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Clinical Practice Handbook for Safe Abortion. Geneva: World Health Organization; 2014.

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Clinical Practice Handbook for Safe Abortion.

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3POST-ABORTION

OBJECTIVES

  • Provide contraceptive information and offer contraceptive counselling and methods.
  • Assess any other sexual and reproductive health needs that may require additional care.
  • Address any immediate complications of abortion.

3.1. Prior to discharge from the health-care facility

  • Provide clear oral and written discharge instructions, including:
    • sexual intercourse, douching or placing anything in the vagina should occur only after heavy bleeding stops;
    • vaginal bleeding for 2 weeks after completed surgical or medical abortion is normal. Women experience light bleeding or spotting following surgical abortion, heavier bleeding occurs with medical abortion and generally lasts for 9 days on average, but can last up to 45 days in rare cases;
    • the woman should return to the hospital or clinic if she experiences:
      • increased intensity of cramping or abdominal pain;
      • heavy vaginal bleeding;
      • fever.
  • Review the risk of becoming pregnant again before her next menses, and the possible return to fertility within 2 weeks following abortion.
  • Provide contraceptive information and offer contraceptive counselling to women who desire it:
    • assist her in choosing the most appropriate contraceptive method to meet her needs should she desire it;
    • provide the chosen contraceptive method (or refer her if her chosen method is not available). Ensure she knows how her selected method works, when to start it and how she can obtain future supplies.
  • Provide iron tablets for anaemia, if needed.
  • Provide any pain medications, if needed.
  • Provide emotional support, if needed.
  • Refer to other services as determined by assessment of her needs, such as STI/HIV counselling and testing, abuse support services, psychological or social services, or other physician specialists.

3.2. Additional follow-up with a health-care provider

  • A routine follow-up visit is recommended only in the case of medical abortion using misoprostol alone, to assess abortion completion.
  • Routine follow-up is not necessary following an uncomplicated surgical or medical abortion using mifepristone and misoprostol; however, women may be offered an optional follow-up visit 7–14 days after their procedure to provide further contraceptive counselling and methods or, further emotional support, or to address any medical concerns.
  • At the follow-up appointment:
    • assess the woman's recovery and confirm completion of the abortion;
    • review any available medical records and referral documents;
    • ask about any symptoms she has experienced since the procedure;
    • perform a focused physical examination in response to any complaints;
    • assess the woman's fertility goals and need for contraceptive services:
      • if no method was started prior to discharge from the facility, provide information and offer counselling and the appropriate contraceptive method, if desired by the woman;
      • if a contraceptive method was already started:
        • assess the method used, satisfaction or concerns;
        • if she is satisfied, resupply as needed;
        • if she is not satisfied, help her select another method that will meet her needs.
  • Refer to other services, as determined by assessment of her needs for additional sexual and reproductive health services, and facilitate any necessary referrals.

3.3. Post-abortion contraception*

Generally, almost all methods of contraception can be initiated immediately following a surgical or medical abortion. Immediate start of contraception after surgical abortion refers to the same day as the procedure, and for medical abortion refers to the day the first pill of a medical abortion regimen is taken. As with the initiation of any method of contraception, the woman's medical eligibility for a method should be verified.

Post-abortion medical eligibility recommendations for hormonal contraceptives, intrauterine devices and barrier contraceptive methods

POST-ABORTION CONDITIONFIRST TRIMESTERSECOND TRIMESTERIMMEDIATE POST-SEPTIC ABORTION
COC111
CIC111
Patch & vaginal ring111
POP111
DMPA, NET-EN111
LNG/ETG implants111
Copper-bearing IUD124
LNG-releasing IUD124
Condom111
Spermicide111
Diaphragm111

CIC, combined injectable contraceptive; COC, combined oral contraceptive; DMPA/NET-EN, progestogen-only injectables: depot medroxyprogesterone acetate/norethisterone enantate; IUD, intrauterine device; LNG/ETG, progestogen-only implants: levenorgestrel/etonorgestrel; POP, progesterone-only pill.

Definition of categories

  • 1: a condition for which there is no restriction for the use of the contraceptive method.
  • 2: a condition where the advantages of using the method generally outweigh the theoretical or proven risks.
  • 3: a condition where the theoretical or proven risks usually outweigh the advantages of using the method.
  • 4: a condition that represents an unacceptable health risk if the contraceptive method is used.

Post-abortion medical eligibility recommendations for female surgical sterilization

POST-ABORTION CONDITIONFEMALE SURGICAL STERILIZATION
UncomplicatedA
Post-abortal sepsis or feverD
Severe post-abortal haemorrhageD
Severe trauma to the genital tract; cervical or vaginal tear at the time of abortionD
Uterine perforationS
Acute haematometraD

Definition of categories

  • A = (accept): there is no medical reason to deny sterilization to a person with this condition
  • C = (caution): the procedure is normally conducted in a routine setting, but with extra preparation and precautions
  • D = (delay): the procedure is delayed until the condition is evaluated and/or corrected; alternative temporary methods of contraception should be provided
  • S = (special): the procedure should be undertaken in a setting with an experienced surgeon and staff, and equipment is needed to provide general anaesthesia and other back-up medical support For these conditions, the capacity to decide on the most appropriate procedure and anaesthesia regimen is also needed. Alternative temporary methods of contraception should be provided, if referral is required or there is otherwise any delay.

Contraceptive methods and medical eligibility after abortion

  • Hormonal methods (including pills, injections, implants, the patch and vaginal ring) may be started immediately after any abortion, including septic abortion.
  • IUDs may be inserted immediately after first- or second-trimester abortion; however, the expulsion risk is slightly higher following second-trimester abortions than following first-trimester abortions. IUDs may be inserted after a medical abortion has been deemed complete.

IMPORTANT

An IUD should not be inserted immediately after septic abortion.

  • Condom use may start with the first act of sexual intercourse after abortion, including septic abortion.
  • Diaphragm or cervical cap use may start with the first act of sexual intercourse after abortion, including septic abortion. Use should be postponed for 6 weeks following abortion beyond 14 weeks' gestation.
  • Fertility-awareness-based methods should be delayed until regular menstrual cycles return.
  • Female surgical sterilization can be performed immediately after uncomplicated abortions. However, it should be delayed if abortion is complicated with infection, severe haemorrhage, trauma or acute haematometra.
  • Vasectomy can be performed at any time.
  • Emergency contraception: women may use emergency contraceptive pills or an IUD within 5 days (120 hours) of an act of unprotected sexual intercourse, to decrease pregnancy risk.
  • Withdrawal use may start with the first act of sexual intercourse, after abortion, including septic abortion.

3.4. Assessing and managing abortion complications

Potentially life-threatening complications are rare following safe abortion, but complications may still occur, even when taking all the necessary precautions.

When abortions are obtained from unsafe providers or locations, complications are much more common. Some women seeking subsequent care may be seriously ill and need immediate emergency attention for life-threatening conditions.

Some methods of unsafe abortion may also lead to complications related to the method used, such as ingestion of poison, toxic substances or medications, insertion of a foreign body in the anus, vagina or cervix, or abdominal trauma. Treatment of complications in these women should include treatment of any such systemic or physical injuries, in addition to any of the abortion-related complications.

Ongoing pregnancy

  • Women with continuing signs of pregnancy or clinical signs of failed abortion should be offered a uterine evacuation in a timely fashion.

Incomplete abortion

Common symptoms of incomplete abortion include vaginal bleeding and abdominal pain. It should also be suspected if, upon inspection, the POC aspirated during surgical abortion is not compatible with the estimated duration of pregnancy.

  • Incomplete abortion following spontaneous or induced abortion may be managed similarly.
  • Clinically stable patients have the following three options:
    • expectant management;
    • vacuum aspiration: (for uterine size of up to 14 weeks' gestation);
    • management with misoprostol (for uterine size of up to 13 weeks' gestation).
  • The decision should be based upon the clinical condition of the woman and her preferences for treatment.

Recommended regimen for management of incomplete abortion with misoprostol

DOSE (μg)ROUTE
600 μgOral
400 μgSublingual
400–800 μgVaginal; may be used if vaginal bleeding is minimal

Comparison of management options for missed and incomplete abortions

METHODPOTENTIAL ADVANTAGESPOTENTIAL DISADVANTAGESEFFICACY (%)
MissedIncomplete
Expectant management a
  • May minimize visits
  • Avoids side-effects and complications of other methods
  • Avoids intrauterine instrumentation
  • Unpredictable time frame
  • May still require follow-up aspiration if not successful
16–7582–100
Misoprostol alone
  • Avoids intrauterine instrumentation
  • May cause more bleeding and need for follow-up than aspiration
  • Short-term side-effects from misoprostol
77–8961–100
Aspiration
  • Quick resolution
  • Surgical procedure
96–10096–100
a

The efficacy of expectant management increases with increasing interval before intervention.

Source: adapted from Goodman S, Wolfe M., the TEACH Trainers Collaborative Working Group. Early abortion training workbook. 3rd ed. San Francisco: UCSF Bixby Center for Reproductive Health Research and Policy; 2007. , with permission.

Haemorrhage

Haemorrhage can result from retained POC, trauma or damage to the cervix, coagulopathy or, rarely, uterine perforation or uterine rupture.

  • Appropriate treatment for haemorrhage depends on its cause and severity, and includes:
    • re-evacuation of the uterus;
    • administration of uterotonic drugs;
    • blood transfusion;
    • replacement of clotting factors;
    • laparoscopy;
    • exploratory laparotomy.
  • Every service-delivery site must be able to stabilize and treat or refer women with haemorrhage immediately.

Infection

  • Common signs and symptoms of infection include:
    • fever or chills;
    • foul-smelling vaginal or cervical discharge;
    • abdominal or pelvic pain;
    • prolonged vaginal bleeding or spotting;
    • uterine tenderness;
    • an elevated white blood cell count.
  • Women with infection require antibiotics for treatment.
  • If retained POC are suspected to be a cause for infection, re-evacuate the uterus.
  • Women with severe infections may require hospitalization.

Uterine perforation

  • Uterine perforation usually goes undetected and resolves without the need for intervention.
  • When available and necessary, laparoscopy is the investigative method of choice.
  • If the woman's status or findings during laparoscopy suggest damage to the bowel, blood vessels or other structures, a laparotomy to repair any damage may be needed.

Anaesthesia-related complications

  • Where general anaesthesia is used, staff must be skilled in the management of seizures and cardiorespiratory resuscitation.
  • Narcotic-reversal agents should always be readily available in settings where narcotics are used.

Complications may occur that are not specific to the abortion procedure

These include:

  • anaphylaxis;
  • asthmatic reactions.

These complications should be treated as they would be following any other procedure.

Footnotes

*

Based on Medical eligibility criteria for contraceptive use. 4th ed. Geneva: World Health Organization; 2009.

Copyright © World Health Organization 2014.

All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob).

Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution – should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html).

Bookshelf ID: NBK190099

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