Surgical or medical abortion of pregnancies between 13⁺⁰and 23⁺⁶weeks’ gestation? A systematic review and new NICE national guidelines

Abstract

BackgroundAbortion in the second trimester may be performed surgically or medically. The objective of this systematic review was to examine the effectiveness, safety and acceptability/satisfaction of surgical compared with medical abortion of pregnancy between 13+0 and 23+6 weeks’ gestation for a new national guideline.MethodsWe searched Embase, Medline and the Cochrane Library on 4 March 2019. We included randomised controlled trials (RCTs; any size) and non-randomised comparative studies with n≥100 in each arm, published in English from 1985. Risk-of-bias was assessed using the Cochrane Collaboration checklist for RCTs. Meta-analysis of risk ratios (RRs)used the Mantel-Haenszel method. The quality of the evidence was assessed using GRADE.ResultsTwo RCTs (n=140) were included. ‘Incomplete abortion requiring surgical intervention’ was clinically significantly higher with medical than surgical methods (RR=4.58, 95% CI 1.07 to 19.64). ‘Abortion completed by the intended method’ was statistically, but not clinically, significantly lower after medical than surgical methods, but was marked by high between-study heterogeneity (RR=0.88, 95% CI 0.79 to 0.98). To the extent that ‘haemorrhage requiring transfusion/≥500 mL blood loss’, ‘uterine injury’, ‘cervical injury requiring repair’ and ‘infection reported within 1 month of abortion’ were reported, they did not differ significantly between methods. Depending on measurement method, ‘patient satisfaction/acceptability’ was either clinically significantly higher or comparable after surgical than medical methods. The quality of this evidence was limited by low event rates and attrition bias.ConclusionBased on this evidence and consensus, women should be offered the choice of medical or surgical methods of abortion between 13+0 and 23+6 weeks’ gestation, unless not clinically appropriate.

A more accurate approach to define abortion cohorts using linked administrative data: an application to Ontario, Canada

“…When local legal and practice regulations evolve to allow medication abortion provision outside hospital settings, selection or continuation of hospital-based surveillance will underestimate the number of abortions, overestimate the proportion of surgical abortions, and will systematically capture more complex abortion cases occurring at later gestational ages. This type of selection process has previously been demonstrated to induce selection bias [27,28]; hospitalonly abortion surveillance will overestimate the frequency of second trimester and surgical abortion (relative to first trimester medication abortion) and will overestimate the risk of abortion complications [29][30][31][32][33][34][35][36][37].…”

Abortion Care Beyond 13 Weeks’ Gestation: A Global Perspective

“…Compared with D&E, medical abortion has higher risk of retained products requiring surgical intervention [relative risk (RR): 4.58, 95% confidence interval (CI): 1.07-19.64], but not an increased risk of hemorrhage or transfusion. 35 In evaluating the evidence to generate new National Institute for Health and Care Excellence (NICE) guidelines for the United Kingdom, Schmidt-Hansen et al 35 found rates of hemorrhage requiring transfusion, uterine injury, cervical laceration requiring repair, and infection within 1 month 24 1.7% serious adverse events* 25 0.04%-0.28% uterine rupture 21 0.2% requiring major surgery 26 0.1%-0.6% hemorrhage requiring blood transfusion 21 0.2%-0.7% reaspiration 23,27 1% cervical laceration 27 0.8% signs of infection 27 0.2%-0.5% confirmed or suspected uterine perforation 21,27 0.002% adverse reaction to paracervical anesthesia 27 Hospital resources Almost always inpatient 24-48 h stay †…”

“…Where both abortion techniques are available, women should receive their preferred method 34,35. Data from randomized controlled trials comparing D&E and medical abortion (MA) are sparse, as individuals often have strong preferences regarding mode of abortion which makes study recruitment almost impossible 36,37.…”

“…Overall rates of serious adverse events for D&E and medical abortion are rare, occurring in <2% of cases (Box 1). Compared with D&E, medical abortion has higher risk of retained products requiring surgical intervention [relative risk (RR): 4.58, 95% confidence interval (CI): 1.07-19.64], but not an increased risk of hemorrhage or transfusion 35. In evaluating the evidence to generate new National Institute for Health and Care Excellence (NICE) guidelines for the United Kingdom, Schmidt-Hansen et al35 found rates of hemorrhage requiring transfusion, uterine injury, cervical laceration requiring repair, and infection within 1 month of abortion were similar for medical abortion and D&E for abortion between 13+0 and 23+6 weeks’ gestation.…”

“…Where both abortion techniques are available, women should receive their preferred method. 34,35 Data from randomized controlled trials comparing D&E and medical abortion (MA) are sparse, as individuals often have strong preferences regarding mode of abortion which makes study recruitment almost impossible. 36,37 When given a choice of methods, women may be more satisfied with D&E, 37 though some may prefer medical abortion if they desire to see or hold the intact fetus, as in cases of termination for fetal anomalies.…”