Dr. Benjamin’s vast experience enables him to provide safe, in-office, surgical care for patients deemed high risk. He is the premier referral source within the South Florida medical community and is highly respected by his peers. Many physician referrals consist of high risk, complex surgical patients. Some of the medically and surgically high risk indicators include:
• Fetal Developmental and Chromosomal Abnormalities
• Cardiac History
• Uterine Fibroids
• Prior Cesarean Section
• Clotting Disorders
• Morbid Obesity
• Multiple Gestation
General Abortion Information
Abortion can best be defined as the expulsion of the products of conception, i.e. a fetus or embryo with associated placenta and membranes, prior to viability. There is no uniform agreement as to the point in pregnancy at which a fetus ought to be considered viable or capable of living outside the uterus. Generally, it is felt to be between 24 and 26 weeks from a standard last menstrual period, even though survival does not become a probability until 28 weeks. If the products of conception are expelled spontaneously, as is frequently the case in nature, the process is referred to as a spontaneous abortion. When the pregnancy is surgically removed for the purpose of terminating a pregnancy, the process is known as an induced abortion. Induced abortion is the subject of this discussion.
In most states, including the state of Florida, a qualified physician may electively induce an abortion until viability. Beyond that stage, abortion is generally permitted only for severe fetal abnormality or to preserve the life of the mother. Because most women recognize pregnancy and make their decision for abortion early, most pregnancy terminations are performed in the first trimester, i.e. at 12 weeks or less of pregnancy.
NOTICE: We offer and recommend IUD (Intrauterine Device/contraception) insertion at the same time as your procedure. The advantages are: You only have one procedure and not two, you will have no pain with the insertion of the IUD, you won’t need any additional visits to the office and you will have immediate protection against pregnancy.
The advantage is avoiding the anxiety of waiting until 6-7 weeks of pregnancy as was previously customary. This is particularly important if severe pregnancy symptoms are present. In addition, less cervical dilation is required. The disadvantage is that confirmation of successful termination may require follow-up pregnancy testing because visual inspection of tissue may not be adequate due to the small size.
First Trimester Abortion
With few exceptions, surgically (as opposed to medically) induced abortions are performed by a procedure generally known as Dilation and Aspiration (“D&A”). Typically, this procedure is performed in a physicians office or abortion clinic. It may also be performed in an out patient surgical center or hospital.
The procedure may safely be performed using local anesthesia with reasonable comfort, but in recent years it has become common practice to provide various levels of sedation or “twilight sleep” using intravenous drugs in the category of narcotics and tranquilizers. Once a satisfactory level of sedation and local anesthesia is achieved, the cervix or neck of the uterus (womb) must be opened to remove the contents of the uterus.
In the first 12 weeks of pregnancy this is generally accomplished by sequentially inserting tapered rods of increasing width called “dilators”. Usually, the cervix needs to be opened no more than 1/4″ – 1/2″ in the first trimester. This can be done with anywhere between 1 and 8 dilator insertions, depending on the stage of pregnancy and the resistance of the individual cervix.
Once the cervix has been adequately dilated, the products of conception are removed by inserting a hollow plastic tube called a “vacurette” and applying negative pressure (suction/ vacuum). Generally, the vacurette is moved in a series of in and out strokes or is rotated to enhance the traction forces at the tip of the vacurette. This is sometimes followed by curetting (scraping) the walls of the uterus to ensure that no tissues are remaining that might cause subsequent problems.
It is appropriate immediately following surgery to examine the tissues to assure compatibility between what was removed and what was expected based on pre-operative evaluation.
D&A in reasonably experienced hands is one of the safest surgical procedures performed today, the mortality being 80 times less than child birth which is quite low. The most common complications involve excessive bleeding and infection that sometimes require recuretting (repeat suctioning) of the uterus.
Infrequently, D&A may result in injury to the uterus or surrounding internal organs, e.g. intestines, bladder or major blood vessels which requires opening the abdomen to surgically repair. The aftermath of D&A typically consists of bleeding which is similar in degree to a normal menstrual period and menstrual-like cramps which are similar in severity to a “bad menstrual period”. These symptoms tend to subside rapidly but persist to some degree for as long as 2 weeks.
Emotional reactions to surgery are common. Mild depression associated with low hormone levels and a feeling of loss is usually brief. The emotionally healthy individual will generally rationalize the situation as they do with other life stresses and quickly put their experience in perspective. On rare occasion, counseling or drug therapy may be required. Long range concerns usually center about future fertility. If there have been serious complications from surgery such as severe infection or excessive bleeding that required vigorous scraping, fertility may be affected.
Obviously, complications, which result in hysterectomy, will result in sterility. These problems are rare. The issue of an increased risk of breast cancer has received wide publicity. This concern has been essentially put to rest by studies which rather than relying on an individual recollection, reviewed patient records.
Mifepristone is a synthetic hormone originally developed in Europe (the French abortion pill). It was used there for many years where it provided to be safe and effective alternative to surgical abortion. After years of delay because of political controversy, it was approved by the FDA for use in the United States in 2000. We have been using Mifepristone since then with very satisfactory results. It has been our experience, that up to the 8th week of pregnancy, Mifepristone is as safe and effective as surgical abortion. Although it involves a longer process and increased pain, Mifepristone is an important option for women whose priority is privacy, autonomy or the comforts of their own home.
Dr. Benjamin provides a preliminary screening which includes pelvic ultrasound to insure that the stage and location of the pregnancy are appropriate for Mifepristone. If there are no medical issues, we administer the Mifepristone table at the time of the initial visit. We provide a second drug, Cytotec, as well as pain medication of choice with instructions for use at home. We include a 2 week follow-up visit to insure that the procedure is complete.
How It Works
Mifepristone, once absorbed into they system, blocks the “hormone of pregnancy”, progesterone. This is the hormone that maintains the lining membrane of the uterus. Once deprived progesterone, the membrane disintegrates and the pregnancy detaches. If no further action is taken, the pregnancy will naturally miscarry. This may not occur, however, for many days. To hasten the process, we have chosen to administer Cytotec, a drug that is well established as a safe and effective method of contracting the uterus. When taken 6 hours after Mifepristone, it rapidly and reliably causes the uterus to contract resulting in miscarriage.
In our experience, Mifepristone followed by Cytotec has been approximately 99% effective in terminating pregnancy when used between the 4th and 8thf week of pregnancy. In the 1% of failure to terminate the pregnancy, surgical termination is strongly recommended and is provided at an additional charge. An additional 1% of patients will require D&C to remove tissue not completely expelled in the process of miscarriage. In general, we have found a high percentage of satisfaction in well selected patients who choose Mifepristone.
Abortion performed in the middle months of pregnancy, i.e. 13-24 weeks is a significantly different procedure from the first trimester. Although there are similarities, as pregnancy progresses through the second trimester, the procedures used require greater time, skill and entail somewhat greater risk, though still significantly lower than carrying a pregnancy to term.
The essential difference is that the cervix must be dilated to increasing diameters with increasing stage of pregnancy. The extent to which the cervix can be safely dilated with dilators varies, generally being easier in women who have delivered children previously. Most experienced physicians will avoid the use of mechanical dilators beyond the 14th week of pregnancy. Some will avoid them after the 10th week. As a general rule, the method of choice for dilating the cervix beyond the 12th week is osmotic dilators.
These are basically stalks of material that absorb water and expand once placed inside the cervix. Once they have been inserted they are left in place anywhere from six hours to overnight. The result is that the cervix is both dilated and softened with little risk of the damage that might occur if wide dilation were to be attempted with mechanical dilators.
In more advanced stages of pregnancy, varying from 20-23 weeks and beyond, dilatation is generally accomplished in a serial fashion. This involves the insertion of a number of osmotic dilators for 6 or more hours to dilate the cervix adequately to insert 10 to 20 or more osmotic dilators followed, usually the next day with the Evacuation (“E”) of D&E of the uterus. This stage of surgery, as in the first trimester procedure is usually performed under sedation combined with local anesthesia. The fetus and placenta are generally removed with forceps, usually followed with suction curettage to remove debris. Sharp curettage may or may not be performed as a final step.
An alternative to this procedure in the mid-trimester and beyond is induction of labor. There are a variety of procedures available to accomplish this end, but in general they all involve stimulating the uterus to contract much the same way as it does in a spontaneous term labor. This approach would seem at first to be ideal, since it may involve no instrumentation and is totally natural.
In reality, however, the uterus is frequently very much disinclined to labor at these early stages, and even when it does, the cervix may be very disinclined to dilate. There are a variety of options for “induction”.
The technique current in commonest use involves a group of drugs called Prostaglandins. These are administered either in the cavity of the uterus by injection or in the vagina as a gel or suppository. These may be used in conjunction with osmotic dilators as well.
There is some controversy as to which of these techniques is the safest. Most available data suggest that prior to 20 weeks gestation, D&E offers greater safety and efficacy. Beyond that stage, there is probably inadequate data to prove either is superior.
We believe that experience is the primary determinant of safety in the later stage procedures. In experienced hands, we believe that D&E is preferable. It is more predictable and entails less serious risk. The final alternative is “hysterectomy” which is basically an early cesarean section.
This procedure is best reserved for situations where emptying the uterus by the vaginal route is not possible. It has the disadvantages of greater risk, greater pain, greater recuperation, and higher cost and perhaps of greatest significance, it precludes future vaginal birth.