Chapter 3. Recommendations and best practice statements across the continuum of abortion care

Cervical priming prior to surgical abortion: Recommendations 17-20 (3.3.7)

3.3.7 Cervical priming prior to surgical abortion

Prior to surgical abortion, cervical priming (also known as cervical preparation) may be considered for all women with a pregnancy of any gestational age, in particular for women with a pregnancy over 12 weeks of gestation. Cervical priming before surgical abortion is especially beneficial for women with cervical anomalies or previous surgery, adolescents and those with advanced pregnancies, all of whom have a higher risk of cervical injury or uterine perforation that may cause haemorrhage (135, 136). It may also facilitate the abortion procedure for inexperienced providers. However, cervical priming has disadvantages, including additional discomfort for the woman, and the extra cost and time required to administer it effectively.

Whether osmotic dilators or medication is used for cervical priming prior to the surgical abortion, this is done in advance of the procedure. As such, cervical priming may be initiated by a health worker other than the provider who will conduct the D&E.

CLINICAL SERVICES Recommendation 17: Cervical priming prior to surgical abortion at < 12 weeks of gestation

Prior to surgical abortion at < 12 weeks:

a. If cervical priming is used: Suggest the following medication regimens:

  • Mifepristone 200 mg orally 24–48 hours prior to the procedure
  • Misoprostol 400 μg sublingually 1–2 hours prior to the procedure
  • Misoprostol 400 μg vaginally or buccally 2–3 hours prior to the procedure

b. Recommend against the use of osmotic dilators for cervical priming.

Remarks:

  • The sublingual route is more effective for misoprostol administration.
  • Appropriate pain medication should be provided.

Source: Recommendation updated from Recommendation 7.2 in WHO (2012) (19).

Note on updating of the recommendation: This recommendation was reviewed using GRADE methods. The suggested mifepristone regimen is unchanged, but the misoprostol regimens have been updated, in terms of timing and route of administration, and laminaria is no longer a recommended option; these recommendations therefore replace the prior recommendation.

Rationale

An update of an existing Cochrane Review serves as the evidence base for this key question. The update identified 8 new studies, which makes a total of 61 included studies that assessed cervical priming methods for vacuum aspiration. From this review, approximately half of the included studies were evaluated to contribute towards the development of the Evidence-to-Decision (EtD) framework. The review includes the following cervical priming methods: medication with mifepristone and/or misoprostol and mechanical methods (i.e. natural or synthetic osmotic dilators). A summary of the evidence is presented in Supplementary material 2, EtD framework for Cervical priming prior to surgical abortion < 12.[1]

For Recommendation 17a, we suggest the option of misoprostol or mifepristone as a cervical priming agent prior to surgical abortion less than 12–14 weeks. For the studies that compared misoprostol versus mifepristone, time to complete the procedure was less for misoprostol, based on moderate-certainty evidence. However, the pre-procedure cervical dilation was greater with mifepristone use, based on moderate-certainty evidence. The side-effects profile was comparable between the two groups, based on very low-certainty evidence.

Regarding the timing of misoprostol administration, studies that compared the interval timing for administration of misoprostol for cervical priming revealed that the highest efficacy was seen (i.e. greater pre-procedure cervical dilation) with the 3-hour interval. This finding was based on high-certainty evidence. Although the 3-hour interval is considered optimal, the 1-hour interval is also included as a result of the expert panel members’ discussions on the feasibility and acceptability of the shorter duration of waiting time prior to a woman’s surgical abortion.

For Recommendation 17b, the reasoning is due to the longer time to complete the procedure if osmotic dilators are used compared with when misoprostol is used for cervical priming, based on high-certainty evidence. In addition, satisfaction rates were higher among those who received misoprostol compared with the laminaria group, based on moderate-certainty evidence.

The expert panel added the buccal route (this was added along with the vaginal route due to buccal and misoprostol concentration curves being similar in pharmacokinetics data), and their remark highlights the sublingual route as being the more effective route.

CLINICAL SERVICES Recommendation 18 (NEW): Cervical priming prior to surgical abortion (MVA or D&E) at ≥ 12 weeks of gestation

Prior to surgical abortion at later gestational ages:

a. For surgical abortion at ≥ 12 weeks: Suggest cervical priming prior to the procedure.

b. For surgical abortion between 12 and 19 weeks: Suggest cervical priming with medication alone (a combination of mifepristone plus misoprostol is preferred) or with an osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both).

c. For surgical abortion between 12 and 19 weeks, when using an osmotic dilator for cervical priming: Suggest that the period between osmotic dilator placement and the procedure should not extend beyond two days.

d. For surgical abortion at ≥ 19 weeks: Recommend cervical priming with an osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both).

Remark:

  • There was limited evidence for cervical priming for gestational ages between 12 and 14 weeks and therefore health workers should use clinical judgement to decide on the most convenient method for cervical priming prior to vacuum aspiration for this gestational age range.

Note: These are new recommendations and they replace Recommendations 8.1 and 8.2 in WHO (2012) (19), which were for D&E after 14 weeks; these new recommendations now include information on methods/regimens for cervical priming at different gestational age ranges.

Implementation consideration

The use of medication for cervical priming prior to surgical abortion beyond 12–14 weeks of gestation can be self-managed and can save travel time for the woman and staff time spent on insertion of osmotic dilators.

Rationale

A Cochrane Review provided the evidence base on cervical priming methods for surgical abortion at later gestational ages. From this review, 16 studies were included in the development of the EtD framework relating to the following cervical priming methods: medication with mifepristone and/or misoprostol; mechanical methods with osmotic dilators and synthetic dilators; one-day versus two-day procedures with laminaria. The study settings included Israel, South Africa, Spain, the United Kingdom and the USA. A summary of the evidence is presented in Supplementary material 2, EtD framework for Cervical priming prior to surgical abortion ≥ 12 weeks.

The inclusion of all medication options for cervical priming was based on the expert panel’s discussion of the feasibility and acceptability of these interventions. The use of mifepristone with misoprostol is favoured over misoprostol alone for cervical priming due to higher pre-procedure cervical dilatation and shorter time to complete the procedure, based on moderate-certainty evidence. The combined use of medication and laminaria is favoured over laminaria alone due to the higher pre-procedure cervical dilatation, decreased need for further dilatation and shorter time to complete the procedure. This is based on high-certainty evidence. Sub-analyses of the included studies showed that the combined use of medication and laminaria appears to be more effective at higher gestational ages.

SERVICE DELIVERY Recommendation 19: Cervical priming with medication prior to surgical abortion at any gestational age

Type of health worker Recommendation Rationalea
Community health workers (CHWs) Suggest

Condition: Provision of medication for the purpose of cervical priming is part of the surgical abortion process so the health worker needs to ensure continuity of care of the woman obtaining the medicines prior to the abortion procedure

Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a In addition, CHWs have been recommended to provide medical abortion at < 12 weeks (see Recommendation 28), which requires similar skills and knowledge as for this task.
Pharmacy workers Suggest

Condition: Provision of medication for the purpose of cervical priming is part of the surgical abortion process so the health worker needs to ensure continuity of care of the woman obtaining the medicines prior to the abortion procedure

Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a In addition, pharmacy workers have been recommended to provide medical abortion at < 12 weeks (see Recommendation 28), which requires similar skills and knowledge as for this task.
Pharmacists Suggest

Condition: Provision of medication for the purpose of cervical priming is part of the surgical abortion process so the health worker needs to ensure continuity of care of the woman obtaining the medicines prior to the abortion procedure

Although no evidence was found on the safety, effectiveness or acceptability of this option, dispensing medicines with a prescription is within the typical scope of practice of pharmacists. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a In addition, pharmacists have been recommended to provide medical abortion at < 12 weeks (see Recommendation 28), which requires similar skills and knowledge as for this task.
Traditional and complementary medicine professionals

Auxiliary nurses/ANMs

Nurses

Midwives  

Recommend Evidence was found for the safety and effectiveness of this option (low-certainty evidence). Cervical priming is part of the training for provision of manual vacuum aspiration. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a
Associate/advanced associate clinicians Recommend Evidence was found for health workers with similar or less comprehensive basic training (e.g. midwives, nurses, ANMs) using such medicines to provide medical abortion (moderate-certainty evidence). Cervical priming is part of the training for provision of manual vacuum aspiration. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a
Generalist medical practitioners

Specialist medical practitioners

Recommend Within their typical scope of practice,b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).

Note on updating of the recommendation: This was an existing recommendation for which evidence relating to all types of health workers was reviewed using GRADE methodology, except for specialist and generalist medical practitioners, which were already “recommend”. After review, the recommendations were upgraded for all reviewed health workers, from “recommend against” to “suggest” for pharmacists, pharmacy workers and CHWs, and from “suggest” to “recommend” for all other health worker categories. The gestational age for this recommendation was also amended from “beyond 12 weeks” to “at any gestational age” after conferring with the expert panel. A summary of the evidence is presented in Supplementary material 3, EtD framework for Cervical priming using medication and osmotic dilators.

a For this and all health worker recommendations, given the limited evidence for many of the health worker–task combinations, the discussions of the expert panel focused on the competency framework in WHO’s 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women’s values and preferences.

b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

No requirement for location (on-site vs off-site).

Implementation consideration
  • Given that cervical priming initiates the process and is done prior to a surgical procedure, with an interval of up to 1–2 days, it is important that the health worker ensures the continuity of care for the woman by ensuring that there is a clear plan for the surgical abortion prior to the woman taking the priming agent and she has access to the existing health system should she desire or need additional support during that interval.

SERVICE DELIVERY Recommendation 20: Cervical priming with osmotic dilators prior to D&E at gestational ages ≥ 12 weeks

Type of health worker Recommendation Rationalea
Traditional and complementary medicine professionals Suggest

Condition: Health worker ensures continuity of care from the time of cervical priming to the D&E

Although insufficient direct evidence was found for the safety and effectiveness of this option, these health workers have been suggested to do other transcervical procedures (e.g. inserting an IUD and vacuum aspiration; see Recommendations 43 and 24). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a The expert panel affirmed that this option has the potential to increase equitable access to quality abortion care in regions where these professionals constitute a significant proportion of the health workforce.
Auxiliary nurses/ANMs Recommend Although insufficient direct evidence was found for the safety and effectiveness of this option, ANMs have been recommended to do other transcervical procedures (e.g. inserting an IUD; see Recommendation 43), and auxiliary nurses have been recommended in certain contexts to do other transcervical procedures (e.g. inserting an IUD; see Recommendation 43). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a The expert panel affirmed that this option may help optimize workflow within a facility and decrease waiting times for women.
Nurses Recommend Although insufficient direct evidence was found for the safety or effectiveness of this option, nurses have been recommended to do other transcervical procedures (e.g. inserting an IUD; see Recommendation 43), and there is evidence that provision of manual vacuum aspiration by nurses is safe and effective (moderate-certainty evidence). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a The expert panel affirmed that this option may help optimize workflow within a facility and decrease waiting times for women.
Midwives Recommend Although insufficient direct evidence was found for the safety or effectiveness of this option, midwives have been recommended to do other transcervical procedures (e.g. inserting an IUD; see Recommendation 43), and there is evidence that provision of manual vacuum aspiration by midwives is safe and effective (moderate-certainty evidence). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a The expert panel affirmed that this option may help optimize workflow within a facility and decrease waiting times for women.
Associate/advanced associate clinicians Recommend Indirect evidence was found for the safety and effectiveness of these clinicians providing vacuum aspiration (moderate-certainty evidence), which includes cervical priming with osmotic dilators for select cases. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a The expert panel affirmed that this option may help optimize workflow within a facility and decrease waiting times for women.
Generalist medical practitioners Specialist medical practitioners Recommend Within their typical scope of practice,b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).

Note on updating of the recommendation: This was an existing recommendation for which evidence relating to all types of health workers was reviewed using GRADE methodology, except for specialist and generalist medical practitioners, which were already “recommend”. After review, the recommendations were upgraded for associate/advanced associate clinicians, midwives and nurses from “suggest” to “recommend”, for auxiliary nurses and ANMs from “recommend against” to “recommend”, and for traditional and complementary medicine professionals from “recommend against” to “suggest”. For pharmacists, pharmacy workers and community health workers, the recommendations remain “recommend against” (not listed). The gestational age for this recommendation was also amended from “beyond 12 weeks” to “12 weeks and above” (≥ 12 weeks) to align this recommendation with Recommendation 18. A summary of the evidence is presented in Supplementary material 3, EtD framework for Cervical priming using medication and osmotic dilators.

a For this and all health worker recommendations, given the limited evidence for many of the health worker–task combinations, the discussions of the expert panel focused on the competency framework in WHO’s 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women’s values and preferences.

b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

In a health-care facility.

KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO CERVICAL PRIMING

  • Denial of cervical priming as punishment for abortion or because it is part of abortion care may violate the right to non-discrimination and equality.

For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

Footnotes

  1. For the sake of consistency across the recommendations, the cut-off gestational age is 12 weeks, but evidence did include women with pregnancies up to 14 weeks of gestation who underwent vacuum aspiration.