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:
Link to the new guidance documents:
https://www.who.int/publications/i/item/9789240039483
Link to Previous article (Part 1):
communitymedicine4all 