DESCRIPTION

Intra-amniotic instillation is a rarely-used technique of electively terminating a pregnancy by inducing an abortion. This particular method involves amniocentesis (a procedure where a small amount of amniotic fluid is withdrawn) and injection of various fluids into the "bag of waters" (amniotic sac of fluid surrounding the fetus) to initiate labor, causing uterine contractions. It is recommended only if your pregnancy test was positive and your last menstrual period was 16 to 20 weeks ago.

The method of instillation abortion was first developed in 1934 by Eugen Aburel. It is most frequently used between the 16th and 24th week of pregnancy. Intrauterine instillation accounted for 0.8 percent of the total incidence of induced abortion in the United States during 2002. The use of such methods in the U.S. declined from 10.4 percent in 1972 to 1.7 percent in 1985. In 1968, abortion by the instillation of saline solution accounted for 28 percent of those procedures performed legally in San Francisco, California.

In a 1998 Guttmacher Institute survey, sent to hospitals in Ontario, Canada, 9 percent of those hospitals in the province which offered abortion services used saline instillations, 4 percent used urea, and 25 percent used prostaglandin. A 1998 study of facilities in Nigeria which provide abortion found that only 5 percent of the total number in the country use saline.

This information and instruction discussion is based on the assumption that you have had counseling and competent guidance in making your decision to seek this procedure for terminating the pregnancy.

INDUCTION ABORTION

Induction abortion is a procedure that uses salt water, urea, or potassium chloride to terminate the viability of the pregnancy. Your abortion provider will insert prostaglandins into the vagina and pitocin will be given intravenously. Laminaria is then usually inserted into your cervix to begin dilation. This procedure is rarely used, and normally only occurs when there is a medical problem or illness in the fetus or women.

The side effects are similar to dilation and evacuation, although in rare cases it is possible for the mother’s blood stream to be accidentally injected with saline or other medications. Excessive bleeding and cramping may also be experienced.

Contact your healthcare provider immediately if your symptoms persist or worsen.

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REASONS FOR PROCEDURE

Personal concerns about the social or economic aspects that involve an unplanned pregnancy.

Continuing with the pregnancy may pose a threat to the life of the mother.

Mother has a genetic condition which the fetus is at significant risk of acquiring, or the fetus has been tested and is known to have the condition (such as cystic fibrosis).

Pregnancy resulted from a rape.

Fetus is affected with a major disorder such as chromosomal abnormality or birth defect.

Fear that the fetus has been harmed by medications or other conditions.

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RISK INCREASES WITH

Obesity.

Smoking.

Poor nutrition.

Recent or chronic illness.

Use of drugs such as anti-hypertensives; muscle relaxants; tranquilizers; sleep inducers; insulin; sedatives; narcotics; beta-adrenergic blockers; or cortisone.

Use of mind-altering drugs, including: narcotics; psychedelics; hallucinogens; marijuana; sedative; hypnotics; or cocaine.

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DESCRIPTION OF PROCEDURE

The procedure is performed in a hospital.

The cervix is usually dilated prior to the procedure using sterile seaweed (luminaria).

Under local anesthesia, the health care practitioner will carefully insert a hollow needle into the uterus through the abdomen. The needle's penetration of the uterus will cause some pain, but it should not last long and should hurt no worse than an injection in any other part of the body.

MoonDragon's ObGyn Womens Health Information: Urea Instillation Method

Amniotic fluid is withdrawn and a chemical solution is introduced into the cavity either in a single dose, or as 2 doses 6 hours apart. The chemical solution consists of either saline, urea, or prostaglandin. The chemical solution induces uterine contractions which expel the fetus.

Contractions begin 12 to 24 hours later and the dead fetus and placenta are delivered. A synthetic hormone may be given to continue contractions until all the tissue has been expelled.

Sometimes a dilation and curettage procedure is necessary to remove any remaining tissue.

Instillation methods can require hospitalization for 12 to 48 hours. In one study, when laminaria were used to dilate the cervix overnight, the time between injection and completion was reduced from 29 to 14 hours. [Stubblefield, Phillip G., Carr-Ellis, Sacheen, & Borgatta, Lynn. (2004). Methods of Induced Abortion. Obstetrics & Gynecology, 104 (1), 174-185.]

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EXPECTED OUTCOME

Termination of the pregnancy.

Expect complete healing without complications. Allow about 1 week for recovery from surgery.

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POSSIBLE COMPLICATIONS

Retained placenta (usually can be removed with the use of surgical instruments).

Excessive bleeding.

Perforation or infection of the uterus.

Cervical laceration (tearing).

Failure of the procedure to expel all the tissue.

Once in common practice, abortion by intrauterine instillation has fallen out of favor, due to its association with serious adverse effects and its replacement by procedures which require less time and result in less physical discomfort.

Saline is in general safer and more effective than the other intrauterine solutions because it is likely to work in one dose. However, it poses a risk of medical emergency if it enters the blood stream. Prostaglandin is fast-acting, but often requires a second injection, and carries more side effects, such as nausea, vomiting, and diarrhea.

Instillation of either saline or prostaglandin is associated with a higher risk of immediate complications than surgical D&C. Dilation and evacuation is also reported to be safer than instillation methods. One study found that the risk of complications associated with the injection of a combination of urea and prostaglandin into the amniotic fluid was 1.9 times that of D&E.

The rate of mortality reported in the United States between 1972 to 1981 was 9.6 per 100,000 for instillation methods. This is in comparison to rates of 4.9 per 100,000 for D&E and 60 per 100,000 for abortion by hysterotomy and hysterectomy.

There have been at least two documented cases of unsuccessful instillation abortions that resulted in live births.

Cervical tears and even fistula may occur, and the cervix should be inspected on completion.

POST-PROCEDURE CARE

GENERAL MEASURES

Following the procedure, rest quietly at home for the remainder of the day.

If you have pain, place a heating pad or hot-water bottle on the abdomen or back. Hot baths frequently promote muscle relaxation and relieve discomfort. Repeat the baths as often as they provide comfort.

Use sanitary pads for bleeding, which may last for several days. If bleeding continues 10-14 days after surgery, you may then use tampons.

If contraception is desired, it can often be initiated shortly after the procedure. If you wish to take birth control pills, begin taking them either on the night you return from surgery or the next day. If you prefer an IUD, diaphragm or cervical cap, the fitting can be made during you next clinical appointment.

Your next menstrual period should begin 4 to 6 weeks after the procedure. If you take birth control pills, your first period will begin after you complete the first cycle of pills.

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MEDICATION

Prescription pain medication should generally be required for only 2 to 7 days following the procedure.

You may use non-prescription drugs, such as acetaminophen, for minor pain.

Antibiotics may be prescribed to reduce risk of infection.

Stool softener laxative, if needed to prevent constipation.

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ACTIVITY

Have someone drive you home from surgery. Rest quietly there for the remainder of the day. Resume normal activities slowly for the next day, if you feel able.

Do not have sexual relations for 2 weeks after surgery.

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DIET

No special diet.



NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...

Any of the following occurs:

Unexplained vaginal bleeding develops.

You develop signs of infection: headache, muscle aches, dizziness or a general ill feeling and a fever temperature of over 100°F orally.

New, unexplained symptoms develop. Drugs used in treatment may produce side effects.

You develop new symptoms, such as nausea, vomiting, constipation, diarrhea or abdominal swelling.

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REFERENCES

1. James, Denise. (2006). Therapeutic Abortion.

2. UIHC Medical Museum. (2006) The Facts of Life: Examining Reproductive Health.

3. Stubblefield, Phillip G., Carr-Ellis, Sacheen, & Borgatta, Lynn. (2004). Methods of Induced Abortion. Obstetrics & Gynecology, 104 (1), 174-185.

4. Potts, D.M. (1970). Termination of pregnancy. British Medical Bulletin, 26 (1), 65-71.

5. Strauss, Lilo T., Herndon, Joy, Chang, Jeani, Parker, Wilda Y., Bowens, Sonya V., Berg, Cynthia J. Centers for Disease Control and Prevention. (2005- 11-15). Abortion Surveillance - United States, 2002. Morbidity and Mortality Weekly Report.

6. Lawson, Herschel W., Atrash, Hani K., Saftlas, Audrey F., Koonin, Lisa M., Ramick, Merrell, & Smith, Jack C. (1989). Abortion Surveillance, United States, 1984-1985. Morbidity and Mortality Weekly Report.

7. Goldstein, P., & Stewart, G. (1972). Trends in therapeutic abortion in San Francisco. American Journal of Public Health, 62(5), 695-9.

8. Ferris, Lorraine E., McMain-Klein, Margot, & Iron, Karey. (1998). Factors Influencing the Delivery of Abortion Services in Ontario: A Descriptive Study. Family Planning Perspectives, 30 (3).

9. Henshaw, Stanley K., Singh, Susheela, Oye-Adeniran, Boniface A., Adewole, Isaac F., Iwere, Ngozi, & Cuca, Yvette P. (1998). The Incidence of Induced Abortion in Nigeria. International Family Planning Perspectives, 24 (4), 156-164.

10. Trupin, Suzanne R. (2006). Abortion.

11. Ferris, L. E., McMain-Klein, M., Colodny, N., Fellows, G. F., & Lamont, J. (1996). Factors associated with immediate abortion complications. Canadian Medical Association Journal, 154 (11), 1677-1685.

12. Grimes, D.A., & Schulz, K.F. (1985). Morbidity and mortality from second-trimester abortions. The Journal of Reproductive Medicine, 30 (7), 505-14.

13. Elliott, Jane. "'I survived an abortion attempt'." (December 6, 2005.) BBC News. P. Clarke, J. Smith, T. Kelly, MJ Robinson (January 2005)." "An infant who survived abortion and neonatal intensive care"". Journal of Obstetrics and Gynecology vol. 25 (1): pp. 73-74.

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MoonDragon's ObGyn Womens Health Information: Abortion Index

Drawings obtained from Obstetrics Illustrated, 3rd Edition by Garrey, Govan, Hodge & Callander.

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