PRE-PROCEDURE MEDICATIONS

PROPHYLACTIC ANTIBIOTICS

There is strong evidence for the use of routine antibiotic prophylaxis in patients undergoing uterine aspiration for abortion. Patients who received antibiotics were 0.59 times as likely to experience post-abortal infection compared to those who received placebo in a Cochrane review of 15 randomized controlled trials (Low 2012). This protective effect was evident in patients with and without risk factors (history of PID, positive CT, or pre-procedural BV). Limited evidence suggests that routine antibiotics are optional for asymptomatic patients undergoing uterine aspiration for EPL (Prieto 1995).

Evidence supports pre-procedure dosing of prophylactic antibiotics for the maximal effect, and the shortest possible course to give the lowest risk of adverse reactions and antibiotic resistance (Achilles 2011). Effective regimens include metronidazole or tetracyclines (e.g. doxycycline) or azithromycin. Despite varying practices in choice of antibiotic and duration of use, there is little data to support post-procedure antibiotics (Achilles 2011) which are often used to maintain NPO status prior to an abortion.

CERVICAL PREPARATION

There has been much research into the role of misoprostol and other methods of cervical ripening for uterine aspiration. Cervical preparation with misoprostol is generally safe and may decrease procedure time for some patients, but it is not routinely indicated prior to a first trimester uterine aspiration due to increased waiting time, bleeding, cramping, other side effects, and minimal demonstrated benefit in terms of ease of dilation or pain (Ipas 2016,  Kapp 2010, Allen 2007). Its use can be considered on an individual basis when a challenging dilatation is anticipated (such as history of difficult dilation). An early study suggests the priming interval for first trimester may be 1 hour after sublingual administration, but with vaginal and buccal administration, 2 to 3 hours provides a better effect (Saav 2015).  The most common regimen prior to first trimester aspiration abortion is 400 mcg.

Rh-D IMMUNOGLOBULIN

Rh-D immunoglobulin (anti-D IgG or RhoGam) is recommended to prevent the isoimmunization of Rho-D negative patients at the time of threatened, therapeutic, or spontaneous abortion, and ectopic pregnancy (Fung Kee Fung 2003). The minimal gestational age at which sensitization can occur is uncertain. Since the introduction of RhoGam in late pregnancy and postpartum, the incidence of isoimmunization has fallen over 8-fold (Fung Kee Fung 2003). Given its success in term pregnancies, its use in a lower dose (50 mcg compared to the 300 mcg full dose) has been extended to miscarriage and abortion up to and including 12 weeks, even though the evidence is sparse for early pregnancy (Jabara 2003).  At or beyond 13 weeks, full dose RhoGam is recommended to prevent isoimmunization.

Antibodies to Rho-D can develop if a patient has already been sensitized from prior pregnancies or from a RhoGam injection within the last 3 months. If a patient has received RhoGam in the past 3 months, an additional injection is only indicated if the previous injection was greater than 3 weeks prior (Bichler 2003). For those who have become sensitized, an additional RhoGam injection will not prevent isoimmunization.

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