In UK Trial, Women Seeking Second-Trimester Abortion Favor Surgical over Medication Procedure
Women seeking an abortion between the 13th and 20th weeks of pregnancy tend to be more satisfied with the procedure and report less pain if they have a surgical abortion rather than a medication one, according to a randomized trial conducted in England.1 Two weeks after the procedure, levels of psychological distress and pain were lower among women who had had a surgical abortion than among those who had had a medication procedure. In addition, compared with women who had had a medication abortion, those who had had a surgical one were more likely to say that they would choose the same method again (100% vs. 53%) and less likely to say that the experience had been worse than expected (0% vs. 53%).
Although both surgical and medication abortions can be performed safely in the second trimester, the two approaches have been compared in randomized trials only in first-trimester pregnancies. To address this gap, researchers at a teaching hospital in Newcastle, England, compared outcomes between surgical and medication abortions among women at 13–20 weeks’ gestation in 2000–2004. Women who spoke English, agreed to participate and did not have a medical condition that precluded medication abortion or a fetus with a congenital abnormality were randomly assigned to undergo either a surgical or medication abortion.
Surgical abortions were performed using vacuum aspiration for gestations of less than 15 weeks; dilation and evacuation was used for pregnancies of 15–20 weeks. Women in the medication abortion group received mifepristone and were asked to return at 8 a.m two days later, at which point they were given up to five doses of misoprostol at three-hour intervals. If abortion had not occurred by midnight, additional mifepristone and, if necessary, gemeprost were administered; the abortion was considered unsuccessful and a surgical termination arranged if the pregnancy had not been terminated by 8 a.m.
Study participants were asked to return two weeks after their abortion to complete the Impact of Events Scale, an instrument often used to assess stress reactions after traumatic events. They also completed the General Health Questionnaire-12 and the Hospital Anxiety and Depression Scale, were asked whether they would have the same type of procedure again and rated their satisfaction with their care before, during and after the abortion.
Between May 2000 and February 2004, a total of 229 women were invited to participate; about half (47%) declined, in most cases because they strongly preferred one of the two abortion procedures. On average, women who agreed to participate were aged 24 and had been pregnant for 15 weeks. Twelve decided to continue their pregnancies, leaving 110 women who underwent a medication or surgical abortion. Sixty-six of them—30 in the medication abortion group and 36 in the surgical group—completed the follow-up questionnaires.
Complication rates for the two abortion types were identical (12%); the main complication of medication abortions was the need for evacuation of retained products of conception, while for surgical abortions it was excessive blood loss (though no women required a transfusion). Sixteen women in the medication abortion group, but none in the surgical group, required an unexpected overnight stay; five women in the medication group needed surgical evacuation of uterus. Women’s ratings of worst pain on the day of the procedure were higher for medication than surgical abortions (mean, 6.8 vs. 4.6 on a 10-point scale); 43% of women who had undergone medication abortion and 23% of those who had had a surgical abortion said their pain had been moderate or severe, though the difference was not statistically significant.
At follow-up, women who had had a surgical abortion were less likely than those who had had a medication procedure to report that they had experienced bleeding heavier than that of a menstrual period (4% vs. 37%). Compared with women in the medication abortion group, those who had had a surgical abortion had lower levels of psychological distress (mean, 2.1 vs. 4.4 on a scale of 0–12) and reported less frequent intrusive thoughts about the procedure (12.0 vs. 18.6 on a scale of 0–30). Moreover, women who had had a surgical abortion were more likely than those in the medication abortion group to say that they would choose the same method again (100% vs. 53%), and less likely to say that the experience was worse than expected (0% vs. 53%). The two groups did not differ on measures of anxiety and depression, and nearly all women (97–100%) said they were satisfied with the information and counseling they had received before, during and after their abortions.
The investigators note that the low participation rate in their study, which resulted in a sample size far smaller than they had desired, illustrates the challenges of conducting a randomized trial comparing outcomes for the two approaches to abortion. In general, however, "women did seem to prefer [surgical termination of pregnancy]," most likely because of the "heavier bleeding, greater pain and unexpected overnight stays" associated with medication abortion. However, given that many women wish to avoid anesthesia and surgery, "a patient-centered abortion service should offer the choice of [medication or surgical termination] after 13 weeks of gestation," the researchers advise.—P. Doskoch