Strong Research Evidence for PAC

Emergency Treatment | Pain Management | Postabortion FP | Male Involvement | Spontaneous Abortions | Abuse | Training | Systems Issues

Emergency Treatment

• Vacuum aspiration (VA) (electric, footpump, manual vacuum aspiration) is as effective as sharp curettage for the treatment of incomplete abortion.
• VA (electric and manual vacuum aspiration) is associated with less bleeding than sharp curettage.
• Using manual vacuum aspiration (MVA) for PAC instead of sharp curettage along with associated changes in protocols and an improved service delivery model can significantly reduce costs of care in most cases.
• Use of misoprostol to evacuate the uterus after early pregnancy failure can:
  • Completely evacuate the uterus 50 to 96 percent of the time if given orally or vaginally, and is more effective than expectant management in reducing the need for surgical intervention.
  • Be administered orally, sublingually, or vaginally with good results; however optimal dose/route combinations have not been firmly established.
  • Have side effects including chills, fever, nausea, vomiting, diarrhea and headache, but are generally mild and self-limiting.
  • Cause slightly more blood loss in women experiencing first trimester pregnancy failure compared to women treated with surgical evacuation, but the difference is not clinically significant.

Pain Management

• Women require pain management for emergency treatment with sharp curettage and VA.
• The evidence on the effectiveness of paracervical block using 1% lidocaine on pain reduction is conflicting.
• Neither the paracervical block technique nor psychological support alone is sufficient in pain management for PAC patients undergoing MVA.
• The use of systemic analgesia with sharp curettage for incomplete abortions with dilated cervix up to 14 weeks is safe, effective, has a smaller chance of requiring a blood transfusion, and does not require the use of the operating theater.
• The use of general anesthesia with suction curettage is associated with increased risks of blood loss, cervical injury, uterine perforation, and subsequent abdominal hemorrhage.

Postabortion Family Planning Counseling and Services

• Postabortion family planning (FP) counseling and services reduces repeat abortions.
• Use of dedicated FP nurse/counselors as compared to FP referrals for contraceptives can increase immediate contraceptive acceptance for PAC patients.
• PAC delivery models that offer FP counseling and methods at the same location where the woman receives emergency treatment can increase the proportion of women leaving with a contraceptive method; and result in fewer unplanned pregnancies, and a reduction of repeat abortions one year later.
• Women who experience either induced or spontaneous abortion and desire another pregnancy should wait at least six months before becoming pregnant again to reduce the incidence of maternal anemia, premature rupture of membranes, low birth weight and preterm delivery in the next pregnancy.
• Use of IUDs in the immediate postabortion period is safe.

Male Involvement with Counseling and Family Planning Service Delivery

• Hospital policies that ban men from obstetrical and gynecology wards make it difficult for male involvement and discourage male participation.
• Many women want their husbands/partners present for counseling, to be informed about their conditions, treatment they are receiving, follow-up care, and family planning methods they intend to use.
• Many male partners want more information about their partners’ conditions during PAC and more information on family planning.
• Counseling husbands of PAC patients on follow-up care, return to fertility, and family planning can increase family planning usage and physical, material, and emotional support for PAC patients during recovery.

Reducing the Incidence of Spontaneous Abortions

• Women are at an increased risk for spontaneous miscarriage if they:
  • Experience physical violence during pregnancy.
  • Are HIV positive.
  • Have malaria during pregnancy.
  • Smoke cigarettes or exposed to smoke during pregnancy.
  • Have bacterial vaginosis.
  • Are exposed to environmental contamination including pesticides and fungicides.

Abuse and Psychological Sequelae

• Women may report suffering negative psychological effects after a spontaneous or induced abortion.
• Between 27 and 39 percent of women seeking abortion have been victims of abuse sometime during their lifetime.

In-Service Training

• Providing contraceptive technology updates, counseling workshops and in-service training in PAC can:
  • Increase the number of PAC patients who report that they received important information on their care and FP options;
  • Increase the number of PAC patients who leave with a FP method regardless of whether MVA or sharp curettage is used; and
  • Improve the quality of care.
• Training increases physician satisfaction with MVA. Training midwives to counsel PAC patients on FP, STIs/HIV and nutrition (in addition to midwives undertaking other aspects of PAC, including emergency treatment using MVA) can increase counseling on these topics.

Systems Issues for Delivering PAC Services

• Allowing trained midwives to provide PAC (using MVA) will help increase access to PAC services.
• Health policy changes, the development and dissemination of protocols and service delivery guidelines for PAC, and the reorganization of services are needed to institutionalize PAC in hospital settings or provide PAC as an outpatient procedure.
• PAC services are needed even where abortion is legal.