WHO issues new guidance on abortion (9 March 2022): Part 2

Background Information:

Conscious sedation: the use of a combination of medicines- a sedative to relax and an anaesthetic to block pain- to induce a depressed level of consciousness during a medical procedure.

Dilatation and evacuation (D&E): D&E is used after 12-14 weeks of pregnancy. It is the safest and most effective surgical technique for later abortion where skilled, experienced practitioners are available. D&E requires preparation of the cervix using osmotic dilators and/or pharmacological agents, and evacuating the uterus primarily with forceps, using vacuum aspiration to remove any remaining blood or tissue.

Osmotic dilators: Short, thin rods made of seaweed (laminaria) or synthetic material. After placement in the cervical os, the dilators absorb moisture and expand, gradually dilating the cervix.

Surgical methods of abortion (surgical abortion): Use of transcervical procedures for terminating pregnancy, including vacuum aspiration, and dilatation and evacuation (D&E).

Key Messages:

Pre-Abortion

7. Cervical priming prior to surgical abortion

Prior to surgical abortion at <12 weeks

If cervical priming is used

Suggest the following medication regimes

  • Mifepristone 200 mg orally 24-48 hours prior to the procedure
  • Misoprostol 400 ug sublingually 1-2 hours prior to the procedure
  • Misoprostol 400 ug vaginally or buccally 2-3 hours prior to the procedure

Recommend against the use of osmotic dilators for cervical priming.

Prior to surgical abortion at later gestational ages

For surgical abortion at >=12 weeks

Suggest cervical priming prior to the procedure.

For surgical abortion between 12 and 19 weeks

Suggest cervical priming with medication alone (a combination of mifepristone plus misoprostol is preferred) or with an osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both).

When using an osmotic dilator for cervical priming

Suggest that the period between osmotic dilator placement and the procedure should not extend beyond two days.

For surgical abortion at >=19 weeks

Recommend cervical priming with an osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both).

Prior to dilatation and evacuation (D&E) at >= 12 weeks

Recommend cervical priming with osmotic dilators by auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners.

Suggest cervical priming with osmotic dilators by traditional and complementary medicine professionals (provided the Health worker ensures continuity of care from the time of cervical priming to the D&E).

8. Pain management for abortion

For pain management for surgical abortion at any gestational age

Recommend that pain medication (e.g. NSAIDs) should be offered routinely and that it should be provided to those who want it; and

Recommend against the routine use of general anaesthesia.

(New) For pain management for surgical abortion at <14 weeks

Recommend the use of a paracervical block; and

Suggest that the option of combination pain management using conscious sedation plus paracervical block should be offered, where conscious sedation is available.

(New) For pain management for surgical abortion at >=14 weeks

Recommend the use of a paracervical block; and

Suggest that the option of combination pain management using conscious sedation plus paracervical block should be offered where conscious sedation is available.

(New) For pain management for cervical priming with osmotic dilators prior to surgical abortion at >= 14 weeks

Suggest the use of a paracervical block.

For medical abortion at any gestational age

Recommend that pain medication (e.g. NSAIDs) should be offered routinely and that it should be provided for the individual to use if and when wanted.

(New) For pain management for medical abortion at >=12 weeks

Suggest consideration of additional methods to control pain or discomfort due to increased pain with increasing gestational age. Such methods include certain anti-emetics and epidural anaesthesia where available.

Useful Links:

Link to related WHO news release:

https://www.who.int/news/item/09-03-2022-access-to-safe-abortion-critical-for-health-of-women-and-girls

Link to the new guidance documents:

https://www.who.int/publications/i/item/9789240039483

Link to Previous article (Part 1):

https://communitymedicine4all.com/2022/03/15/who-issues-new-guidance-on-abortion-9-march-2022-part-1/

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