Human Reproduction, Vol. 16, No. 1, 67-71,
January 2001
© 2001 European Society of Human Reproduction and Embryology
A comparative study of surgical and medical procedures: 932 pregnancy terminations up to 63 days gestation
Department of Obstetrics and Gynaecology, Women's Centre, The John Radcliffe Hospital, Headington, Oxford, UK
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Abstract |
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The aim of this retrospective study was to compare the efficacy and complications associated with early medical and surgical pregnancy termination. The study population comprised 932 consecutive women undergoing pregnancy termination at gestations of 63 days or less. There were no age or parity differences between the study groups. Medical termination was performed with mifepristone 200 mg orally and misoprostol 800 µg vaginally; surgical aspiration termination was performed under general anaesthesia. Outcome measures were: surgical curettage for presumed retained products of conception; ongoing pregnancy; and planned and emergency review in the unit. Early medical and surgical termination were associated with a 90.2 and 94.5% complete abortion rate respectively (P = 0.025). The complete abortion rate with medical termination decreased significantly with increasing parity; no such relationship with surgical abortion was found. Women of parity three or more were less likely to have a complete abortion following a medical (83.3%) compared to surgical procedure (97.7%) (P = 0.028). The ongoing pregnancy rate was 0.9% with medical and 0.5% with surgical termination (P = NS). Medical termination was associated with a lower complete abortion rate than surgical termination, particularly for women of higher parity. However, early medical termination allows over 90% of women to avoid the risks of surgical instrumentation of the uterus and anaesthesia.
Key words: abortion/medical/mifepristone/surgical/termination
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Introduction |
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Medical termination using the antiprogesterone mifepristone in combination with a prostaglandin analogue is acceptable to women, has a low complication rate, and results in complete evacuation in 95–97.5% of cases (Hill et al., 1990
; Henshaw et al., 1993; Urquhart et al., 1997; Ashok et al., 1998). Surgical termination, when carried out by vacuum aspiration, is also safe, acceptable, and efficacious with complete evacuation rates of at least 95–99% (Heisterberg and Kringelbach, 1987; Hakim-Elahi et al., 1990; Westfall et al., 1998). Comparative studies have been performed and generally confirm a lower complete abortion rate, due to both retained products and ongoing pregnancy, with medical compared to surgical termination (Cameron et al., 1996; Winikoff et al., 1997; Jensen et al., 1999). However the majority of studies have used the less efficacious oral, as opposed to vaginal, route of prostaglandin administration for medical termination or numbers of patients have been small (El-Refaey et al., 1995). With a retrospective analysis, the efficacy of surgical and medical pregnancy termination (using vaginal prostaglandin administration) performed up to 9 weeks gestation was compared for 1 year in our institution. Efficacy was defined as the termination of pregnancy with complete expulsion of the fetus without the need for surgical evacuation within 6 weeks of termination. Outcome measures were (i) the need for a surgical evacuation of the uterus within 6 weeks of termination, and (ii) the presence of an ongoing pregnancy. |
Materials and methods |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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The study consisted of 932 consecutive women undergoing pregnancy termination at a gestation of 63 days or less in the National Health Service at the John Radcliffe Hospital, Oxford during a 12 month period. The name, hospital number, age, parity, date of, and gestation at, termination of each of the women were obtained from records. Gestation of pregnancy was measured from the first day of the last menstrual period according to menstrual history, pelvic examination, and if there was doubt, pelvic ultrasound. Women who had been admitted during their termination because of complications, or returned to the unit for assessment during the 6 weeks after abortion, were identified by cross-checking each patient's name and hospital number against the gynaecology unit database. This database was prospectively created and included the details of all women seen as emergencies in the unit. All surgical evacuations were confirmed by checking the operating theatre diary and patient records. Women with an ongoing pregnancy were identified from the gynaecology and obstetric unit databases.
Women with an unwanted pregnancy of 63 days gestation or less who had no contra-indications to medical or surgical termination were offered the choice of either method after counselling. Medical terminations were performed using mifepristone 200 mg orally followed 48h later by the vaginal administration of misoprostol 800 µg. If the conceptus was not passed during the 7h following misoprostol administration the patient was asked to return to the hospital for assessment 1 week later. If a missed abortion or ongoing pregnancy was diagnosed then surgical evacuation was arranged. All other medical termination patients were instructed to see their general practitioner for review at 1 week. Surgical terminations were performed as a day case using vacuum aspiration with a plastic cannula under general anaesthesia. Neither infection screening nor prophylactic antibiotics were routinely used. Nulliparae underwent cervical priming using gemeprost 1 mg vaginally 2–3 h prior to surgery. Additive oxytocics were used at the discretion of the surgeon. Women were instructed to see their general practitioner 3–6 weeks after surgery. As the John Radcliffe is the only hospital serving Oxford, patients with problems requiring specialist assessment would be referred back to us by their general practitioner, present as an emergency to the unit, or be diagnosed through the follow-up offered to some medical termination patients. Evacuation for incomplete abortion was performed when there was clinical evidence of retained products of conception.
All data were collected by one author (T.J.C.) and analysed using the 
2-test, the Mantel–Haenszel 2-test for trend, or Fisher's exact test as appropriate. Two tailed P values of < 0.05 were taken to indicate statistical significance.
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Results |
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Demographic data are shown in Table I
. The study groups were similar with respect to age and parity.
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A total of 533 (57.2%) women had a medical termination and 399 (42.8%) a surgical abortion. Women undergoing a medical termination were significantly more likely to be advised to undergo a further procedure (52/533 = 9.8%) than those having a surgical termination (22/399 = 5.5%) (P = 0.025; Table II
). There was a significant decrease in the rate of complete abortion with increasing parity in the medical group which persisted after adjusting for gestation (P = 0.012). This was not due to any increase in continuing pregnancies with higher parity (four of the five women were nulliparae). There was no relationship between parity and efficacy in the surgical group. Women who had had three or more previous births (parity 
3) were significantly less likely to have complete abortion with medical rather than surgical termination (P = 0.028). Women of other parity showed no such difference between procedures. For both study groups, gestation appeared to have no effect on outcome even after adjusting for parity.
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Table III
shows the number of women returning to the unit after medical or surgical termination and the indication for and type of further procedure undertaken. Seventy-six (76/533 = 14.3%) women returned, as requested, to the unit for assessment because of uncertainty over the completeness of abortion. Six further women were requested to return but did not (and one of these was later diagnosed with a continuing pregnancy). Of the 76 who returned, four had a continuing pregnancy, managed as detailed below, and 12 had a surgical evacuation arranged following a diagnosis of missed abortion. Forty-eight (9.0%) women presented as emergencies during the 6 weeks following medical termination. Nine of these women had already attended once for medical review in the follow-up clinic. Therefore 115 [(76 + 39)/533 = 21.6%] women in the medical group returned at least once to the unit. Of the 48 women presenting as emergencies with pelvic pain and/or bleeding 31 had a surgical curettage for incomplete abortion, one was diagnosed with a mid-trimester continuing pregnancy, and 16 were treated conservatively with reassurance. Twenty (3.8%) women in the medical group required admission overnight following prostaglandin treatment mainly due to excessive bleeding; four (0.8%) of these women underwent surgical evacuation. Following surgical abortion none of the patients required emergency overnight admission on the day of termination; 35 (8.8%) women returned to the hospital within 6 weeks. Two of these women were diagnosed as having a continuing pregnancy, 20 with incomplete abortion subsequently undergoing uterine curettage, and 13 were managed conservatively. The return rate (including planned and emergency reviews) following medical abortion was significantly higher than that following surgical termination (P < 0.001). However the rate of emergency presentation was similar for the two groups (9.0% medical and 8.8% surgical).
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There were five (0.9%) continuing pregnancies in the medical and two (0.5%) in the surgical group (P > 0.05). All five women with continuing pregnancies after medical termination had been requested to return to the hospital for medical review following recognition of failure to pass the conceptus on the day of prostaglandin administration. One patient was subsequently advised by her general practitioner that she need not keep the appointment as she had passed the conceptus at home. She returned to the unit 8 weeks later as an emergency with continued bleeding; an ultrasound scan diagnosed a 16 week viable pregnancy and she underwent mid-trimester medical termination. A further patient returned for her ultrasound a week following attempted medical termination to find a viable fetus of 14 weeks gestation; it was concluded that she had been 12+ weeks pregnant at the time of the failed medical termination. The three remaining patients underwent a successful surgical termination. The gestation at termination of the five ongoing pregnancies was 7 weeks gestation for one, 8 weeks gestation for three, and 12+ weeks for the last; four of the patients were nulliparous and one para one. The two continuing pregnancies in the surgical group both occurred at 9 weeks gestation, one in a nulliparous and the other a parous woman. Both returned as emergencies due to continued bleeding and a further termination was performed.
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Discussion |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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This study has shown that medical termination is associated with a lower rate of complete abortion compared to surgical termination. This supports the findings of other comparative studies (Cameron et al., 1996
; Winikoff et al., 1997; Jensen et al., 1999). In this study the complete abortion rate of 90.2% for medical termination is lower than that reported in studies using the vaginal route of prostaglandin administration but higher than studies using oral prostaglandin (Hill et al., 1990; Henshaw et al., 1993; Cameron et al., 1996; Urquhart et al., 1997; Winikoff et al., 1997; Ashok et al., 1998; Spitz et al., 1998; Jensen et al., 1999). A recent report of 2000 medical terminations of up to 63 days gestation using the same regimen as reported here demonstrated a complete abortion rate of 97.5% (Ashok et al., 1998). The UK Multicentre Trial of 1018 women using 600 mg of mifepristone and a 1 mg vaginal pessary of gemeprost reported a complete abortion rate of 94.8%, which is similar to the rates in the other vaginal prostaglandin trials (Henshaw et al., 1993; El-Refaey et al., 1995; Cameron et al., 1996; Urquhart et al., 1997). Prostaglandin has been shown in a randomized study to be associated with a lower rate of complete abortion when administered orally (87%) compared to vaginally (95%) (El-Refaey et al., 1995). This is supported by recent trials from the USA using mifepristone and oral misoprostol where complete abortion rates range from 77–92% depending on gestation (Spitz et al., 1998; Jensen et al., 1999). The surgical complete abortion rate in the current study is at the lower end of previously reported rates, which generally range from 95.0 to around 99.5% (Heisterberg and Kringelbach, 1987; Hakim-Elahi et al., 1990; Henshaw et al., 1993; Sykes, 1993; Cameron et al., 1996; Westfall et al., 1998; Jensen et al., 1999). This lower surgical rate may be due in part to relative inexperience of the surgeon and/or overdiagnosis of retained products of conception with a reluctance to use conservative management in such cases (unpublished observations). Unnecessary surgical evacuation of retained products could also explain the lower complete abortion rate with medical termination compared to other studies.
A significant relationship was found between increasing parity and need for a further procedure following medical abortion (P = 0.012). Such a trend has not been reported previously. The UK Multicentre Trial found no such relationship and the other vaginal prostaglandin trials do not report on parity (Urquhart et al., 1997). Interestingly Spitz and colleagues found that, apart from gestation, the number of previous therapeutic abortions was the only factor related to outcome (Spitz et al., 1998). Previous therapeutic abortion decreased the complete abortion rate by a further 10% at gestations of 63 days. Unfortunately data are not available on previous terminations in the current study population. No relationship was found between parity and outcome for surgical termination. For women of parity 3 medical termination was associated with a significantly lower complete abortion rate (83.3%) compared to surgical abortion (97.7%). This difference in outcome in women of high parity warrants further investigation.
For medical termination, the duration of gestation was not related to complete abortion rate. This agrees with the findings of the UK Multicentre Study but not those of Ashok et al. (Urquhart et al., 1997; Ashok et al., 1998). The latter found the complete abortion rate at gestations under 49 days to be significantly higher than later gestations. The oral prostaglandin route however is generally associated with a decrease in complete abortion with increasing gestation. Much of the increased failure rate is due to an increase in ongoing pregnancies at higher gestations in these studies. The ongoing pregnancy rate of 0.9% following medical termination in the current study is similar to rates in other vaginal prostaglandin trials (Urquhart et al., 1997; Ashok et al., 1998). It emphasizes the importance of careful follow-up of these patients. The occurrence of two ongoing pregnancies following surgical termination also emphasizes the importance of advising patients that this might occur and that persistent pregnancy symptoms, continued bleeding or amenorrhoea should be investigated.
Prostaglandin induction–abortion time data were not collected for the women undergoing medical abortion in this study. During a previous year 470 women undergoing the same medical regimen at our hospital were found to have an induction–abortion interval of 5.5 (3–13) h [median (range)] (unpublished data).
A criticism of the current study is its retrospective design. We are confident however that due to the meticulous cross-referencing of each patient's name and hospital number against the gynaecological unit admission database, follow-up should be near complete. As our hospital is the only one serving Oxford and its environs it would be expected that patients with symptoms severe enough to require a further procedure would have returned to our institution. Some women may however have been admitted to hospitals outside Oxford. No information was available on the visitation rate of women to their general practitioner for termination-related symptoms. Additionally some patients with complications will be reluctant to present to doctors. Minor symptoms are therefore undoubtedly under-represented in this study. Although a prospective randomized study would have been ideal the patient groups in this study are very evenly matched with respect to age and parity. We have been offering first trimester medical termination using mifepristone and prostaglandin to women since 1991 and reported our early experience of the technique in 1990 (Hill et al., 1990). The data demonstrate the outcome of medical and surgical abortion in a busy general gynaecological unit with great experience of both methods.
It should be noted that the manufacturer's recommended regimen comprises a 600 mg oral dose of mifepristone followed 36–48 h later by the vaginal administration of 1 mg of gemeprost. However, a 200 mg dose of mifepristone has been shown to be as effective as 600 mg, and misoprostol as effective as gemeprost [World Health Organization (WHO) Task Force, 1993; El-Refaey et al., 1994]. The regimen of 200 mg mifepristone and 800 µg misprostol, which was used in the current study, is not licensed for medical termination of pregnancy but is effective and widely used (Ashok et al., 1998). Also, misoprostol does not have a product license for use in pregnancy termination. However, the European Community Pharmaceutical Directive 89/341/EEC specifically permits doctors to use `licensed medicines for indications or in doses or by routes of administration outside the recommendations given in the licence' (Ferner, 1996).
In summary, this study has demonstrated, with one of the largest comparative studies analysing terminations of 63 days gestation or less, the differences in early recovery using a medical or surgical technique. Medical termination was associated with a lower complete abortion rate than surgical termination, particularly for women of higher parity. However, early medical termination allowed over 90% of women to avoid the risks of surgical instrumentation of the uterus and anaesthesia. It is felt that early pregnancy medical termination deserves to be more widely available and utilized both in developed and developing countries.
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Acknowledgments |
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The authors wish to thank the gynaecological nursing staff, particularly Roz Ingle, for their work in maintaining the early medical abortion and emergency admission database.
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Notes |
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1 To whom correspondence should be addressed at: McGill Reproductive Centre F6, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, PQ H3A 1A1, Canada. E-mail: Tim.child{at}muhc.mcgill.ca
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Submitted on May 22, 2000; accepted on September 21, 2000.
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