Safety The overall annual risk of death with legal abortion decreased markedly, from 4.1 per 100,000 in 1972 to 1.8 in 1976, and remained less than 1 per 100,000 since 1987. Risk of death with vacuum curettage was 0.1 per 100,000 at or before 8 weeks in 1993 to 1997 and 0.2 per 100,000 at 9 to 10 weeks (320). Risk increases exponentially with gestational age, reaching 2.7 per 100,000 for dilatation evacuation abortion at 16 to 20 weeks and 7.2 per 100,000 at 21 weeks or more. The maternal mortality rate in the United States is 12.7 per 100,000 (321); hence, abortion by dilation and evacuation (D&E) through 20 weeks’ gestation is safer than continuing pregnancy. It was estimated that 87% of the legal abortion deaths occurring after 8 weeks would have been prevented had the woman been able get abortion services by 8 weeks (322).
For individual women with high-risk conditions (e.g., cyanotic heart disease), even late abortion is a safer alternative to birth. Because of the availability of low-cost, out-of-hospital, first-trimester abortion, 88% of legal abortions are performed during the first trimester (before 13 weeks of amenorrhea), when abortion is the safest.
Vacuum Curettage Most first-trimester abortions are performed by vacuum curettage. Most are performed with local anesthesia with or without conscious sedation, and usually on an outpatient basis in a freestanding specialty clinic or doctor’s office (323). Cervical dilatation is accomplished with metal dilators, or by laminaria tents or misoprostol, 400 μg, given vaginally or by the buccal route 3 to 4 hours before the procedure (324). A plastic vacuum cannula of 5-to 12-mm diameter is used with a manual vacuum source or an electric vacuum pump. Manual vacuum provided by a modified 50-mL syringe is as effective as the electric pump through 10 menstrual weeks (325). Doxycycline is given to prevent infection and has proven effective (326). Complications of a large number of vacuum curettage procedures before 14 weeks of gestation from Planned Parenthood of New York City are presented in Table 10.10. Mild infection not requiring hospitalization and retained tissue or clot requiring resuctioning in the clinic were the most common complications. Somewhat less than 1% experienced any complications, and less than 1 per 1,000
Table 10.10 Complications of 170,000 First-Trimester Abortions aCausing amenorrhea. bAfter local anesthesia. cRequiring hospitalization.dTwo or more days of fever 40◦C or higher. eIntrauterine and tubal pregnancy. Adapted from Hakim-Elahi E, Tovel HM, Burnhill HM, et al. Complications of first trimester abortion: a report of 170,000 cases. Obstet Gynecol 1990:76:129–135.
were hospitalized (327). More extensive descriptions of the management of complications are published elsewhere (328,329).