Comprehensive analysis of the use of pre-procedure ultrasound for first- and second-trimester abortion

doi:10.1016/j.contraception.2010.06.014

Contraception

Volume 83, Issue 1, January 2011, Pages 30-33

https://doi.org/10.1016/j.contraception.2010.06.014 Get rights and content

Abstract

Background

The use of ultrasound (US) is common in some settings before an abortion procedure. However, its positive effect on the safety or efficacy (ability to complete abortion) of the procedure has not been established. Our aim was to determine whether the use of pre-procedure US improves safety and/or efficacy of the abortion procedure.

Methods

We searched the following databases: Pubmed, Embase, Lilacs and Popline; reference lists of retrieved papers; and Google. We considered any controlled trial comparing women seeking abortion who received pre-procedure US to those who did not. Our outcome measures were efficacy of the abortion, complication rates and side effects.

Results

We did not identify any controlled trials or systematic reviews comparing the use of pre-procedure US to no US prior to abortion.

Conclusions

Ultrasound is widely used in pregnancy to estimate gestational age and to detect any abnormalities of the pregnancy or uterus. The effect of its use among women undergoing abortion is unclear, and only indirect evidence is available.

Introduction

Ultrasound assessment before an abortion procedure during first or second trimester of pregnancy has been recommended in some guidelines, although it is supported by little evidence [1], [2]. In settings where ultrasound (US) is widely used and easily available, its use for confirming intrauterine pregnancy, assessing gestational age as well as excluding ectopic pregnancy or uterine malformations has often become routine before performing abortion [3], [4], [5].

Assessment of gestational age by US in the first trimester is obligatory in some countries (for example, Switzerland), in order to be able to offer the choice for medical or surgical abortion, as well as to confirm that the pregnancy is within the legal limits for termination. In the second trimester, besides assessing gestational age, possible anomalies of the pregnancy, such as placenta previa, may be detected and precautions can be taken accordingly [6]. On the other hand, routine US can be costly, possibly unnecessary and may increase training and maintenance requirements in already under-resourced settings. Additionally, use of US can introduce error into pre-abortion assessment as its accuracy is dependant upon training, equipment and case volume.

The objective of this review was to determine whether the use of pre-procedure US, when compared to no use of US, prior to first- or second-trimester medical or surgical abortion affects either the safety or the efficacy of the procedure.

Section snippets

Types of studies

Randomized controlled trials (RCTs) would be the ideal study design to address our objective in a research setting using both excellent clinicians and sonographers. However, in the absence of RCTs, we considered all study designs comparing the use of pre-procedure US to no use of US. Studies needed to report on the use of pre-procedure US for safety or efficacy outcomes in first- and second-trimester medical or surgical abortion.

Types of participants

Women pregnant in the first or second trimester requesting

Results

Our search revealed about 750 citations, which were scrutinized by the two authors (RK, NK), and 25 full text papers were obtained. Evaluation of the full-text articles was performed by both authors.

We did not identify any systematic reviews, randomized controlled trials or reports of any comparative studies of the use of pre-procedure US with no use of US for either safety or efficacy outcomes.

Discussion

Ultrasound in some settings is used commonly to assess pregnancies in women before they undergo abortion. There is no evidence available, however, whether this practice improves either the safety or efficacy of abortion procedures.

Although no studies reported on our outcomes of interest, pre-procedure US has been studied to answer other questions. We report on these studies identified by our search strategy but not meeting inclusion criteria, as they may inform the decision-making process

Implications for practice

There is no evidence available on the effects of pre-procedure US for first- and second-trimester abortion with regard to either safety or efficacy, despite the fact that US in some settings is widely used to estimate gestational age and to detect pregnancy abnormalities. Any implications for routine US may be greater for pregnancies beyond the first trimester, where appropriate procedures for abortion change with increasing gestational age.

Implications for research

The use of resources to research this issue is

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There are more references available in the full text version of this article.

Cited by (23)

Barriers and Facilitators to the Implementation of First Trimester Medical Abortion With Mifepristone in the Province of Québec: A Qualitative Investigation
2020, Journal of Obstetrics and Gynaecology Canada
Mifepristone became available in Canada in January 2017, but provincial medical policy delayed its use for medical abortion (MA) in Québec for 1 year. The objective of this study was to identify barriers and facilitators experienced by physicians who could potentially provide this newer abortion practice in Québec.
This study was part of the Canadian Contraception and Abortion Research Team-Mifepristone Implementation Study, an observational, prospective, mixed-methods study. Interviews were conducted with physicians representing all health regions of Québec. Using thematic analysis guided by diffusion of innovation theory, the study identified key barriers and facilitators to implementation.
From January 2017 to March 2018, study investigators interviewed 25 family physicians and 12 obstetrician-gynaecologists. Most were women (81%), over 40 years old (65%), with >20 years in practice since residency (49%). Less than half of the sample provided abortion services (41%), and only 8% provided MA with mifepristone. Key barriers to implementation were: (1) uncertainty or confusion about policies regarding MA, (2) lack of human resources or support from colleagues, (3) uncertainty about product distribution, (4) confusion about professional collaboration, and (5) lack of local infrastructure. Key facilitators were: (1) perception of support and influence from colleagues, (2) previous experience with provision of first trimester MA, (3) requests for first trimester MA by patients or other physicians, and (4) knowledge of research on mifepristone MA.
Despite Health Canada's approval of mifepristone in Canada and supportive federal policies for provision of MA in primary care, physicians in the province of Québec face onerous barriers to the practice of mifepristone MA.
La mifépristone est offerte au Canada depuis janvier 2017, mais les politiques médicales provinciales du Québec ont reporté d'un an son utilisation aux fins d'avortement médicamenteux. Cette étude avait pour objectif de déterminer les obstacles et les facilitateurs qu'ont connus les médecins qui pourraient possiblement fournir cette nouvelle méthode d'avortement au Québec.
Cette étude cadre dans l'étude du Groupe de recherche sur l'avortement et la contraception du Canada sur la mise en œuvre de la mifépristone, une étude observationnelle prospective d'après des méthodes mixtes. Des entretiens ont été réalisés auprès de médecins représentant toutes les régions sanitaires du Québec. Cette étude a déterminé les principaux obstacles et facilitateurs de la mise en œuvre au moyen d'une analyse thématique guidée par la diffusion de la théorie de l'innovation.
De janvier 2017 à mars 2018, les chercheurs de l'étude se sont entretenus avec 25 médecins de famille et 12 obstétriciens-gynécologues. De cet échantillon, 81 % étaient des femmes, 65 % avaient plus de 40 ans et 49 % comptaient plus de 20 années de pratique depuis leur résidence. Moins de la moitié des professionnels de l'échantillon offraient des services d'avortement (41 %) et seulement 8 % offraient l'avortement médicamenteux par mifépristone. Les principaux obstacles de la mise en œuvre étaient (1) l'incertitude ou la confusion par rapport aux politiques relatives à l'avortement médicamenteux, (2) le manque de ressources humaines ou de soutien des collègues, (3) l'incertitude relative à la distribution du produit, (4) la confusion relative à la collaboration professionnelle et (5) le manque d'infrastructures locales. Les principaux facilitateurs étaient (1) la perception de soutien et l'influence des collègues, (2) les expériences passées en matière de prestation de services d'avortement médicamenteux au premier trimestre, (3) les demandes d'avortement médicamenteux au premier trimestre par des patientes ou d'autres médecins et (4) la connaissance des recherches sur l'avortement médicamenteux par mifépristone.
Malgré l'approbation de la mifépristone par Santé Canada et les politiques fédérales favorables à la prestation de l'avortement médicamenteux dans les soins de santé primaires, les médecins du Québec font face à de lourds obstacles à la prestation de l'avortement médicamenteux par mifépristone.
First-trimester aspiration abortion practices: a survey of United States abortion providers
2019, Contraception
To assess whether first-trimester aspiration abortion practices of US providers agree with evidence-based policy guidelines.
We sent surveys by mail or electronically to all abortion facilities in the United States identified via professional networks and websites from June through December 2013. Administrators reported on the volume of procedures performed at their site(s) through 13 weeks 6 days' gestation and on clinic services. Clinicians reported on personal demographic characteristics and abortion practices. We reviewed guidelines from key US professional organizations to determine how well reported practices aligned with available recommendations and the extent to which guidelines have changed since the time of the survey.
We identified 703 clinical sites in the United States; 383 (54%) sites responded, 256 of which offer first-trimester aspiration abortions. Most providers identified as obstetrician-gynecologists (74%) and female (64%); 52% were less than 50 years old compared to 36% in 2002. Overall, reported practices follow evidence-based guidelines, including routine administration of periprocedure antibiotics (85%), use of misoprostol for cervical ripening in the late first trimester (94%), pain management practices, and same-day contraception provision (98%) including long-acting devices (76%). Less evidence-based practices include routine preprocedure ultrasound (99%), not providing abortion before 5 weeks' gestation (66%), restrictive fasting policies, and prolonged and postprocedure antibiotic provision.
Overall, the first-trimester aspiration abortion practices revealed in our survey agree with professional evidence-based policy guidelines, though some related to preprocedure ultrasound use, very early abortion provision, preanesthesia fasting protocols, and antibiotic regimens deserve attention.
In this third cross-sectional survey of US abortion practices (prior surveys 1997 and 2002), first-trimester aspiration abortion providers are younger than before, reflecting an improvement in the “graying” of the abortion provider workforce. Research and education are needed to further improve evidence-based practice in abortion care.
Providing Abortion Services in the Primary Care Setting
2018, Primary Care - Clinics in Office Practice
Citation Excerpt :
GA can be accurately diagnosed with patient history of LMPs and use of clinical pelvic examination or ultrasound.39,40 Although ultrasound is widely used, it is not required for first-trimester abortion.52,53 Routine use of ultrasound has not been shown to improve the safety or efficacy of abortion but should be used when GA is uncertain or when there are symptoms of bleeding or pain.53
A noninferiority randomized controlled trial to compare transabdominal and transvaginal sonography for eligibility assessment prior to medical abortion
2018, Contraception
Citation Excerpt :
The routine use of TVS may be a holdover from early clinical trials of medical abortion efficacy, but sonography persists as an element of care for many clinicians despite insufficient evidence that it is necessary for all patients [20–23]. In 2011, Kulier and Kapp [24] reviewed the literature on preabortion ultrasound evaluations and found no published data addressing its impact on abortion safety or efficacy in either the first or second trimester. Some clinicians do provide medical abortion without using ultrasound first, but many hesitate to do so without first evaluating the pregnancy location and gestational age.
To compare transabdominal sonography (TAS) to transvaginal sonography (TVS) in medical abortion eligibility assessment, specifically to measure how often clinicians chose to order additional testing for eligibility assessment following TAS and TVS, and to look for differences by patient and clinician characteristics. Also, to compare patient acceptability between the two modalities.
This pragmatic multisite randomized noninferiority trial compared TAS to TVS at 10 New York City and New Jersey health centers that provide medical abortion. Women seeking medical abortion were randomized 1:1 to receive TAS or TVS. Following the study ultrasound examination, clinicians determined whether participants were eligible for medical abortion based on these results or warranted further testing. All participants completed an acceptability questionnaire. We compared additional testing and acceptability between TAS and TVS.
Of those randomized to TAS, 63/317 (19.9%) received additional testing compared to 15/312 (4.8%) randomized to TVS. After TAS, most additional testing consisted of a same-day TVS. Other tests included β-hCG testing, scheduled repeat sonography or return visit. After TAS, 13.4% seen by physicians and 27.6% seen by advanced practice nurses (APNs) received additional testing (p<.01). Additional testing was more common in early gestational ages for both groups. We enrolled too few women with a body mass index (BMI) >35 kg/m² to make comparisons. Participants found TAS more acceptable than TVS, and two thirds preferred TAS for future care.
TAS provided sufficient information for clinicians to assess medical abortion eligibility without additional tests for most patients. However, the frequency of additional testing was exceedingly close to our predefined noninferiority boundary. Why APNs ordered substantially more additional testing than physicians is unclear. TAS was more acceptable to patients than TVS.
TVS use requires high-level disinfection, which is resource-intensive and thus can be a barrier to care. Instead, TAS can be first-line for most women, reducing resources needed to provide medical abortion. Further research could help to establish gestational age and BMI thresholds beyond which TVS would be a more informative first test. We also need to evaluate whether additional training in using TAS would decrease additional testing.
N<sup>o</sup> 360 - Avortement provoqué: avortement chirurgical et méthodes médicales au deuxième trimestre
2018, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
Qualité des preuves : basse.) Avant un AP, il est recommandé d'effectuer une échographie systématique, car la détermination de l'âge gestationnel (AG) est essentielle21. Il a aussi été montré qu'une échographie peropératoire réalisée dans le cadre d'un AC au deuxième trimestre diminue les complications comme la perforation utérine22.
La présente directive clinique examine les données probantes sur l'avortement chirurgical et l'avortement médical au deuxième trimestre, y compris les soins prodigués avant et après l'intervention.
Gynécologues, médecins de famille, infirmières, sages-femmes, résidents et autres fournisseurs de soins de santé qui pratiquent ou enseignent, ou ont l'intention de pratiquer ou d'enseigner, l'avortement provoqué (AP).
Femmes dont la grossesse de premier ou de deuxième trimestre est non désirée ou anormale.
Des recherches ont été menées dans PubMed, Medline et la base de données Cochrane à l'aide des mots-clés « first-trimester surgical abortion », « second-trimester surgical abortion », « second-trimester medical abortion », « dilation and evacuation », « induction abortion », « feticide », « cervical preparation », « cervical dilation » et « abortion complications ». Nous n'avons tenu compte que des revues systématiques, des essais cliniques randomisés, des essais cliniques et des études observationnelles de langue anglaise ou française publiés entre 1979 et juillet 2017. Des directives cliniques nationales et internationales ont été consultées. Nous n'avons pas effectué de recherches dans la littérature grise (non publiée).
La qualité des données probantes a été évaluée au moyen de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Le résumé des conclusions peut être fourni sur demande.
L'AP est sûr et efficace. Les avantages en surpassent les dommages et les coûts potentiels. Aucun nouveau dommage ou coût direct n'a été associé à la présente directive clinique.
No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods
2018, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
Level of evidence: Low). Routine ultrasound prior to IA is recommended, as determination of GA is critical.21 In second trimester SA, intraoperative ultrasound has been shown to decrease complications including uterine perforation (UP).22
This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.
Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.
Women with an unintended or abnormal first or second trimester pregnancy.
PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.
The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.
IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.

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^☆: Funded by UNDP/UNFPA/WHO/World Bank Special Programme of Research: Human Reproduction Programme (HRP).

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Review articleComprehensive analysis of the use of pre-procedure ultrasound for first- and second-trimester abortion☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Types of studies

Types of participants

Results

Discussion

Implications for practice

Implications for research

Am J Obstet Gynecol

Contraception

Am J Obstet Gynecol

The care of women requesting induced abortion

The use of first trimester ultrasound

J Obstet Gynaecol Can

Combined sonographic–pathologic surveillance in elective first-trimester termination of pregnancy

Obstet Gynecol

Review article
Comprehensive analysis of the use of pre-procedure ultrasound for first- and second-trimester abortion☆