Andre Seidenberg, Switzerland
Local anaesthesia as the safest analgesic method for a surgical abortion up to 12 weeks could fall into oblivion in many high standard countries. WHO (2003), British (RCOG 2004) and French (ANAES 2001) official guidelines recommend to favour local in preference to general anaesthesia.
These guidelines refer mainly to an old but very large American CDC study on mortality (Peterson 1981, Lawson 1994). Nevertheless the evidence to favour local in preference to general anaesthesia was confirmed by several new studies with morbidity parameter as end points (Osborn 1990, Thonneau 1998, Pons 2004).
Deaths from abortion are very rare in developed societies with good access to legal medical care. In the US 8.5 deaths per 1 million abortion were registered in the CDC-study. Nearly four times more death cases were recorded after general than after local anaesthesia. In-depth analysis of the large data set revealed this disadvantage of general anaesthesia, both among those woman whose death was directly caused by the anaesthesia as well among those whose died through causes not directly connected to the analgesic technique. Confounding factors like sterilizations, pre-existing diseases or gestational age had no crucial influence: general anaesthesia remained 2.5 times riskier than local anaesthesia.
No doubt general anesthesia techniques have improved during the past 3 decades. E.g., Halothane had undesired effects on the uterus. Nevertheless, the younger studies exhibit more perforations of the uterine wall, cervical lesions and severe bleedings through general anaesthesia than through local anaesthesia (Soulat 2006, Osborn 1990).
Even so, we want to point to the fact that local anaesthetics could be lethaly overdosed. Experience and good surgical technique are of high importance for surgical abortion (Hern 1990). The technique of local anaesthesia for surgical abortion was described in a dissertation monograph by Ambassa 2007. Independent of the lower costs, many women prefer to have an abortion under local anesthesia rather than under general anesthesia, when given the choice (Bachelot 1992).
Anatomy and clinical aspects
André Seidenberg (Switzerland)
Local anesthesia is the method of choice for an induced abortion by the surgical suction method. This is the evidence based recommendation of the WHO (2003) and the official British (RCOG 2004) and French guidelines (ANAES 2001). A general anesthesia is not recommended as method of choice for an induced abortion by the surgical suction method.
These recommendations are mainly based on an old CDC-study comparing the mortality following abortion with local anesthesia versus general anesthesia (Peterson 1981, Lawson 1994). Deaths caused by induced abortion at less than 12 weeks gestation are rare in developed countries offering a good access to contraception and abortion treatment: In the USA 8.5 deaths among 1 million legal induced abortion cases were found. According to the CDC-study almost four times more woman died by general anesthesia than by local anesthesia for an induced abortion by the surgical suction method. These correlations were also visible analyzing only deaths not directly caused by the method of the anesthesia: 3½ times more woman died after general anesthesia than after local anesthesia. The same correlations revealed when biases as sterilization, preexisting diseases, or duration of the gestation were considered for the calculations: general anesthesia remained minimally 2.5 times riskier than local anesthesia. Younger studies with morbidity end points revealed the same technical advantages of the local anesthesia compared to general anesthesia for an induced abortion by the surgical suction method (Pons 2004, Thonneau 1998, Osborn 1990). With general anesthesia (without Halothane®) more uterine perforations, cervical lesions, and severe bleedings were recorded (Soulat 2006, Osborn 1990).
Experience and good surgical technique (Hern 1990) are crucial. A French thesis (Ambassa 2007) of last year gives an overall view on local anesthesia for an induced abortion by the surgical suction method. Priming (with 2 tabs Misoprostol intra vaginally) is recommended 3 hours before the operation. Only the cervix is anesthetized, which alleviates dilation. The pain caused by the uterine contraction during and after the suction procedure is not influenced by the local anesthesia. The sensible nerve fibers deriving from the inferior hypo gastric plexus enter at the isthmus of the uterus. Be aware of the close neighborhood of these blood vessels and be careful with avoiding intra vascular injection. The maximum of 3 mg / kg Lidocain (≈ 20 ml of a 1% solution) should not be exceeded. All deaths caused directly through local anesthesia were due to overdose (Peterson 1981).
Para Cervical Infiltration / Para Cervical Block
Intra Cervical Infiltration
Trans Canalicular Infiltration
Sub Epithelial Infiltration Modified acc. Ambassa 2007
There are principally 2 techniques for the infiltration of the local anesthetic (Ambassa 2007): the para cervical block and the intra cervical Infiltration. Many variants are used in practice. For the para cervical block the anesthetic depot is injected at 4 and 8 a clock in 2-5 mm depth. For intra cervical infiltration often a 2% solution of Lidocain is used. Addition of Adrenalin is not recommended because diffusion is suppressed and a longer effect of the anesthetic is not needed for cervical the dilation. Adrenalin additionally accentuates side effects as there are oppression and palpitations.
Comparing pains the local anesthesia for induced surgical abortion causes an acceptable level of analgesia (Ambassa 2007). E.g. pains during the cervical dilation are comparable to menstrual pains.
Regardless of the lower costs many woman prefer the local anesthesia to general anesthesia for induced abortion by the surgical suction method (Bachelot 1992).
Experiences of health care professionals
André Seidenberg (Switzerland)
Not only by the general public but also by health professionals induced abortion is regarded as something special. Emotional, ethical, and psychological considerations were inevitable and a matter of course. We conducted a little survey on opinions and measures in the region of Zurich, Switzerland. Medical directors of gynaecological clinics take precautions for their staff, who is involved in induced abortion treatment.