Abortion in the First Trimester. Guideline of the DGGG (S2k-Level, AWMF Registry No. 015-094, December 2022) – Part 2 with Recommendations for Surgical Termination of Pregnancy and Follow-up Care After Termination of Pregnancy

Abstract

Purpose The aim was to develop evidence-based recommendations where possible. The guideline presents the medical principles and scientific evidence for indications, counselling of affected persons, performing terminations, the choice of method, and the care and monitoring of a terminated pregnancy up until week 12 + 0 of gestation p. c.

Methods In accordance with the requirements for an S2k-guideline, the contents of the guideline were drafted following a systematic search of the literature by a representative interdisciplinary group of experts. Guideline authors held several formal meetings under the auspices of the German Society for Gynaecology and Obstetrics (DGGG) during which the contents of the guideline were finalised and agreed upon.

Recommendations The guideline provides recommendations on the surgical termination of pregnancy and follow-up care after termination of pregnancy.

Key words

guideline - abortion - medical termination of pregnancy - surgical termination of pregnancy - 1st trimester

I  Guideline Information

Guidelines programme of the DGGG, OEGGG and SGGG

For information on the guidelines programme, please refer to the end of the guideline.

Citation format

Abortion in the First Trimester. Guideline of the DGGG (S2k-Level, AWMF Registry No. 015-094, December 2022) – Part 2 with Recommendations for Surgical Termination of Pregnancy and Follow-up Care After Termination of Pregnancy. Geburtsh Frauenheilk 2023; 83: 1221–1234

Guideline documents

The complete long version of this guideline in German together with a list of the conflicts of interest of all of the authors is available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-094.html

Guideline authors

See [Tables 1] and [2].

Table 1 Leading and/or coordinating guideline author.

Author	AWMF professional society
Prof. Dr. Matthias David	German Society for Gynaecology and Obstetrics [Deutsche Gesellschaft für Gynäkologie und Geburtshilfe] (DGGG)
Prof. Dr. Stephanie Wallwiener	German Society for Psychosomatics in Gynaecology and Obstetrics [Deutsche Gesellschaft für Psychosomatik in Frauenheilkunde und Geburtshilfe] (DGPFG)

Table 2 Contributing guideline authors.

Author Mandate holder	DGGG working group (AG)/ AWMF/non-AWMF professional society/ organisation/association
Anne Achtenhagen	Federal Association donum vitae for the Promotion of the Protection of Human Life [Bundesverband donum vitae zur Förderung des Schutzes des menschlichen Lebens]
Prof. Dr. Christian Bamberg	German Society for Ultrasound in Medicine [Deutsche Gesellschaft für Ultraschall in der Medizin]
Dr. Cornelia Bormann	Gynaecological Endoscopy Working Group [Arbeitsgemeinschaft Gynäkologische Endoskopie]
Prof. Dr. Matthias David	German Society for Gynaecology and Obstetrics
Prof. Dr. Ursula Felderhoff-Müser	German Society for Pediatric and Adolescent Medicine [Deutsche Gesellschaft für Kinder- und Jugendmedizin]
Sylvia Groth	Working Group on Womenʼs Health in Medicine, Psychotherapy and Society [Arbeitskreis Frauengesundheit in Medizin, Psychotherapie und Gesellschaft]
Kristina Hänel	German Society for General and Family Medicine [Deutsche Gesellschaft für Allgemein- und Familienmedizin]
Dr. Klaus König	Federal Association of Gynaecologists [Berufsverband der Frauenärzte]
Prof. Dr. Matthias Korell	German Society for Gynaecological Endocrinology and Reproductive Medicine [Deutsche Gesellschaft für gynäkologische Endokrinologie und Fortpflanzungsmedizin]
Prof. Dr. Susanne Michl	Academy for Ethics in Medicine [Akademie für Ethik in der Medizin]
Prof. Dr. Silke Redler	German Society for Human Genetics [Deutsche Gesellschaft für Humangenetik]
Prof. Dr. Ekkehard Schleußner	German Society of Perinatal Medicine [Deutsche Gesellschaft für Perinatalmedizin]
Helga Seyler	Federal Association pro familia – German Society for Family Planning, Sexual Education and Sexual Counselling [Bundesverband pro familia – Deutsche Gesellschaft für Familienplanung, Sexualpädagogik und Sexualberatung]
Prof. Dr. Markus Wallwiener	Gynaecological Oncology Working Group [Arbeitsgemeinschaft Gynäkologische Onkologie]
Prof. Dr. Stephanie Wallwiener	German Society for Psychosomatics in Gynaecology and Obstetrics

The following professional societies/working groups/organisations/associations stated that they wished to contribute to the guideline text and participate in the consensus conference and nominated representatives to attend the conference ([Table 2]).

The guideline was moderated by Dr. Monika Nothacker (AWMF-certified guidelines adviser/moderator).

Abbreviations

AWMF: Association of the Scientific Medical Societies in Germany [Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften]

BfArM: (German) Federal Institute for Medicinal Products and Medical Devices [Bundesinstitut für Arzneimittel und Medizinprodukte]

BVF: (German) Federal Association of Gynaecologists [Berufsverband der Frauenärzte]

GW: weeks of gestation

β-hCG: beta-human chorionic gonadotropin

IUD: intrauterine device

LNG: levonorgestrel

p. c.: post conception

NIH: National Institutes of Health

p. m.: post menstruation

SOP: standard operating procedure

StGB: (German) Criminal Code [Strafgesetzbuch]

WHO: World Health Organisation
 

II  Guideline Application

Purpose and objectives

The aim of this guideline is to present the medical principles and scientific evidence for methods, indications, counselling of affected women, performing terminations, choice of method, and the care and monitoring of a termination of pregnancy up until week 12 + 0 of gestation p. c.

Targeted areas of care

• Inpatient care sector, and

• outpatient care sector

Target user groups/target audience

This guideline is aimed at the following groups of people:

• gynaecologists in private practice

• hospital-based gynaecologists

• other physicians involved in abortion counselling and carrying out terminations of pregnancy

• staff in counselling centres in accordance with § 218/219 StGB

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/representatives of the participating medical professional societies, working groups, organisations, and associations and the board of the DGGG and the DGGG Guidelines Commission as well as by the boards of the SGGG and OEGGG in November 2022 and was thereby approved in its entirety.

This guideline is valid from 26 January 2023 through to 25 January 2026. Owing to the contents of this guideline, this period of validity is only an estimate. The publication of new information or changes to care needs may require the guideline to be updated earlier (see next chapter).

III  Methodology

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines the two approaches.

This guideline was classified as: S2k.

Grading of recommendations

The grading of evidence based on the systematic search, selection, evaluation, and synthesis of an evidence base which is then used to grade the recommendations is not envisaged for S2k guidelines. The individual statements and recommendations are only differentiated semantically, not by symbols ([Table 3]).

Table 3 Grading of recommendations (based on Lomotan et al., Qual Saf Health Care 2010).

Description of binding character	Expression
Strong recommendation with highly binding character	must/must not
Regular recommendation with moderately binding character	should/should not
Open recommendation with limited binding character	may/may not

Statements

Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is not possible to provide any information about the level of evidence for these statements.

Achieving consensus and level of consensus

At structured NIH-type consensus-based conferences (S2k/S3 level), authorised participants attending the session vote on draft statements and recommendations. The process is basically as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by a repeat vote. Finally, the level of consensus is determined, based on the number of participants ([Table 4]).

Table 4 Level of consensus based on extent of agreement.

Symbol	Level of consensus	Extent of agreement in percent
+++	Strong consensus	> 95% of participants agree
++	Consensus	> 75 – 95% of participants agree
+	Majority agreement	> 50 – 75% of participants agree
–	No consensus	< 51% of participants agree

Expert consensus

As the term indicates, this refers to consensus decisions taken relating specifically to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP).

The strength of the recommendation is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).

IV  Guideline

Introduction

In principle, pregnancies can be terminated with medication or surgery. Which method is best in each individual case should be decided during an open-ended, unbiased discussion with the pregnant woman.

This guideline was compiled in accordance with the regulations of the AWMF (Association of the Scientific Medical Societies in Germany). In accordance with the requirements for S2k-guidelines, the contents of this guideline, based on a systematic search of the literature, were formally agreed upon by a representative interdisciplinary group of experts.

Details on the methodological approach are available in the guidelines report.

This guideline is mainly aimed at physicians who perform abortions and the professionals involved in the care and counselling of women who wish to have an abortion.

It also aims to support women seeking advice, persons working in counselling centres as defined in § 218/219 StGB, patients and their families.

The following recommendations and two statements focus on surgical terminations of pregnancy and the follow-up care of women who have terminated a pregnancy.

Surgical termination of pregnancy

Consensus-based recommendation 6.E62
Expert consensus	Level of consensus ++
A suitable examination should be carried out in good time prior to performing surgical termination of pregnancy to identify any somatic and psychological disorders which could be associated with a higher risk of complications. Further investigations on an outpatient or inpatient basis may be carried out in individual cases.

Consensus-based recommendation 6.E63
Expert consensus	Level of consensus ++
Women in whom a pregnancy has been surgically terminated may be offered peri-operative antibiotic prophylaxis in the form of single-dose prophylaxis.

Consensus-based statement 6.S1
Expert consensus	Level of consensus ++
Doxycycline, metronidazole, and β-lactam antibiotics such as cephalosporins can reduce the risk of infection after a termination of pregnancy.

Consensus-based recommendation 6.E64
Expert consensus	Level of consensus ++
Women with a relevant risk of or a suspected sexually transmissible infection should be examined for sexually transmissible diseases or cervical infection in good time prior to performing the surgical termination of pregnancy. If the infection is confirmed, the affected woman should receive evidence-based medical therapy in addition to peri-operative administration of antibiotics.

Consensus-based recommendation 6.E65
Expert consensus	Level of consensus ++
Cervical priming with 400 µg misoprostol should be carried out prior to surgical termination of pregnancy, especially in nulliparous women or women who have had prior cervical surgery.

Consensus-based recommendation 6.E66
Expert consensus	Level of consensus ++
Alternatives that may be used instead of misoprostol are: intracervical osmotic dilators placed 3 – 4 hours before the termination or mifepristone 200 – 400 mg administered orally 24 – 48 hours before surgical termination of pregnancy.

Consensus-based recommendation 6.E67
Expert consensus	Level of consensus +++
An early surgical termination of pregnancy (< 7 + 0 weeks of gestation) should be combined with routine, pre- and post-operative ultrasound examination and post-operative inspection of the aspirated tissue.

Consensus-based recommendation 6.E68
Expert consensus	Level of consensus ++
A β-hCG follow-up test must be performed if no pregnancy tissue is detected.

Consensus-based recommendation 6.E69
Expert consensus	Level of consensus +++
If a pregnancy of unknown location is suspected post-operatively, serial determination of the patientʼs β-hCG serum levels should be carried out.

Consensus-based recommendation 6.E70
Expert consensus	Level of consensus ++
The method of choice for surgical termination of pregnancy in the first trimester (< 14 + 0 GW p. m.) must be vacuum aspiration.

Consensus-based recommendation 6.E71
Expert consensus	Level of consensus +++
A not too large suction cannula (aspiration pipette) adapted to the week of gestation should be used.

Consensus-based recommendation 6.E72
Expert consensus	Level of consensus ++
Abortions should not be carried out using a metal curette.

Consensus-based recommendation 6.E73
Expert consensus	Level of consensus +++
A metal curette must not be used to carry out post-operative curettage.

Consensus-based recommendation 6.E74
Expert consensus	Level of consensus +++
Specially shaped, blunt-tip abortion forceps may be used when terminating a pregnancy late in the first trimester (12 + 0 to < 14 + 0 GW) to remove foetal parts and placental tissue.

Consensus-based recommendation 6.E75
Expert consensus	Level of consensus ++
After being informed about the advantages and disadvantages of the different anaesthetic techniques, women must be able to choose which method they prefer.

Consensus-based recommendation 6.E76
Expert consensus	Level of consensus ++
Vacuum aspiration carried out under local anaesthesia should be carried out by physicians who have sufficient experience and routine with this technique.

Consensus-based statement 6.S2
Expert consensus	Level of consensus +++
Oral non-steroidal antiphlogistic agents may be administered for pain relief prior to the intervention.

Consensus-based recommendation 6.E77
Expert consensus	Level of consensus +++
Analgosedation must not be offered as a method of choice to women who wish to have a surgical termination of pregnancy.

Consensus-based recommendation 6.E78
Expert consensus	Level of consensus +++
The choice of anaesthetic procedure should be a joint decision by the well-informed patient and the anaesthesiologist.

Consensus-based statement 6.S3
Expert consensus	Level of consensus +++
General anaesthesia in the form of total intravenous anaesthesia (TIVA) is a possible, commonly used option for outpatient surgical terminations of pregnancy. In clinical inpatient/outpatient practice, options in addition to TIVA may include balanced anaesthesia or a regional anaesthetic procedure, e.g. spinal anaesthesia.

Consensus-based recommendation 6.E79
Expert consensus	Level of consensus +++
Many women consider non-pharmacological support and interventional measures during the termination of pregnancy to be helpful and they may therefore be offered to patients.

Consensus-based recommendation 6.E80
Expert consensus	Level of consensus ++
Routine histopathologic examination of the tissue obtained during surgical termination of pregnancy does not have to be carried out.

Consensus-based recommendation 6.E81
Expert consensus	Level of consensus +++
If the pregnancy is being terminated because of embryonic or foetal abnormalities detected during a prenatal diagnostic workup, a discussion must be held with the patient whether further genetic investigations are indicated and, if they are required, the aim and content of such tests. The statutory requirements of the German Genetic Diagnostics Act must be taken into account. (Please additionally refer to the AWMF S2e-guideline “First Trimester Diagnosis and Therapy @ 11 – 13 + 6 Weeks of Gestation”, registry number 085-002).

Consensus-based recommendation 6.E82
Expert consensus	Level of consensus +++
To reduce the risk, especially the risk of uterine perforation, a vaginal ultrasound examination should be carried out prior to the termination to determine the position of the uterus, any uterine malformations, and possible disorders of placentation and establish the actual gestational age.

Consensus-based recommendation 6.E83
Expert consensus	Level of consensus ++
If the patient is already known to be at higher risk of surgical complications, the termination of pregnancy should only be carried out in facilities with the structures and staffing which will ensure that any such complications can be adequately treated without delay if they occur.

Consensus-based recommendation 6.E84
Expert consensus	Level of consensus ++
Every institution in which surgical terminations of pregnancy are carried out should have written emergency protocols (SOP), which describe which procedures to follow for the most common peri-operative complications during surgical termination of pregnancy.

Consensus-based recommendation 6.E85
Expert consensus	Level of consensus +++
If there is a suspicion that an intrauterine pregnancy has persisted after surgical termination of pregnancy, this must be checked quickly by ultrasound examination or serial determination of serum β-hCG levels.

Consensus-based recommendation 6.E86
Expert consensus	Level of consensus +++
Any infection of the genital organs after surgical termination of pregnancy must be treated with antibiotics.

Consensus-based recommendation 6.E87
Expert consensus	Level of consensus +++
After surgical termination of pregnancy, women must be informed about the different forms that bleeding and pain may take and the use of non-steroidal antiphlogistic agents for pain relief and how pregnancy symptoms will disappear over time.

Consensus-based recommendation 6.E88
Expert consensus	Level of consensus +++
Women must be informed that they can get pregnant again just a couple of days after the termination and that, if they do not want to become pregnant, they must use contraceptives.

Consensus-based recommendation 6.E89
Expert consensus	Level of consensus +++
Recommendations about not using tampons, menstruation cups or similar and not having sexual intercourse for some time after surgical termination of pregnancy must not be given because evidence for them is lacking.

Consensus-based recommendation 6.E90
Expert consensus	Level of consensus +++
After surgical termination of pregnancy, women must be informed about signs and symptoms of complications (residual pregnancy tissue, infection of the lesser pelvis) and must know who they need to contact in such an event.

Consensus-based recommendation 6.E91
Expert consensus	Level of consensus ++
After the termination, all women should be offered a routine follow-up examination after surgical termination of pregnancy.

Consensus-based recommendation 6.E92
Expert consensus	Level of consensus ++
The decision to carry out a second intervention must be primarily based on clinical symptoms and must be made together with the woman after she has been informed about the risks and benefits of the intervention.

Follow-up care after termination of pregnancy

Consensus-based recommendation 7.E93
Expert consensus	Level of consensus +++
Women who have a surgical termination of pregnancy and, if necessary, their partner must be informed that they may experience a wide range of different emotions, as can occur with other serious life choices, and that these emotions are not indications of a mental disorder.

Consensus-based recommendation 7.E94
Expert consensus	Level of consensus +++
The medical staff involved in the termination of pregnancy must be accepting and respond supportively to the emotional reaction of women who undergo an abortion. Stigmatising behaviour must be avoided.

Consensus-based recommendation 7.E95
Expert consensus	Level of consensus +++
After the abortion, women and, if necessary, their partner must be encouraged to seek support from suitable persons in their private circle of friends and family and, in special situations, seek professional support.

Consensus-based recommendation 7.E96
Expert consensus	Level of consensus +++
Women with the relevant risk factors or suffering from noticeable psychological stress must be informed after the abortion about the range of available pregnancy conflict counselling services for the follow-up period and about psychological counselling services. Their partner must be informed that these offers of support are also available to them.

Consensus-based recommendation 7.E97
Expert consensus	Level of consensus +++
Women with known psychological problems should be asked whether they are receiving psychotherapeutic or psychiatric support and whether they are able to broach the issue of problems relating to their abortion during their support sessions. If necessary, they must be informed about (additional) specific counselling services.

Consensus-based recommendation 7.E98
Expert consensus	Level of consensus ++
Additional dissenting opinion of the BVF to 7.E98: From the point of view of medical specialists, contraindications listed in the risk catalogue of the BfArM must be considered.
Women must be offered contraception counselling during the preliminary talk as well as immediately before or after the termination of pregnancy.

Consensus-based recommendation 7.E99
Expert consensus	Level of consensus +++
Women must be provided with the means to contraception immediately following surgical termination of pregnancy or, if they have a medical termination, on the day of taking mifepristone (if they are using hormonal methods) or after complete abortion has been confirmed (if they are using an intrauterine method).

Consensus-based recommendation 7.E100
Expert consensus	Level of consensus +++
Contraception counselling must provide the basis for an informed decision by the woman about her choice of preferred method of contraception.

Consensus-based recommendation 7.E101
Expert consensus	Level of consensus +++
Possible reasons for the failure of contraception or failure to use contraception before the abortion should be enquired into without making any value judgements.

Consensus-based recommendation 7.E102
Expert consensus	Level of consensus +++
During every counselling session on contraception, it is important to ensure that no pressure is brought to bear on the woman. The decision not to use any form of contraception must be respected.

Consensus-based recommendation 7.E103
Expert consensus	Level of consensus +++
Hormonal contraceptives may be started – after taking contraindications and risks into consideration (see the BfArM risk catalogue) – concurrently with the termination of pregnancy, irrespective of the method used for the termination, without affecting the risk profile or the success of the termination.

Consensus-based recommendation 7.E104
Expert consensus	Level of consensus +++
If depot medroxyprogesterone acetate (DMPA) and mifepristone are taken concurrently during a medical termination of pregnancy, the patient should be informed about the slightly higher persistent pregnancy rate, even if the overall risk is classified as low.

Consensus-based recommendation 7.E105
Expert consensus	Level of consensus +++
If a woman opts to have an IUD as her method of contraception, the IUD should be placed either immediately after surgical termination of the pregnancy or, in women who have had a medical termination, as early as possible after complete abortion has been confirmed.

Consensus-based recommendation 7.E106
Expert consensus	Level of consensus ++
Tubal sterilisation should not be offered as a method of contraception directly after termination of a pregnancy.

The detailed list of references is available in the long German-language version of the guideline.

Publication History

Received: 05 April 2023
Received: 11 April 2023

Accepted: 14 April 2023

Article published online:
05 October 2023