasopressin was associated with a lower
prior to procedure.158
likelihood of blood loss >250 mL.163 A small RCT164 in
• between gemeprost 1 mg and OD inserted 3–4 hours prior
women with a mean GA of 16.8 weeks showed that
to procedure.158
paracervical vasopressin (n = 13) compared with placebo in-
NO donors are inferior to prostaglandins,160 including jection (n = 15) did not result in significant changes in uterine
MISO159 or use of prostaglandin plus NO.156 NO donors pulsatility or blood loss (Level of evidence: High).
are associated with more bleeding and more side Both the National Abortion Federation and the Society of
effects.160 Family Planning clinical guidelines recommend the use of
dilute intracervical vasopressin to reduce blood loss for
Recommendations second trimester SA.3,166 Adverse effects of vasopressin
15. Cervical preparation is not routinely required prior are rare and self-limiting (high blood pressure, bradycar-
to first trimester surgical abortion (Strong recom- dia, etc.).169,170
mendation. Level of evidence: Moderate).
16. Cervical priming before first trimester surgical abor- Summary Statement
tion may be considered in nulliparous women and 6. Intracervical vasopressin may reduce blood loss in
when cervical dilation is expected to be difficult (Weak second trimester surgical abortion (Level of evi-
recommendation. Level of evidence: Very low). dence:
17. The following are recommended cervical prepara- Low).
tion regimens (Strong recommendation. Level of
evidence: High): Recommendation
a. misoprostol 400 µ g vaginally 3 hours pre- 18. Vasopressin 4 units in 20 mL for cervical local an-
procedure; or aesthesia may be considered during second trimester
b. misoprostol 400 µg sublingually, 2–3 hours pre- surgical abortion to reduce blood loss (Strong rec-
procedure; or ommendation. Level of evidence: Low).

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Cervical dilation prior to second trimester SA Recommendation

Laminaria/ODs are routinely used in second trimester 20. For early second trimester surgical abortion, cervi-
SA.62,171,172 They reduce the risk of cervical laceration: from cal preparation can be achieved with laminaria/
14–18 weeks, the risk decreases from 0.8% to 0.4%, and at synthetic osmotic dilators alone or misoprostol 400 µg
18–20 weeks, the risk is reduced from 5% to 1.6%.173,174 A 3–4 hours pre-procedure (Strong recommendation.
GRADE approach was used to answer the following Level of evidence: Moderate).
question: MIFE: Two studies comparing MIFE with other cervical
preparation methods were identified. One RCT179 com-
Should MISO, laminaria/ODs, MIFE, or a combination of pared MIFE 200 mg orally (n = 24) with ODs (n = 25) for
previous options be used prior to second trimester SA? overnight cervical preparation at gestation of 14 to 16 + 6
Early second Trimester SA (Before 17 Weeks) weeks. No difference was shown in procedure time, but
baseline dilation and ease of procedure were significantly
MISO versus laminaria/ODs: Two retrospective case greater when ODs were used. One unintended fetal expul-
studies175,176 and 2 RCTs62,177 compared the use of buccal sion and significantly more pain and diarrhea were
MISO 400 µg or 600 µg, 3–4 hours pre-D&E with the use experienced in the OD group. Women’s satisfaction was
of overnight ODs and showed no difference in procedure higher with MIFE.
time. One RCT61 reported a significantly longer procedure
time with vaginal MISO alone compared with laminaria. Another RCT180 compared oral MIFE 200 mg (36 hours
Three RCTs61,62,177 reported that women using MISO alone before SA) plus oral MISO 400 µg (3 hours prior) with 2
had a lower baseline dilation or required additional dila- groups receiving either MIFE or MISO alone, for gesta-
tion before D&E compared with those using ODs. One tions of 12 + 1 to 14 + 3 weeks. Procedure time was reduced,
RCT63 showed no benefit in procedure time when MISO baseline dilation increased, and intraoperative bleeding was
was added to laminaria. One lower-quality retrospective less in the combined MIFE-MISO group. Rates of hem-
cohort study178 showed that improved baseline dilation when orrhage and side effects were similar in all groups. Ease of
laminaria was added to pre-procedural MISO. procedure and satisfaction were rated higher by physicians
in the MIFE-MISO group. Women’s satisfaction did not
Complication rates were similar between MISO and ODs differ between groups.
(4.02% vs. 3.2%, chi square test; P = 0.63).61–63,176,178 However,
women using MISO reported more pain before D&E,61–63 Summary Statement
more chills61,178 and more diarrhea.177,178 Women using lami- 8. More research is required to state whether use of
naria reported more pain overnight in 1 study.61 mifepristone confers benefit for cervical dilation prior
to early second trimester surgical abortion (Level of
Physicians rated procedures significantly harder when cer- evidence: Very low).
vical preparation was done with MISO alone61,62,177,178
compared with ODs (with or without MISO). Overall sat- Recommendation
isfaction of physicians and women was identical between 21. For early second trimester surgical abortion, mifepristone
groups.62 In 1 study,61 women preferred MISO over over- is not recommended for cervical preparation (Weak
night laminaria because of shorter overall procedure time. recommendation. Level of evidence: Very low).

Summary Statements Later second trimester SA (17–24 weeks)

7. For early second trimester surgical abortion, use of MISO versus laminaria/ODs: Two RCTs compared
buccal/vaginal misoprostol 400 µg 3–4 hours before use of overnight laminaria alone with MISO 400–800 µg
dilation and evacuation: buccally 3–4 hours pre-D&E 177 or 600 µ g vaginally
a. may not achieve as much dilation as osmotic dila- overnight.181 Four RCTs compared use of ODs alone with
tors alone (Level of evidence: Moderate). MISO 400 µg buccally 3 hours pre-D&E plus ODs for 2
b. results in similar complication rates as for osmotic days,64 overnight,63,65 or the same day.66 Another cohort
dilators, but does increase side effects (Level of evi- study 178 compared MISO with MISO plus overnight
dence: Medium). laminaria. Inconsistent effects on procedure time were
c. reduces ease of procedure compared with use of observed,63,64,177,181 although MISO plus overnight ODs
osmotic dilator (Level of evidence: High). reduced procedure time among nulliparous women.65 Most

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studies showed that baseline dilation was higher when MISO preparation was required when MIFE was added to ODs
was added to an ODs regimen.63–65,177,178 and MISO.185 Procedure time was significantly shorter in the
MIFE groups in 2 RCTs.65,182 Baseline dilation and side effects
The addition of MISO to dilators does not decrease were variable across studies.65,182–184 Complications rates re-
complication rates (7.88% vs. 9.02%, chi square test; ported in 2 RCTs65,185 were 3.3% in the MIFE groups versus
P = 0.559).63–66 However, women using MISO reported more 9% in non-MIFE groups (Fisher exact test; P = 0.11). In
pain 3–4 hours before D&E, more analgesic requirement,63–66 1 RCT, 9 unscheduled fetal expulsions before D&E were
and more side effects (nausea, 64,181 chills 64,65,178 and reported, but MIFE was given 48 hours pre-procedure
diarrhea177,178). The risk of unscheduled fetal expulsion oc- (n = 877).182
curred more often when overnight MISO was given.181
Ease of procedure was assessed as identical in both groups
Inconsistent effects on ease of procedure were in 2 RCTs,183,185 while physicians’ satisfaction was higher with
reported.63–65,177,178,181 In 1 study, 25% of women in the MISO MIFE groups in 2 RCTs.65,184 Satisfaction of women was
plus laminaria group versus 6% in the laminaria alone group either equal between groups65,185 or higher in the MIFE
found this abortion worse than a prior second trimester abor- groups.183,184
tion (P = 0.04).64 In 2 other studies, satisfaction of women
was identical between groups.65,66 Summary Statement
10. For late second trimester surgical abortion, use of
Summary Statements mifepristone overnight with osmotic dilators and/
9. For late second trimester surgical abortion, use of buccal or buccal/sublingual/vaginal misoprostol 400 µg 3–4
misoprostol 400 µg 3–4 hours plus laminaria/synthetic hours before dilation and evacuation facilitates cer-
osmotic dilators before dilation and evacuation: vical preparation and decreases procedure time (Level
a. achieves significantly more dilation than osmotic di- of evidence: Low).
lators alone without influencing procedure time
(Level of evidence: Moderate). Recommendation
b. does not decrease severe complications (Level of 23. For late second trimester surgical abortion, use of
evidence: Moderate) compared with use of osmotic mifepristone 200 mg orally overnight is recom-
dilator alone, but may increase side effects such as mended, in addition to osmotic dilators and/or
pain, nausea, chills, and diarrhea (Level of evi- misoprostol 400 µg 3–4 hours pre-procedure (Weak
dence: Low). recommendation. Level of evidence: Low).

Recommendation Second Trimester MA

22. For late second trimester surgical abortion, the use Second trimester medical abortion consists in the use of
of misoprostol 400 µg 3–4 hours pre–dilation and medications that induce fetal expulsion. It may be pre-
evacuation in addition to serial insertions of osmotic ferred to D&E, and indeed offered, when an intact fetus
dilators is recommended but is associated with side is preferred for psychosocial or diagnostic indications. It is
effects (Strong recommendation. Level of evi- commonly performed in a hospital setting as induction may
dence: Moderate). take more than 24 hours. While the regimens discussed may
be considered in the setting of midtrimester fetal demise,
MIFE: Five RCTs using MIFE before late gestation only evidence pertaining to abortion was reviewed. The fol-
D&E were identified. MIFE 200 mg orally was used lowing regimens are inappropriate for midtrimester induction
overnight, 65 or 48 hours pre-procedure, 182 along with where a live birth is desired.
ODs,65 buccal/sublingual/vaginal MISO 400 µg 1.5–6 hours
pre-procedure,182–184 or both.182,185 Comparator groups The World Health Organization–recommended MISO regi-
were overnight OD alone,65,183 serial sets of ODs plus mens are as follows186,187:
buccal MISO 400 µg 90 minutes pre-procedure,185 vaginal/
sublingual MISO 600 µg 1.5–2.5 hours pre-D&E with or • 13–24 weeks: MISO 400 µg vaginal/sublingual/buccal
without ODs,182 or vaginal MISO alone 400-µg 4–6 hours every 3 hours
pre-procedure.184 • 25–28 weeks: MISO 200 µg vaginal/sublingual/buccal
every 4 hours
Procedure time was not different among groups in 3 • >28 weeks: MISO 100 µg vaginal/sublingual/buccal every
RCTs183–185; however, in 1 RCT, 1 less day of cervical 6 hours

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Cervical dilation prior to second trimester MA mononitrate prior to MISO induction compared with no
preparation.203 In a placebo-controlled RCT (100 women),
Since induction requires significant resources, cervical rip- no significant difference was found in time to expulsion.204
ening may decrease time to expulsion and cost. A GRADE Complications rates were similar between groups in both
approach was used to answer the following question: studies.

Should mechanical dilation, ODs, MISO, NO, MIFE, or a MIFE: Four RCTs, comprising 610 women, demon-
combination of previous options be used prior to second strated significant reductions in time to expulsion (−2 to −10
trimester MA? hours) when additional MIFE 200 mg was added to
Mechanical dilation: One retrospective188 and 4 prospec- prostaglandin/oxytocin regimens, with similar rates of ex-
tive cohort studies189–192 examined use of intracervical pulsion and side effects.205–208 In most cases, MIFE was
catheters prior to induction with MISO. When compared administered approximately 24 hours before admission. In
with no preparation, the use of a double-balloon catheter a case series of 999 women, 2 had unintended expulsion
was associated with similar induction-to-expulsion times (21.1 prior to induction (0.2%).209
hours vs. 23.1 hours; P = 0.393).188 When compared with
no cervical preparation, adding an intracervical catheter was Two RCTs (99 women) showed that MIFE reduced time
not associated with a decrease in time to expulsion in 2 to expulsion by 3.5 to 6 hours when compared with lami-
studies,189,190 and a reduced duration in 1 study (7.5 hours naria priming and was associated with less pain.198,210
[combined] vs. 11.76 hours [cervical preparation with MISO]
We identified 9 studies and 1 systematic review comparing
vs. 19.76 hours [catheter]; P < 0.0001).191 Catheter traction
the interval between MIFE and MISO administration for
is superior to no traction.192 In all studies, complication rates
induction.211–219 Simultaneous MIFE and MISO adminis-
were similar among groups.
tration (2 RCTs) was associated with longer MISO-to-
ODs: Seven studies193–199 were identified where ODs were expulsion time by 5.1–5.3 hours when compared with
evaluated prior to second trimester MA. In 3 cohort administration of MIFE 24–36 hours prior to MISO
studies193–195 and 2 RCTs,196,197 laminaria compared with no induction.211,212 In a 3rd RCT, administration of MIFE within
OD yielded limited reduction in time to expulsion. Con- 12 hours of MISO induction resulted in lower likelihood
versely, in 2 cohort studies193,194 and 1 RCT,196 comprising of expulsion within 12 hours, but similar rates at 24 hours.213
151 women, there was an overall increased duration in time Three RCTs and 2 cohort studies (752 women) compared
to expulsion using laminaria with or without MISO versus 1- and 2-day MIFE-MISO intervals, showing either no or
MISO alone (18.1 vs. 15.4 hours; P < 0.001). In 1 time series modest reduction in time to expulsion in the 48 hour-
on 174 women, adding laminaria to MIFE-MISO resulted interval group (less than 2 hours).214–218 In 1 cohort study
in shorter time to expulsion (7.5 hours vs. 12.7 hours; using gemeprost induction, prolonging the MIFE interval
P = 0.001) and time in hospital (3 days vs. 4 days; to 72 hours resulted in longer time to expulsion.219
P < 0.001).195 In an RCT comparing laminaria to MIFE prior
to induction, laminaria was associated with more pain and Summary Statements
longer time to expulsion (10 hours vs. 16 hours; P = 0.01).198 11. For second trimester medical abortion:
Laminaria reduced time to expulsion compared with no a. use of mifepristone 24–48 hours prior to induc-
preparation in 1 RCT where PGE2 was used for induction.199 tion reduces time to expulsion without added side
effects (Level of evidence: High).
MISO: In 1 pilot study comparing 19 women who self- b. mechanical dilation with intracervical catheters
administered MISO 50 µg buccally the evening prior to MISO prior to induction rarely confers benefit (Level of
induction with a historical cohort not receiving such evidence: Low).
preparation,200 median time to expulsion was 33% less when c. laminaria/synthetic osmotic dilators prior to in-
MISO priming was used; however, 3 women experienced duction do not confer any benefit and may increase
nausea and 11 had cramping overnight. No unintended ex- both pain and time to expulsion (Level of evi-
pulsion occurred prior to induction. Two small RCTs dence: Moderate).
comparing oral MISO 400 µg versus placebo or no treatment
prior with MISO201 or gemeprost202 induction reported con- Recommendations
flicting results on time to expulsion. 24. For second trimester medical abortion, use of
NO donors: In an open-label RCT (50 women), time to mifepristone 24–48 hours prior to misoprostol in-
expulsion was reduced by 8 hours with isosorbide duction is recommended (Strong recommendation.

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SOGC CLINICAL PRACTICE GUIDELINE

Level of evidence: High). The specific timing of phy, highly sensitive β-hCG serum testing, and gross
mifepristone should be based on provider and patient examination of POC cost less and can identify tissue,226,227
preference (Weak recommendation. Level of evi- even in very early abortions.135–137
dence: Moderate). Although baseline risk of GTN in women undergoing abor-
25. For second trimester medical abortion, use of mechani- tions is not higher than in the general population (1 in 2699
cal dilation or osmotic dilator prior to induction is not cases in a Canadian study),228,229 women with unidentified
recommended (Strong recommendation. Level of evi- GTN are more likely to have delayed diagnosis and subse-
dence: Low). Mechanical dilation may be considered when quent complications from invasive disease.228 Therefore,
other cervical priming approaches must be avoided (Weak histopathological examination of POC remains important
recommendation. Level of evidence: Low). in cases of abnormal exam or when GTN or EP is
26. For second trimester medical abortion, there is in- suspected.40 Cytogenetics should also be performed when
sufficient evidence to recommend the use of nitric genetic diagnosis is required.
oxide donors or misoprostol priming prior to induc-
tion (Weak recommendation. Level of evidence: Low). Standard POC examination: Immediately following the pro-
cedure, the aspirate is placed in a glass container with a small
Additional Considerations in Late second amount of water, or, if further analysis (eg, chromo-
Trimester IA somes) is needed, saline. Acetic acid may also be used.
Previa: in the setting of PP, SA is preferable to MA as it is Examination is most often performed with backlighting, such
associated with lower blood loss.220 Laminaria can be in- as an X-ray view box placed flat on the countertop. De-
serted as an outpatient in the presence of an asymptomatic cidual tissue is clear, light colored, or reddish brown, and
PP.216 Use of intracervical vasopressin and rapid removal the decidua capsularis is an opaque sheet with hemor-
of the placenta are recommended to reduce hemorrhage and rhagic areas. The GS is thin, transparent, and can be
perforation. fragmented. Chorionic villi are transparent frond-like pro-
jections that appear fluffy or feathery.138,230 When blood and
Recommendation clots impede visualization, the tissue should be rinsed until
27. In the presence of placenta praevia, intracervical va- good visualization is possible.
sopressin, ultrasound guidance, and rapid removal of
Prior to 7 weeks, confirmation of completion requires vi-
the placenta are recommended. Expert backup is
sualization of both sac and villi.128 POC volume or weight
advised in case of significant bleeding (Strong rec-
poorly correlates with GA.132,231 A GS, decidua, chorionic
ommendation. Level of evidence: Very low).
villi, and small fetal parts can be seen by 9 weeks of ges-
Fetal anomalies: In cases of fetal anomalies, a stillbirth is not tation. In the second trimester, major fetal parts including
guaranteed unless feticide takes place, therefore; neonatal pal- the calvarium, pelvis, spine, 4 extremities, and adequate pla-
liative care should be offered prior to induction.221 To aid with cental tissue for gestational age must be visualized to confirm
grieving, many facilities have implemented measures to help completion of the procedure.147,232 If a discrepancy occurs
women and families.222 These include mementos such as between POC examination and pre-procedure GA, foot
footprints, ultrasound pictures, and identification bracelets, length should be used for fetal dating.138,233–235
which can be provided whether the woman chooses SA or MA.
Abnormal exam: When examination is inconsistent with
Stillbirths: In Canada, a stillbirth occurs after expulsion preoperative assessment, retained POC must be ruled out,
of a fetus greater than 20 weeks or 500 g. Some consider and imaging or reaspiration is mandated. If possible, ultra-
that “The process for the registration and reporting of thera- sound guidance should be used for reaspiration.
peutic abortions should be separate from that for In early pregnancies or PULs when POC examination is in-
spontaneous fetal deaths.” 223 In all jurisdictions, any still- conclusive, serial β-hCG measurements should be used to
birth must be reported to Vital Statistics, recorded by a rule out ongoing or ectopic pregnancy.
Certificate of Death, and be disposed of appropriately
(cremated or buried). Hydropic villosities are associated with GTN or aneu-
ploidy. In these cases, the specimen should be sent for
Histopathology histological analysis, and proper FU arranged. Women with
Routine histopathological examination has been histori- persistent bleeding or who have not resumed their periods
cally recommended for the detection of GTN, aneuploidy, within 8 weeks must also be reassessed for ongoing
and confirmation of an IUP.224,225 Currently, ultrasonogra- pregnancy or GTN.

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Recommendations postpartum depression, or premenstrual dysphoria.242,243

Women terminating a wanted pregnancy because of fetal
28. Routine gross examination of uterine contents should anomaly may benefit from short-term grief counselling.
be performed immediately after induced abortion
(Strong recommendation. Level of evidence: Very low).
Immediate Complications
29. Histopathological examination of products of con-
Complications of surgical abortion
ception must be performed when gestational
trophoblastic neoplasia or ectopic pregnancy is sus- Failed attempted abortion: Failed attempted abortion is
pected (Strong recommendation. Level of evidence: rare (0.15%).244 If a failed attempt occurs before disrup-
Very low). tion of the pregnancy (patient is stable and not bleeding),
a repeat attempt should be planned after pre-treatment with
MISO, MIFE, or ODs.245,246
POST-ABORTION CARE
If dilation becomes difficult and the pregnancy has been
Following SA, patients must be continuously observed until
disrupted or there is bleeding (or another reason that im-
discharge criteria (Aldrete score236) are met, which varies by
mediate completion is necessary), os finders, and ultrasound-
procedure and anaesthetic. Women should receive written
guided insertion of rigid dilators may be helpful. For more
information including normal findings, self-care, and warning
advanced gestations, simultaneous insertion of more than
signs of complications (Table 4). A 24/7 emergency number
1 large rigid dilator may allow passage of D&E forceps to
should be provided to the patient.
facilitate tissue extraction. Many providers employ ovum
Following IA, most women feel normal emotionally and forceps when there is inadequate dilation for second tri-
physically. Urine pregnancy tests may remain positive up to mester procedures at the expense of increased passes.
60 days,237,238 and are not recommended as part of FU. Preg-
nancy symptoms generally subside within 24–48 hours,239 In cases of marked obesity, hip flexion, increased uterine
and the uterus involutes rapidly. Bleeding is variable but is traction, use of Moore-Graves vaginal speculum, lateral re-
usually less than menstrual flow. While some women ex- tractors, steel cannula extender, and long forceps may help.
perience no bleeding, bleeding and cramping may transiently When there is uterine anomaly, a markedly anteflexed or ret-
increase 4–10 days after the procedure, and, if self-limiting, roflexed uterine body, or a tortuous cervical canal, use of
does not indicate a complication.239 By 2–3 weeks, most flexible cannula may be useful. Flexible hysteroscopy has
women have stopped bleeding. Unscheduled bleeding may also been utilized to enter the uterine cavity. MA may need
persist due to initiation of contraception. Like bleeding, to be considered to complete the termination.
cramping can be variable and is likely attributed to uterine Hemorrhage: Hemorrhage at the time of abortion is in-
involution.239 Cramping may occur with or without bleed- consistently defined and includes >250 mL, >500 mL,
ing and is generally relieved with NSAIDs. Routine hemodynamic instability, or requiring transfusion.166 In the
prescribing of opioids is inappropriate. United States, between 2011 and 2013, the Centers for Dis-
In many studies, the dominant emotional reaction after IA eases Control and Prevention reported 6 deaths among
is relief,240,241 including after second trimester, although data abortion patients related to hemorrhage. Of these, 3 were
are limited.234,235,240,241 Because some women experience mood related to perforation/cervical laceration, 2 to atony, and 1
symptoms following any pregnancy outcome, clinicians was unspecified.144
should be attentive to women with pre-existing mental illness,
Risk factors for hemorrhage at the time of abortion can be
classified as166:
Table 4. Warning signs of complications following IA
• Moderate risk: 2 or more CSs, PP following previous CS,
Symptoms Severe pain not controlled by analgesics
Feeling sick with flu-like symptoms (weakness/ bleeding disorder, history of postpartum hemorrhage
faintness, nausea, vomiting, diarrhea) not requiring transfusion, GA beyond 20 weeks, large
Continuing symptoms of pregnancy fibroids, obesity.
Depressive symptoms and suicidal ideation
• High risk: suspicion of abnormal placentation, history of
Signs Soaking 2 maxipads per hour for 2 consecutive hours
Severe pain not reduced by common analgesics
postpartum hemorrhage requiring transfusion, clinician
Orthostatic symptoms: lightheadedness, fainting concern.
Fever more than 38°C lasting more than 6 hours
Abnormal foul-smelling vaginal discharge When determining causes of hemorrhage, the “Four Ts”
Absence of menstruations for 8 weeks after IA
(Tone, Trauma, Tissue, Thrombin) still apply, with atony

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SOGC CLINICAL PRACTICE GUIDELINE

Table 5. Management of hemorrhage at the time of A low threshold for reaspiration should be maintained as
abortion retained POC can cause brisk bleeding, and aspiration en-
Steps: Re-evaluate at
courages compression of the placental bed (Table 5). If there
each step and determine is suspicion of a high cervical laceration or perforation, trans-
next best step Actions fer should be arranged. Embolization by interventional
1 – Identify risk factors Determine if preoperative planning is radiology, if available, is preferred. If unavailable, laparos-
needed or if patient is suitable for copy or laparotomy may be required.
facility.
2 – Recognize bleeding Establish IV access and start IV fluids;
and ask for help consider complete blood count and
Uterine Perforation: The risk of UP with SA is around
group, crossmatch, coagulation 1–4 in 1000 cases,29,151 most commonly occurring during di-
profile, and screen. lation for first trimester SA and with forceps evacuation in
If unstable, CALL CODE or PREPARE second trimester SA. The risk increases with uterine anoma-
FOR A TRANSFER.
Obtain medications: lies, marked uterine flexion, cervical stenosis, inadequate
• MISO 200 to 600 µg cervical, difficult or prolonged uterine evacuation, or less
sublingual/buccal/rectal × 1 experienced providers.246,249 For advanced gestations or when
• Methylergonovine 0.25 mg IM
q2h – DO NOT ADMINISTER IV
the cervix is stenotic, cervical preparation decreases the risk
• PGF2α 0.25 mg IM or intracervical × 8 of cervical trauma and perforation compared with me-
• Oxytocin 20–40 units in 250–500 mL chanical dilatation alone.250 In 2 retrospective analyses,
IV if GA over 16 weeks
If under GAn: notify anaesthetist and
underestimation of the duration of pregnancy, inadequate
reduce inhaled anaesthetics. cervical dilation, and failure to use ultrasound during the
3 – Palpation Apply direct pressure to uterus with procedure were associated with UP.22,251
sponge stick/hand and fundal
pressure. In practice, UP often is often unrecognized and does not
4 – Inspection To explore the source of bleeding, need further intervention.147 Special management (Table 6)
perform “cannula” test: insert cannula
should be considered if any of the following occurs:
to fundus and slowly withdraw until
brisk bleeding ensues. If bleeding is
coming from the cervix, consider • woman experiences sudden pain during the procedure
urgent embolization or laparotomy.
If external laceration, repair under local • instruments pass without resistance further than expected
anaesthesia. • contact with the gritty surface of the endometrium lost
5 – Retained POC Re-examine tissue – re-image • fat or bowel brought down with the suction or identi-
ultrasound – reaspirate fied on gross examination
6 – Intervention Intrauterine balloon tamponade • bleeding in excess of what is expected,
Emergent referral to gynaecology • persistent post-procedural pain especially if lateralized or
(if needed)
Laparoscopy if perforation suspected associated with rebound tenderness
Laparotomy if unstable • suspicion of a possible lateral perforation
Adapted from Hamilton Health Sciences Protocol with permission.248
• unstable vital signs present following completion of the
procedure
• missing fetal parts following D&E when uterus feels empty
247
being most common in the second trimester. Procedure-
Cervical trauma: In the second trimester, cervical lacera-
specific causes include perforation, cervical laceration,
tion occurs in approximately % to 2% of SAs173 and is a
retained POC and atony, and less commonly, abnormal pla-
potentially severe complication. Risk increases with increas-
centation, arteriovenous malformation, and DIC.
ing GA, history of cervical surgery (eg, conization), and
Each facility should have a hemorrhage protocol (eg, Table 5), cervical/uterine abnormalities. Cervical preparation reduces
access to resuscitation medications, and a transfer proto- the risk of laceration, particularly at 18+ weeks.173 Super-
col if out of hospital. ficial laceration related to tenaculum use and application of
local anaesthetic is normal during an abortion and can be
Bleeding from the tenaculum site responds well to direct observed. Persistent tenaculum site or injection site bleed-
compression. If there is increased bleeding from the uterus, ing is most easily rectified by applying pressure or
direct bimanual compression, compression with a sponge compression with a sponge stick or a ring forceps. If a lac-
on a stick with fundal counterpressure, or intrauterine tam- eration is bleeding, or is large (>1 cm), it should be repaired
ponade (catheter) will improve tone and reduce bleeding. with an absorbable suture.

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Table 6. Management of suspected uterine perforation3,245,252

Stop the procedure immediately; evaluate and reassess the patient.
If vital signs are not stable, IV fluids should be started.
Evaluate with ultrasound or laparoscopy.
Prepare for a transfer to hospital if necessary.
If the uterine perforation occurs and the pregnancy is disrupted Complete the procedure under laparoscopic guidance as soon as
possible in order to evaluate visceral injury, to assess bowel
integrity, and ensure internal bleeding is controlled.
If the uterine perforation occurs and the pregnancy is not disrupted Complete the procedure with either ultrasound or laparoscopic
and the patient is stable with no signs of hemorrhage or injury guidance, either immediately or after a 1–2 week-delay to allow for
uterine healing.
If the procedure is thought to be complete when uterine perforation Evaluate the patient:
is suspected • If there are stable vital signs, no sign of visceral injury, minimal
bleeding (<200 mL): close observation.
• Uterotonics and antibiotics may be considered.
• In select cases where patient is stable after 2–4 hours: patient may
be discharged with close FU plans and instructions to seek
emergent care if they develop concerning symptoms.
If bowel or omentum is visualized at the cervix or brought into the Leave tissue in situ to identify and repair of bowel as well as the
uterine cavity uterus. These patients must be evaluated by laparoscopy or
laparotomy and may require surgical consult.
If there is suspicion of a lateral perforation Transvaginal ultrasound and/or laparoscopic evaluation should be
performed owing to the risk of retroperitoneal bleeding

While external lacerations are largely benign, internal ones fatal, occurring in 1 in 8000 to 1 in 80 000 pregnancies.258
are more serious as they can result in significant bleeding. DIC often manifests after a few hours: in a case series of
Visible lacerations can be repaired vaginally when pos- 24 women with idiopathic DIC, the mean time to presen-
sible; higher cervical tears may require urgent embolization tation was 153 minutes following D&E.257 The clinician may
or laparoscopy. Cervical laceration can be diagnosed in part be alerted to DIC in the setting of ongoing oozing despite
using a cannula test (Table 5). adequate management, blood that does not clot in a basin,
or a significant decrease in hemoglobin compared with
Repeat aspiration: A systematic review of 36 studies re- pre-procedure.
ported that ≤3.0% of SAs required repeat immediate or
delayed aspiration.253 Reaspiration is indicated for ongoing Management consists of inpatient correction of hypovo-
pregnancy, retained POC, hemorrhage, and hematometra.128,254 lemia, factor replacement, typically fresh frozen plasma,
and treatment of underlying cause. Platelets should be
Hematometra is the result of an accumulation of blood in replaced only if there is significant thrombocytopenia.
the endometrial cavity that the uterus is unable to expel. The benefit of recombinant factor VII must be weighed
Women present with increasing pelvic pain (some women against the lack of evidence, the high risk of thrombosis,
report deep pressure or rectal pain), absent or decreased and cost.245
vaginal bleeding, and, at times, hemodynamic compro-
mise. This may develop immediately after abortion or Other
insidiously over 2–3 days. It occurs at a rate of 2 per 1000
SAs245 and may be treated with repeat aspiration.245,255 Seizure: If a seizure occurs during SA, the abortion should
be discontinued.259 Initial treatment includes maintaining the
DIC: DIC results from activation of clotting and fibrino- patient’s airway, monitoring vital signs, administering IV
lytic systems and leads to hemorrhage, end-organ ischemia/ fluids, and oxygen.245,259 The majority of seizures will resolve
necrosis, hypotension, and microangiopathic hemolysis.256 spontaneously.245,259 Treatment options for seizure lasting
It is rare, affecting about 0.2% of second trimester greater than 5 minutes or repetitive seizures include IM
abortions.257 Risk factors include advanced GA, intrauter- midazolam 10 mg single dose if no IV access, IV midazolam
ine fetal demise (particularly if remote), previous abruption, 2–5 mg, or IV diazepam 0.15–0.2 mg/kg/dose to a
abnormal placentation, amniotic fluid embolization, and maximum of 10 mg/dose and may repeat dose once.260
blood transfusion.145,256 Amniotic fluid embolism is rare but Transfer to the nearest hospital should be done if SA was
often performed in an outpatient setting.259

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Asthma exacerbation: Approximately 8% of women Recommendation

seeking IA report current use of asthma medication.245
Women with well-controlled asthma can undergo usual SA 19. The use of misoprostol for second trimester medical
but should be advised to use their asthma medication the abortion is safe after 1 prior low-transverse Caesar-
day of the procedure and to bring their inhalers.259 A delay ean section. There is insufficient evidence regarding
in the procedure may be considered if a woman’s asthma its use in women with 2 or more prior Caesarean sec-
symptoms require continuous steroid therapy or if she has tions or a prior classical Caesarean section (Weak
current acute symptoms, frequent exacerbations, or a recent recommendation. Level of evidence: Very low).
attack requiring medical treatment.245 If an asthma exacer- Severe bleeding: In women undergoing MA, the inci-
bation occurs (mostly in relation to NSAID sensitivity), dence of hemorrhage requiring transfusion is between
observation in a monitored setting and oxygen administra- 0.7% and 3.0%. 209,292–294 One recent study reported a
tion to maintain oxygen saturation of at least 90% must be higher incidence of blood transfusion of 6% in 2008/
done.245,261 If there is no response, consider oral systemic 2010 and 4% in 2014.295 Retained POC is the most common
corticosteroids,261,262 and organize transfer to the nearest cause.166 MIFE-MISO might be associated with less blood
hospital. loss.166 Comparative studies of second trimester MA versus
SA found either less severe bleeding with SA294,296 or no
Vasovagal syncope: A vasovagal reaction can be precipi- difference.293,296,297
tated by stress, pain, venipuncture, PCB, or cervical dilation.245
The woman may experience hypotension and, rarely, Late Complications
bradycardia.245 She should remain supine with legs el- Infection
evated. All instruments should be removed from the vagina The incidence of infection requiring antibiotics after first
and cervix. Most episodes resolve without treatment.245 For and second trimester SA has been reported to be 0.01% to
prolonged or severe incidents, consider treatment with at- 2.44% and 0.8% to 1.6%, respectively.36 Rates are more dif-
ropine 0.5 mg IV in addition to hydration, antiemetics, and ficult to measure with second trimester MA due to
airway support.245 prostaglandin-induced pyrexia.36 Some report that the dif-
ference in infection rate is not significative between second
Recommendations trimester SA and MA,296 while others find it higher for second
30. Each facility where abortions are performed should trimester MA.36 Typical symptoms of infection start within
have easily available written emergency protocols a few days and include fever (≥38°C), chills, increased pelvic
(Strong recommendation. Level of evidence: Very low). pain, and foul-smelling discharge or prolonged bleeding.
31. Every facility where abortions are performed should Findings also include uterine tenderness and possibly an el-
engage in regular emergency drills (Strong recom- evated white blood cell count. Treatment includes broad-
mendation. Level of evidence: Very low). spectrum antibiotics and antipyretics and, in case of severe
infection, hospitalization, debridement, and IV antibiotics.
Retained POC should be aspirated to eliminate a nidus of
Complications of second trimester MA infection.40,41,245 There is no evidence that abstaining from
Uterine rupture: Uterine rupture is a rare complication of sexual intercourse after SA or MA reduces post-abortion
labour induction.263,264 It was reported with scarred and infection.
unscarred uterus and with urea/PGF2α,265 oxytocin,266
MISO,267–272 and MIFE-MISO.273,274 Retained products of conception
Symptoms of retained POC commonly include vaginal bleed-
The incidence of rupture with the use MISO was 0.4% (2 ing, abdominal pain, and signs of infection.41 Routine
of 461) with 1 prior low-transverse CS, 0% (0 of 46) with ultrasonography following IA to exclude retained prod-
2 prior low-transverse CS, and 50% (1 of 2) with a prior ucts is not recommended. Appropriate treatment includes
classical CS in 1 review,275 and it was 0.28% (2 of 722) in vacuum aspiration or MISO.41
women with a prior CS in another review,276 compared with
0.04% (1 of 2834) in women without a prior CS.276 In 1 pro- First trimester SA: Retained POC is uncommon (0.7% to
spective study277 and several retrospective studies and case 4%) following vacuum aspiration by a skilled provider.41,128
series,278–291 uterine rupture was observed with scarred uterus Sharp curettage does not decrease the risk of retained POC.41
in some studies283,285–287,290 and not in others.277–282,284,288,289 Inspection of the POC immediately after SA is recom-
Uterine rupture happened at any GA, with any MISO dosage, mended, and, if incomplete, imaging and reaspiration are
and, in some cases, with oxytocin.291 indicated.3,41

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Second trimester IA: Retained POC are more common Recommendation

following second trimester MA than SA. In 1 RCT on 18
women,250 4 of 9 women in the MA group required a vacuum 35. Women referred for abortion from a fetal diagnosis
aspiration: 3 for retained placenta and 1 for delayed pre- clinic should be offered follow-up to review any ad-
sentation of retained POC. One case series of D&E between ditional information obtained from the abortion and
13 and 26 weeks173 and another case series with MIFE- provide support (Strong recommendation. Level of
MISO between 13 and 21 weeks209 showed retained POC evidence: Low).
in 0.3% of D&E versus 7% of MIFE-MISO MA. The initial
method failed in 0.2% of D&E versus 3% of MIFE- Future Reproductive Outcomes
MISO MA at 24 hours and 1% at 36 hours.209 Experts Many studies on long-term sequelae of SA are either case-
recommend that, for second trimester MA, 4 hours should control or retrospective cohort studies where choice of
be allowed following fetal expulsion for the expulsion of the control groups is critical. Ideally, controls should be re-
placenta if the woman is stable. If bleeding is heavy or if cruited from the same population as cases or exposed women
the placenta does not deliver, vacuum aspiration with a large and have had a IA in the most recent pregnancy.300
cannula (14–16 mm) can be used. If the placenta is sitting
in the cervix, attempt extraction with sponge forceps. Im-
mediate inspection of the placenta is always necessary. Asherman syndrome
Asherman syndrome (intrauterine adhesions) is a rare com-
plication linked to direct and/or indirect trauma of the
Failed abortion and continuing pregnancy endometrium, and it can occur following delivery, miscar-
SA includes a 0.1% risk of failure.128 A study of 33 090 SAs riage, or SA.301–305 Gentle surgical techniques, use of vacuum
using suction curettage up to 12 weeks reported a 0.23% aspiration (MVA or EVA), and limiting sharp curettage are
failure rate.133 The risk was increased with SA performed advised.41,151,306 Adhesion formation in the presence of re-
prior to 6 weeks of gestation, in multiparous women, and tained POC may be more likely after CS than after SA or
women with uterine anomalies.128 Failed abortion is usually vaginal birth; curettage postpartum may lead to the most
recognized by immediate POC examination.12 In case of an severe adhesions.303,305 Management of the adhesions (hys-
ongoing pregnancy, women might fail to have a period within teroscopic resection) has a reasonable success rate to restore
4–8 weeks after abortion and complain of continuing symp- fertility when desired.303,305,307–310
toms and signs of pregnancy. A uterine evacuation procedure
should be offered.41
Subfertility
Recommendation Studies on the risk of subsequent fertility impairment are
32. If women fail to have a period within 8 weeks fol- limited to small cohort studies, case-control studies and case
lowing induced abortion and/or complain of reports, many of which employing outdated techniques.311–322
continuing symptoms and signs of pregnancy, a new Reviews do not find evidence of association between
or ongoing pregnancy should be suspected and repeat SA and subsequent subfertility, but highlight methodologic
procedure offered (Strong recommendation. Level of problems and call for high-quality large prospective
evidence: Very low). cohort studies.315,317 Two notable, but rare, exceptions relate
to: (1) midtrimester SA complicated by a retained fetal
bone fragment; and (2) SA complicated by intrauterine
Follow-Up
adhesions.310,313,315,323,324
Routine FU after IA is not required but may be recom-
mended to confirm complete abortion, discuss or reinforce
contraception, and diagnose complications.298 Women who Ectopic pregnancy
are referred for abortion following a diagnosis of fetal Most large case-control studies with adequate control groups
anomaly should be offered a follow-up appointment once and control of confounding factors have found no asso-
the abortion is complete. A systematic review concluded ciation between 1 or more SAs and further risk of EP.325–334
that routine FU after SA is unnecessary when examination Significant associations between SA and subsequent EP were
of POC confirms a complete abortion and contraceptive observed in studies with small numbers of EP cases, those
needs have been met.299 All women should be informed that failed to control for important risk factors or chose in-
about signs and symptoms (Table 4) that should trigger a adequate control groups, and those conducted in countries
visit, and those who wish to have FU care should be where abortion was illegal and complicated by infection or
offered an appointment. retained POC.311,332,335–338

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SOGC CLINICAL PRACTICE GUIDELINE

Miscarriage LBW.339,345,359,363,365,373,376,379,380,386,388–390 However, a 2009

The majority of large case-control or retrospective cohort meta-analysis368 found a slight increased risk of subse-
studies with adequate control groups and control of quent LBW following IA (OR 1.35; 95% CI 1.20–1.52)
confounding factors confirmed no association between 1 but no increased risk of SGA. LBW risk increased with
or more induced SAs and the risk of miscarriage in a sub- the number of IAs.368 One review article332 found no sig-
sequent pregnancy.332,338–346 A dose-response effect was not nificant increased risk of LBW in the pregnancy after IA
demonstrated.339,343,345,347 However, 1 large cohort study346 via vacuum aspiration, but did find an increase association
showed an increased risk of miscarriage when women with second trimester SA. In addition, significant associa-
became pregnant within again less than 3 months of a first tions between IA and subsequent LBW infants were
trimester IA (OR 4.06; 95% CI 1.98–8.31) regardless of observed in 3 studies that failed to distinguish MA versus
abortion method. Significant associations between induced SA, chose inadequate control groups, or failed to control
SA and subsequent miscarriage were observed in studies that for important risk factors.391–393
failed to control for important risk factors or chose inad-
equate control groups.332,347,348 In addition, an association Summary Statements
between miscarriage and IA via dilation and sharp curet- 13. An abundant amount of evidence provides reassur-
tage has been described.332 ance concerning future reproductive outcomes
following induced abortion (Level of evidence: Low).
Placenta previa 14. Sharp curettage during induced abortion appears as-
Most large case-control or retrospective cohort studies with sociated with the development of uterine adhesions,
adequate control groups and control of confounding factors risk of miscarriage, placenta previa, and subfertility
confirm absence of association between 1 or more SAs and (Level of evidence: Low).
subsequent abnormal placentation, especially PP.171,349–360
Similar findings are reported in women obtaining MA.360–362 Recommendation
Significant associations between induced SA and placental
33. Sharp curettage is not recommended in replace-
abnormalities were observed in studies with small samples,
ment for vacuum aspiration (Strong recommendation.
inadequate control for risk factors or inadequate control
Level of evidence: Low), nor should routine sharp
groups, and those that were conducted in countries where
curettage be performed during induced abortion
abortion was illegal, complicated by infection or per-
(Weak recommendation. Level of evidence: Low).
formed with sharp curettage.338,358,363–367 With respect to causal
relationship, sharp curettage may result in uterine scarring
and subsequent faulty placentation. Contraception Post-Abortion
Ovulation can occur as early as 8–10 days after an abor-
Preterm birth tion, with a mean between 21 and 29 days after SA.394–397
Two meta-analyses368,369 and several large case-control or ret- More than 80% of women ovulate within 1 month of IA,
rospective cohort studies with various control groups and with estrogen and progesterone levels returning to near
control of some confounding factors found an associa- normal levels within 1 week.394,397 Thus, if contraception is
tion between 1 or more surgical IAs and an increased risk desired, it should be initiated promptly. Moderate-quality evi-
of subsequent PTB.317,332,338,370–378 PTB risk increased with dence indicates that same-day access to contraception and
the number of previous surgical SAs.368,369,371–374 However, abortion leads to fewer subsequent abortions and births at
several cohort studies with adequate control groups and 12 to 24 months and is associated with an increased likeli-
control for important confounders,327,379–383 as well as several hood of using a highly effective method.398–400
smaller studies with various methodological flaws,359,365,384–387
did not demonstrate an association between 1 or more Intrauterine contraception
induced SAs and the risk of PTB in the next further In the absence of method contraindications401–403 or com-
pregnancy. Many studies did not differentiate between plications of IA, immediate insertion of a levonorgestrel
spontaneous and induced PTB, which may confound the intrauterine system or a copper IUD may be performed.
results.316 Moderate-level evidence indicates that immediate
IUCD insertion post SA is safe45,400,404,405 and does not
Low birth weight carry an increased risk of perforation, infection, or
The majority of well-designed case-control or retrospec- discontinuation.45,405–408 Expulsion rates may be higher for
tive cohort studies reported no association between 1 immediate insertion compared with delayed insertion, but
or more surgical IAs and risk of subsequent not all studies found the difference to be significant.45,400,404,409

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An increase in expulsion rate was noted when insertion oc- should be used until initiation of the method and for the
curred after second trimester SA compared with first first 48 hours of POP use or first 7 days following DMPA
trimester SA,45,48,404–407 but the difference was not signifi- administration.
cant in all studies and should not preclude immediate IUCD
placement immediately after a second trimester IA. Other reversible contraceptives methods
Condoms and spermicides can be used as soon as inter-
RCTs have demonstrated that immediate IUCD place-
course resumes.416,417 There is no optimal timing for use of
ment at time of both trimester SA is associated with higher
the cervical cap or diaphragm after SA; it is suggested that
IUCD use at 6 months45,48,49 and statistically significant re-
the diaphragm and cap should not be used until 6 weeks
ductions in repeat pregnancies compared with delayed
after a second trimester IA.403 Natural family planning
placement,48,49,399,410 likely due to lower likelihood of women
methods should not be used until menstrual cycles have
returning for interval insertion.48,49,399,410 One prospective
resumed. Women who have had a failure of their contra-
cohort study411 and 1 RCT408 demonstrated a significant de-
ceptive method, who are relying on less effective methods,
crease in repeat abortions at 24 months after IUCD insertion
or who have difficulty with adherence should also be coun-
compared with initiation of other contraceptive methods
selled about the use of EC.417 Advance provision of EC is
(6.5% vs. 14.5%; P < 0.001)411 or oral contraceptives (1.4%
safe, increases the likelihood of EC use,418 and should be
vs 5.6%; P = 0.003).408
considered for all post-abortion patients.419
No backup contraception is required if the IUCD is in-
serted immediately. If initiation is delayed more than 7 days Permanent contraception
post-abortion, backup or abstinence is required for 7 days Tubal ligation can safely be performed laparoscopically at
after levonorgestrel intrauterine system insertion (no backup the time of first and second trimester SA.420–422 The risk of
is required following copper IUD insertion).402 pregnancy following immediate tubal ligation is lower com-
pared with women who delay their procedure.421
Hormonal contraception
In the absence of contraindications, hormonal contracep- Recommendation
tion can be initiated immediately after IA.403 34. Contraception should be started as soon as pos-
sible after the abortion (Strong recommendation. Level
CHC: CHC (COC, patch, and ring) can be initiated imme- of evidence: High).
diately after first trimester SA.402,403 Although evidence is
available, CHC may be started after a second trimester IA
once completed. Immediate COC start after SA is not as- CONCLUSION
sociated with an increase in vaginal bleeding, side effects, One third of Canadian women will undergo abortion in their
or clinically significant changes in coagulation parameters lifetime, and IA is among the commonly performed pro-
compared with delayed initiation or other non-hormonal con- cedures in Canada and globally. While IA is very safe,
traceptive methods. 412,413 Limited evidence on vaginal evidence-based best practices are associated with fewer com-
contraceptive ring used immediately post first trimester IA plications, improved ease, and increased satisfaction for
has demonstrated no increase in infection or other adverse patients and providers.
events at 3 months.414 One RCT of immediate contracep-
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