Written by Mansi Shah, MD

What special considerations might there be for fat patients seeking abortion care? In this article, the word fat here is used in the tradition of fat scholars and activists who do so with the aim of reclaiming the word as a neutral descriptor of bodies.¹ Fat folks encounter significant stigma when seeking out health care, and our medical system continues to be a key institution that drives the anti-fat bias that is entrenched in our society. Like other aspects of reproductive care, outpatient abortion care can be safely provided to fat patients. Notably, the studies discussed below reported findings using BMI. BMI is commonly used as a framework for referencing weight, despite its racist origins and limitations as a measure of health.²

Medication abortion is safe, and mifepristone and misoprostol are highly effective in combination for pregnancy termination.³ A 2009 study showed that there was no difference between the rate of failed medication abortion requiring procedural intervention for over 1000 patients undergoing medication abortion with mifepristone and misoprostol when divided into two groups based on a BMI cutoff of 30.⁴

Uterine aspiration is also safe in the outpatient setting, irrespective of weight. Multiple studies have found no association between BMI and complication rates for patients undergoing abortion procedures in the first and second trimester; instead, one study instead found that complications increased as gestational age advanced.^5,6* Furthermore, moderate sedation can safely be provided for fat patients in the outpatient setting, as supported by the American Society of Anesthesiologists guideline on moderate sedation and a study showing no association to BMI and rare adverse outcomes related to moderate sedation during abortion procedures.^7,8** Taken together, these studies support the safety of outpatient procedural abortion care for fat patients, with moderate sedation if desired.

Exam techniques should aim to minimize or counteract patient discomfort. A trauma-informed approach to gynecologic exams includes asking patients about their needs and considering alternative positions, as not all positions may be accessible to patients. Hyperflexion of the hips (essentially mimicking a squatting position, with or without hyperflexion of the knees) often facilitates visualization of the cervix if it is difficult in lithotomy position. Positioning the patient in this way can be accomplished with the appropriate leg supports or with the help of assistants.*** In addition, medium-sized speculums, including the Klopfer and medium Graves speculums, are often sufficient for visualizing the cervix. Consider increasing the anterior-posterior diameter of the speculum to aid in visualization. Larger and longer speculums often create more discomfort for patients. These strategies can be particularly useful when completing gynecologic exams for fat patients.

In summary, abortions can safely be provided to fat patients in the outpatient setting, as supported by research and clinical practice.

*The complications studied included estimated blood loss >= 200 mL, repeat uterine aspiration, cervical laceration, uterine perforation, infection, emergency department visit, and hospitalization. This study showed an overall complication rate of 1.4% which is consistent with other reports of complication rates in outpatient abortion care, per the UpToDate article on “First-trimester pregnancy termination: Uterine aspiration.”

**Of the 20,000 patients in this study, approximately 4000 patients had a BMI above 30 and more than 500 patients had a BMI above 40.

***Adjustable leg supports can be used to place the knees in a position where the hips are flexed to 90+ degrees. If the knee position is not adjustable in that fashion, the patient can be asked to place their feet where the knees would typically rest.

RHAP Resources:

Early Abortion Options

Contraceptive Pearl: Alternative Positions for Pelvic Exams

Sources:

1. Gordon A. “You Just Need to Lose Weight”: And 19 Other Myths about Fat People. Beacon Press; 2023.

2. Your Fat Friend. The bizarre and racist history of the BMI. Medium. October 18, 2019. Accessed December 18, 2023. https://elemental.medium.com/the-bizarre-and-racist-history-of-the-bmi-7d8dc2aa33bb.

3. Bartz DA, Blumenthal PD. First-trimester pregnancy termination: Medication abortion. UpToDate. July 10, 2023. Accessed December 18, 2023. https://www.uptodate.com/contents/first-trimester-pregnancy-termination-medication-abortion#H1492527808.

4. Strafford MA, Mottl-Santiago J, Savla A, Soodoo N, Borgatta L. Relationship of obesity to outcome of medical abortion. Am J Obstet Gynecol. 2009;200(5):e34-e36. doi:10.1016/j.ajog.2008.10.016

5. Benson, Lyndsey S. MD, MS; Micks, Elizabeth A. MD, MPH; Ingalls, Carly MD; Prager, Sarah W. MD, MAS. Safety of Outpatient Surgical Abortion for Obese Patients in the First and Second Trimesters. Obstetrics & Gynecology 128(5):p 1065-1070, November 2016. | DOI: 10.1097/AOG.0000000000001692

6. Lederle L, Steinauer JE, Montgomery A, Aksel S, Drey EA, Kerns JL. Obesity as a Risk Factor for Complications After Second-Trimester Abortion by Dilation and Evacuation. Obstet Gynecol. 2015 Sep;126(3):585-592. doi: 10.1097/AOG.0000000000001006. PMID: 26244536; PMCID: PMC4545380.

7. Horwitz G, Roncari D, Braaten KP, Maurer R, Fortin J, Goldberg AB. Moderate intravenous sedation for first trimester surgical abortion: a comparison of adverse outcomes between obese and normal-weight women. Contraception. 2018;97(1):48-53. doi:10.1016/j.contraception.2017.09.001

8. Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018; 128:437–479 doi: https://doi.org/10.1097/ALN.0000000000002043

Pharma-free: The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or products. The information in the Insights is unbiased, based on science alone.

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